Vaccination campaigns

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.

Boy receiving polio drops from a health worker, with his mother during a polio vaccination campaign in 2015. © WHO / Alex Shpigunov

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

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In October:

No case of WPV1 was confirmed
3.53 million children were vaccinated during October 2021 in KP outbreak response.
0.6 million children were vaccinated at 73 Permanent Transit Points

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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.
809 981 children were vaccinated against polio

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In September:

No case of WPV1 was confirmed
41.5 million children were vaccinated during NIDs.
0.8 million children were vaccinated at 72 Permanent Transit Points

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In August:

No case of WPV1 was confirmed
23.4 million children were vaccinated during sNIDs.
1 million children were vaccinated at 121 Permanent Transit Points

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In July:

No case of WPV1 was confirmed
1,2 million children were vaccinated at 121 Permanent Transit Points

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In May:

No case of WPV1 was confirmed
900,000 children were vaccinated at 121 Permanent Transit Points

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In May:

No new Wild Poliovirus (WPV1)cases and 5 new cVDPV2 cases were confirmed.
712,739 children were vaccinated against polio

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In April:

No new Wild Poliovirus (WPV1)cases and 5 new cVDPV2 cases were confirmed.
679,355 children were vaccinated against polio

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Children wait to be vaccinated as part of national polio vaccination campaign in Mogadishu. © Siyaad Mohamed /Ildoog/ WHO SOMALIA

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.

Volunteers Abdul Basit and Misbahuddin trek up a hill in Aab-e-barik village, Argo district, Badakhshan province. ©Shaim Shahin/WHO Afghanistan

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.”

Volunteers Ziaullah and Nawid Ahmad give polio drops to Sanaullah and Khadija in Doshakh village, Rukha district, Panjshir province. ©Ahmadullah Amarkhil/WHO Afghanistan

Badakhshan province

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”.

Herat Province

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”.

Yasameen, two months old, and her mother Sitara. Yasmeen lost her father recently and her mother does domestic work to support the family. ©Ramin Afshar/WHO Afghanistan

Jalalabad Province

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.

Twin brothers, Habib-u Rahman and Hamid-u Rahman, and their niece, show their inked fingers after being vaccinated against polio in Botawar village, Rukha district of Panjshir province. ©Ahmadullah Amarkhil/WHO Afghanistan

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.

Polio outbreak response in Chad, 2018 ©WHO/D Levison

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.

Somalia’s vaccine advocates

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.

Read this story on the UNICEF Somalia site.

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.

Community Health Workers deliver polio vaccine in Pehlwan Goth in Karachi. ©PEI/2020

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.

Samreen delivers polio drops to children whose parents initially rejected vaccination. ©PEI/2020

“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.

Samreen and Maulana Mohammad Hanif vaccinate the children of local resident Tayyab Khan. ©PEI/2020

“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.

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Dr. Ana Elena Chevez with her medical school cohort in El Salvador. During her career, Dr. Ana has made an immense contribution to polio eradication and broader public health. Credit: Provided by Dr. Ana Elena Chevez

Little Ana first learned about the importance of vaccines from her father, a pediatrician. Growing up during El Salvador’s 12-year civil war meant that electricity cuts were a common occurrence. Whenever the electricity went out, Ana’s father would rush the vaccines he kept in his clinic to the nearby hospital, where generators kept the cold chain refrigerators working. Seeing her father’s dedication to his work, Ana knew she would also become a doctor.

Fast-forward to 2020. Dr. Ana Elena Chevez has dedicated over twenty years of her life to protecting children from vaccine preventable diseases. She has worked in four countries across two regions, and currently serves as a Regional Immunization Advisor for polio at the Pan American Health Organization (PAHO), the Regional Office for the Americas of the World Health Organization, supporting the 52 countries and territories of the Americas to maintain polio-free status.

Throughout her career, she has never stopped dreaming high – advice given to her by family, mentors and colleagues.

Dr. Ana’s first job in public health was as a national immunization manager in El Salvador. Her mentor was PAHO/WHO immunization advisor Dr. Salvador Garcia. “Dr. Garcia taught me everything I needed to know about running an immunization programme. I knew that I could call him at any time, and I would get the answer that I needed,” she said.

The last mile of polio eradication in Nigeria

As polio cases surged in the African region in 2007, Dr. Ana was selected to go to Nigeria to support outbreak response. In a twist of fate, a three-month assignment turned into four years as Nigeria’s Supplementary Immunization Activity (SIA) coordinator.

It was in Nigeria that Dr. Ana refined her skills as a polio eradicator, as well as finding a ‘home away from home’. Credit: Dr. Ana Elena Chevez

This experience was pivotal for Dr. Ana’s career – it solidified her passion for polio eradication and introduced her to new colleagues and a new

country, which would soon become Dr. Ana’s second family and her home-away-from-home.

Dr. Ana was inspired by the constant innovation she saw in Nigeria. “We were always looking for ways to improve quality of the campaigns – improve training, surveillance, cold chain. It was always innovation, innovation, innovation.”

Dr. Ana believes that way of thinking really took Nigeria to the next level. “We started seeing fewer cases, more children vaccinated, and a higher level of acceptance among parents and leaders.”

As SIA coordinator, Dr. Ana oversaw all polio campaigns in the country. During these years, polio campaigns were happening on an almost monthly basis, alongside campaigns for yellow fever, tetanus elimination, and measles. It was overwhelming. “By the time we returned from the field to analyze one campaign, it was already time to start preparation for the next one. It was tiring for everyone – for us (the WHO staff), the partners, for the national/state/local health authorities, and of course for the vaccinators.”

Despite the pressure, Dr. Ana said, “If you were to ask me if I would do it again, I would say yes in a heartbeat. For me, it was being a part of an important moment in history – for the country, for public health, and for the polio programme.”

Maintaining momentum in a region certified free of polio for over 25 years

In 2017, Dr. Ana became PAHO/WHO’s Regional Advisor in charge of polio. The last case of wild poliovirus in the Americas was in 1991 and the region was certified free of polio in 1994. Although more than 25 years have passed since the Americas received polio free status, until polio is eradicated everywhere, the disease is still a risk.

25 years since the Americas were certified polio-free, Dr. Ana emphasizes that the region remains at risk until polio is eradicated everywhere. Credit: Dr. Ana Elena Chevez

Dr. Ana explains, “Even though new generations of nurses, doctors, and epidemiologists have not seen a case of polio firsthand, they understand the risk remains.” There have been 26 meetings of PAHO’s Technical Advisory Group (TAG) meeting on vaccine preventable diseases, and polio has been included on the agenda for every meeting.

It has not always been easy to keep this momentum. In recent years, countries in the Americas have had trouble meeting the indicators required to prove sensitive surveillance systems. For the last few years, PAHO has been holding almost yearly regional polio meetings to sensitize countries on the GPEI’s requirements for eradication and stress the importance of achieving high immunization coverage rates for polio and high standards of surveillance.

Dr. David Salisbury, chair of the Global Certification Commission for Polio Eradication, said at the regional PAHO polio meeting in 2017 that “there will be no free pass” for countries that are polio-free. All nations must provide documentation of certification standard surveillance to back up their belief that polio is eliminated amongst their population.

For Dr. Ana, these words hit home, “The work done by those that here before me has helped the countries to be aware. It has been my role to keep that momentum alive and help countries meet the required goals established in the Endgame Strategy.”

A message for the new generation of women public health leaders

In recent decades, women leaders in public health and immunization made important contributions to a field once dominated by men.

Dr. Ana recalls many of the women leaders that she’s worked with and considers that they have gone above and beyond what is expected. “They have raised the bar and have given the message that other women can work in public heath – it doesn’t matter your religion or colour – it matters that you care.”

Dr. Ana is excited to see more women step into leadership roles. “The new generation is coming. We need them – we need to prepare them. We are close to polio eradication, but we must think about what is next and prepare the new generation to tackle these issues with confidence. I tell my nieces that they can go and contribute to the world and make an impact.”

Reflecting on her own motivation, Dr. Ana says, “I always believed that I could make an impact, I just needed the tools, time and opportunity.”

“Young women leaders: Keep dreaming high. Keep dreaming that you can influence the health of whole populations. Don’t be afraid to set high goals– don’t be afraid to think that it is possible to control, eliminate, or even eradicate a disease.”

Nabeela, a polio frontline worker in Pakistan, vaccinates a child in Liaqatabad using the ‘no touch’ method. © UNICEF/Pakistan

Vaccinators in countries including Afghanistan, Angola, Burkina Faso and Pakistan took to the streets this month to fill urgent immunity gaps that have widened in the under-five population during a four month pause to polio campaigns due to COVID-19.

Campaigns resumed in alignment with strict COVID-19 prevention measures, including screening of vaccinators for symptoms of COVID-19, regular handwashing, provision of masks and a ‘no touch’ vaccination method to ensure that distance is maintained between the frontline worker and child. Only workers from local communities provided house-to-house vaccination to prevent introduction of SARS-CoV2 infection in non-infected areas.

Although necessary to protect both health workers and communities from COVID-19, the temporary pause in house-to-house campaigns, coupled with pandemic-related disruptions to routine immunization and other essential health services, has resulted in expanding transmission of poliovirus in communities worldwide. Modelling by the polio programme suggests a potentially devastating cost to eradication efforts if campaigns do not resume.

A child has their finger marked during the campaign in Angola. ©WHO/AFRO

In Afghanistan, 7858 vaccinators aimed to vaccinate 1 101 740 children in three provinces. Vaccinators were trained on COVID-19 infection control and prevention measures and were equipped to answer parents’ questions about the pandemic. Through the campaign, teams distributed 500 000 posters and 380 000 flyers featuring COVID-19 prevention messages.

In Angola, 1 287 717 children under five years of age were reached by over 4000 vaccinators observing COVID-19 infection prevention and control measures. All health workers were trained on infection risk, and 90 000 masks and 23 000 hand sanitizers were distributed by the Ministry of Health.

In Burkina Faso, 174 304 children under five years of age were vaccinated in two high-risk districts by 2000 frontline workers. Vaccinators and health care workers were trained on maintaining physical distancing while conducting the vaccination. 41 250 masks and 200 litres of hand sanitizer were made available through the COVID-19 committee in the country to protect frontline workers and families during the campaign.

In Pakistan, almost 800 000 children under the age of five were reached by vaccinators in districts where there is an outbreak of circulating vaccine-derived poliovirus. Staff were trained on preventive measures to be followed during vaccination, including keeping physical distance inside homes and ensuring safe handling of a child while vaccinating and finger marking them.

Farzana, a polio worker in Karachi’s Liaqatabad Town, Pakistan uses hand sanitizer during the campaign. ©UNICEF/Pakistan

“Our early stage analysis suggests that almost 80 million vaccination opportunities have been missed by children in our Region due to COVID-19, based on polio vaccination activities that had to be paused,” said Dr Hamid Jafari, Director for Polio Eradication in the Eastern Mediterranean Region. “That’s close to 60 million children who would have received important protection by vaccines against paralytic polio.”

Over the coming months, more countries plan to hold campaigns to close polio outbreaks and prevent further spread, when the local epidemiological situation permits.

“Our teams have been working across the Region to support the COVID-19 response since the beginning of the pandemic, as well as continuing with their work to eradicate polio,” said Dr Hamid Jafari. “We must now ensure that we work with communities to protect vulnerable children with vaccines, whilst ensuring strict safety and hygiene measures to prevent any further spread of COVID-19”.

In Afghanistan, 7858 vaccinators aimed to vaccinate 1 101 740 children in three provinces. ©WHO/Afghanistan

Dr Matshidiso Moeti, WHO Regional Director for Africa, commented, “We cannot wait for the COVID-19 pandemic to be contained to resume immunization activities. If we stop immunization for too long, including for polio, vaccine-preventable diseases will have a detrimental effect on children’s health across the region.”

“The campaigns run by the Polio Eradication Programme demonstrate that mass immunization can be safely conducted under the strict implementation of COVID-19 infection prevention and control guidelines.”

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Community surveillance teams for COVID-19 and acute flaccid paralysis speak to households about any individuals with symptoms in their area. The Somali polio team is currently steering the COVID-19 response and fighting ongoing polio outbreaks amidst challenging conditions. ©WHO/Somalia

For Somalis, COVID-19 is the most immediate crisis in a seemingly unending cycle of floods, food insecurity, conflict and outbreaks of vaccine-preventable diseases like measles, cholera and polio. Against this backdrop, the World Health Organization’s polio programme is working to steer the COVID response and, more broadly, maintain vaccine immunity levels and improve access to healthcare. It’s no easy feat.

Dr Mohamed Ali Kamil, the outgoing World Health Organization Polio Team Lead and COVID-19 incident manager for Somalia, is in awe of the commitment shown by health staff. He recently phoned a Polio Logistician diagnosed with COVID-19 who was experiencing symptoms, to insist he stop working remotely from his sickbed. Dr Kamil recalls, “He said, “No Sir, I will continue.”

Since the first COVID-19 case was diagnosed in Somalia on 16 March 2020, the polio programme has fought the pandemic from the ground up. Dr Kamil explains, “No other health programme has comparable expertise to serve the Somali population during COVID-19. During their time in the programme, members of the polio team have responded to many different disease outbreaks. This means they were well placed and well trained to respond to COVID-19.”

“The polio programme has spent years building staff capacity and systems to implement vaccination campaigns and detect the poliovirus in the community. In some ways, the team are the first and last line of defense.”

The response includes education, case identification, contact tracing, case management and data support. As of June, polio staff working as part of rapid response teams (RRTs) had reached 2.6 million people with messages about COVID-19 prevention. District Polio Officers within the RRTs have led the investigation of over 4500 people with suspected COVID-19 across the country. The country has set up three COVID-19 testing facilities and the polio structure established for the collection and shipment of stool samples from AFP cases has been used for the transportation of COVID-19 samples.

Dr Mohamed Ali Kamil, the outgoing World Health Organization Polio Team Lead and COVID-19 incident manager for Somalia, speaks to a polio vaccinator before the onset of the pandemic. ©WHO/Somalia

Throughout, polio personnel have continued their full-time work to end the circulating vaccine-derived poliovirus (cVDPV) outbreaks that have thus far paralyzed sixteen children since 2017.

The team are driven by a humanitarian commitment to the Somali population, who have suffered over 30 years of protracted conflict and insecurity. At least 5.2 million people are in need of humanitarian assistance, and secondary and tertiary healthcare is virtually non-existent outside of a few large cities. Health literacy is low, and populations are highly vulnerable to diseases like polio, measles, cholera and now COVID-19. In November 2019, widespread flooding brought further turmoil and danger to Somali families.

The team’s work is made more difficult by the emotional toll wrought by the pandemic. To date at least 143 health workers have been identified with COVID-19 infection. In April, Ibrahim Elmi Mohamed, a District Polio Officer who spent 19 years striving for a polio-free Somalia, died of a COVID-19-related illness. His death, one of many frontline staff around the world due to COVID-19, remind us of the risks they face every time they go to work.

Challenges lie ahead to defeat polio

Dr Kamil is clear that the polio programme will require ongoing funding and the support of authorities, partners and communities in order to maintain polio activities amidst the pandemic.

“To sustain the immunity gains we must implement a number of polio vaccination campaigns each year until the routine immunization programme can reach every Somali child with all polio vaccines. Somalia is extremely fragile and at high risk of becoming endemic for poliovirus if we do not maintain and support the polio infrastructure,” he says.

Since the cVDPV outbreaks were first detected in 2017, the programme has streamlined disease surveillance for cases of acute flaccid paralysis and other preventable diseases, including by introducing mobile technology to record details of suspected cases. For the first time, environmental disease surveillance was introduced. Over three years, frontline health workers have implemented more than 15 polio campaigns, including integrated campaigns with the measles programme.

A volunteer vaccinator gives two drops of the polio vaccine to a Somali child in August 2019. Despite efforts, many inaccessible areas remain where the programme cannot deliver vaccines. ©WHO/Ilyas Ahmed

Dr Kamil explains, “We still don’t know where the virus is coming from exactly. There are many inaccessible areas, where we cannot deliver vaccines or respond with immunization campaigns. We suspect that the virus is circulating among vulnerable children and communities living in these areas.”

Dr Kamil feels strongly that the polio programme has a duty to support other health interventions. He says, “COVID-19 shows what the frontline polio staff can achieve and the strength of surveillance and response systems.’’

Despite the challenges, Dr Kamil retains his belief that with ongoing funding and support, the cVDPV outbreaks in Somalia can be brought to a close. He reflects, “COVID-19 is a huge emergency in Somalia. Our staff are working flat out, and we expect to see many more cases, but at the same time we must continue to fight polio. The Somali community and the world deserve to be free of this disease.”

“We must reschedule our March polio vaccination campaign which was delayed because of the COVID 19 outbreak. We must do everything possible to keep health workers safe from COVID-19. It’s a hard situation, but we must not stop until we overcome both viruses.”

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In May

1 case of wild poliovirus were reported
318 children were vaccinated.
Polio vaccination activities continued to stay postponed due to COVID-19 outbreak