- No case of WPV1 was confirmed
- 23.4 million children were vaccinated during sNIDs.
- 1 million children were vaccinated at 121 Permanent Transit Points
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.
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.
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.
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.
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.
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.
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.
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.
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.”
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.
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.
“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”.
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.”
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.
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.
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.”
Dr Fiona Braka holds one of the highest-stake roles in the African regional polio programme – supporting the Government of Nigeria in their fight to defeat wild poliovirus.
She is the first woman to hold her position in Nigeria, and before that was the first female polio team lead in Ethiopia.
Fighting the last wild virus in Africa
Dr Braka’s work involves leading the country team to strengthen routine immunization and maintain high quality disease surveillance systems in Nigeria. She is also heavily involved in the COVID-19 response, lending expertise established over decades of fighting polio.
In 2016, the detection of wild virus in Nigeria after nearly two years without cases was a devastating setback. “When the outbreak broke out, I was in Uganda on a break with my family. I was having lunch with a friend and my phone was ringing, persistently ringing – a Geneva number. When I picked up the phone it never crossed my mind it would be a wild virus,” Dr Braka remembers.
“A good proportion of Borno state was inaccessible due to armed conflict. Delivering vaccination services and conducting surveillance in that area had not been easy. With interventions going on to address the conflict by the Nigerian Government, some ground was gained, and people trapped for over three years were able to move out of the liberated areas to internally displaced persons camps. With population movement, a wild polio case was detected in an internally displaced child.”
Cutting short her family holiday, Dr Braka raced to Borno to help launch a truly innovative outbreak response with the government and partners. Adapting strategies for polio response to an insecure setting, the programme started settlement-based microplanning guided by local security assessments, innovative surveillance approaches, and the use of GIS and satellite imagery to estimate trapped populations.
The estimated number of children inaccessible to vaccinators has dropped from over 400,000 in September 2016 to less than 30,000 in May 2020 – an enormous achievement for the programme.
Balancing motherhood and a career in public health
The challenges were very different when Dr Braka was working on the 2013 Horn of Africa outbreak in Ethiopia’s Somali region. Cases of polio were occurring among pastoral communities and the programme had to rethink tactics to ensure the children of nomadic populations could be reached with vaccines. To maintain the cold chain, polio teams travelled on donkeys or on foot through the bushes. Community leaders among the nomads were employed to help vaccination teams reach families on the move.
“I recall the advice of a parent of a nomadic child who had contracted polio. He said, “We follow where the clouds and rain go – unless the polio programme also moves with the clouds and the rains as we do, you will never reach us and our children will never get the vaccine”. This became a guiding quote for us,” Dr Braka remembers.
This was also a time of personal challenge, as Dr Braka’s youngest daughter was less than a year old. On one occasion, Dr Braka brought her baby with her to a vital cross-border collaboration meeting in Somali region between the Somalia, Kenya and Ethiopia teams. She recalls, “I had to stay in the same hotel as the meeting so I could run upstairs during the break to breastfeed. That moment really stands out an example of the tough decisions you must make as a parent.”
Dr Braka praises steps taken so far to promote women’s professional development in public health and leadership, whilst noting there is more to do.
“The WHO Regional Director for Africa, Dr Matshidiso Moeti, has provided opportunities for capacity building for women. There has been the first training this year for senior women leaders in the African region – I am proud to be part of this.”
Part of the Global Polio Eradication Initiative Gender Strategy 2019-23 commits to promoting a gender-responsive organizational culture. By placing gender at the heart of operations, the strategy closely aligns with the policies of major donors to polio eradication including Canada, Germany, Australia and the United Kingdom.
Explaining why she is a strong supporter of gender equality at all levels of public health, Dr Braka finds, “Even occupying leadership roles you have to have gender in mind – you have to be prepared to prove yourself a bit more.”
“It remains our responsibility to create a policy environment that gives opportunities for men and women.”
A duty to end polio
Dr Braka emphasizes that many people forget how damaging the disease is.
“Whilst we have polio anywhere in the world, we are all at risk of cross-border virus spread. Until polio is eradiated globally, we must be on our toes with robust surveillance systems and infrastructure to deliver vaccines.”
Dr Braka has been able to sustain her demanding job in part thanks to the support of her family. She explains, “I have a very supportive spouse…He knows the polio programme as well as I do!”
“My late father was also very supportive of my career. My mother has been more than a mother – a strong pillar of support, mothering her grandchildren when I am not there and providing moral support in the background.”
She explains that she can’t imagine a next generation suffering from polio when a vaccine is available.
“Vaccines are a powerful tool and the evidence is clear for saving lives. They reduce burden on families, economically, emotionally, and they prevent the suffering of children.”
“We have a duty to secure children’s future to be healthy citizens.”
On 4 June 2020, the UK Government hosted Gavi’s third donor pledging conference, the Global Vaccine Summit, to mobilize at least US$ 7.4 billion to protect the next generation with vaccines, reduce disease inequality and create a healthier, safer and more prosperous world. Responding to this unique call for global solidarity, leaders from donor countries and the private sector made unprecedented commitments of US$ 8.8 billion in order to save up to 8 million lives.
Since 2019, the Global Polio Eradication Initiative (GPEI) has strengthened its collaboration with Gavi, inviting Gavi to become the sixth core partner of the GPEI. While the GPEI will continue its focus on interrupting virus transmission and eradicating polio through immunization campaigns using the oral polio vaccine (OPV), Gavi’s support for the inactivated polio vaccine (IPV) at an estimated cost of US$ 800 million during its 2021-25 strategic period represents the insurance policy for the success of the Polio Endgame Strategy.
Thanks to the remarkable mobilization and solidarity of leaders worldwide, Gavi will be able to maintain immunization in developing countries, mitigating the impact of the COVID-19 pandemic. Gavi will also be able to sustain health systems so that countries are ready to rapidly introduce COVID-19 vaccines. And by 2025 Gavi will have immunized more than 1.1 billion children, saving 22 million lives. Ngozi Okonjo-Iweala, Chair of the Gavi Board, highlighted why this is so important, saying, “Vaccinations should be recognized as a global public good. With your support and commitment, we can generate US$ 70 to US$ 80 billion additional economic benefits.”
Henrietta Fore, Executive Director of UNICEF, added, “We have effective vaccines against measles, polio and cholera. While circumstances may require us to temporarily pause some immunization efforts, these immunizations must restart as soon as possible, or we risk exchanging one deadly outbreak for another.” UN Secretary-General Antonio Guterres urged partners to “find safe ways to continue to deliver vaccinations during COVID-19.” GPEI, Gavi, WHO and UNICEF have issued guidance for countries to encourage resuming immunization activities once it is safe to do so, in recognition of the fact that numerous countries are facing COVID-19 and multiple other disease outbreaks.
During the Summit, top Gavi donors reaffirmed their leadership, including Norway, the UK and the USA, as well as the Bill & Melinda Gates Foundation. Prime Minister Boris Johnson pledged £1.65 billion, recommitting the UK as Gavi’s leading donor while the Gates Foundation committed US$ 1.6 billion. More than 60 leaders from all regions of the world in the Asia-Pacific, Middle East, Africa, Europe and the Americas pledged support to Gavi, the Vaccine Alliance both for its upcoming strategic period as well as for COVID-19 response.
The COVID-19 pandemic reminds us of the power of vaccines. WHO Director-General Tedros Adhanom noted, “COVID-19 is a devastating reminder that life is fragile, and that in our global village our individual health depends on our collective health. … Now is the moment for the world to come together in solidarity to realise the power of vaccines for everyone.” Responding to this challenge, Gavi has launched the Gavi Advance Market Commitment for COVID-19 (Gavi Covax AMC), which aims to raise additional funding in late June under the leadership of the European Union. Bill Gates, noted, “We would have to create Gavi if it did not exist today to solve the COVID-19 crisis.”
Michel Zaffran, director of the WHO polio eradication programme, said, “Congratulations to the Gavi family for this exemplary mobilization and demonstration of global solidarity. We are immensely grateful to Gavi and its donors for their precious partnership and generous support for the inactivated polio vaccine (IPV). The COVID-19 pandemic is a terrible tragedy, which brings us together more than ever and requires to think collectively how best to address the needs of the communities.”
Rotary, one of the six GPEI partners, echoed statements from other agencies. “Rotary and its members applaud the commitment of the donors and governments who have pledged their support to ensuring that vulnerable communities can receive lifesaving vaccinations,” said Michael K. McGovern, Polio Oversight Board and Chair of Rotary’s International PolioPlus Committee. “Continued investment from the global community in programmes such as the Global Polio Eradication Initiative is crucial to not only achieving the eradication of polio, but ensuring stronger health systems worldwide. This firm commitment truly embodies the “Plus” in PolioPlus.”
While the Global Vaccine Summit secured the IPV requirements for polio eradication efforts through 2025, further financial commitment is needed for the GPEI to restart the immunizations campaigns that have been paused during the COVID-19 pandemic. More intensive and integrated immunization activities are needed to finish the job and to strengthen the capacities of the governments, health workers and networks, so that the investment in polio eradication can serve as a foundation for future pandemic response. While celebrating the success of the Global Vaccine Summit, GPEI calls for reiterated donor support to eradicate polio once and for all.
Part of Joana’s role as a nurse involves vaccinating children in Barangay 105 Happyland, Tondo, in the city of Manila. A vaccine-derived poliovirus outbreak was detected in the Philippines in 2019, and health workers are working to close a polio immunity gap present amongst some of the nation’s children. To successfully vaccinate children in Barangay 105 Happyland, the teams speak to community leaders, dodge traffic, and answer the questions of parents about the vaccine.
*This footage was recorded before the introduction of measures to reduce the spread of COVID-19 in the Philippines.
To find out more about the response, please visit WHO’s Polio Outbreak in the Philippines webpage
This week, the Global Polio Eradication Initiative (GPEI) celebrates World Immunization Week (WIW) alongside partners around the world who have worked tirelessly to protect children from vaccine-preventable diseases. Every year, the GPEI vaccinates more than 450 million children against polio in almost 50 countries. These efforts would not be possible without the dedication of vaccine champions – including health workers, parents, government leaders and donors – who are committed to sharing the message that #VaccinesWork for All.
This WIW comes at a difficult time as immunization campaigns – including polio campaigns – are being suspended around the world due to the threat of COVID-19. But, it’s also an important moment to acknowledge the incredible progress we’ve made against polio thanks to our generous donors. (Read more on how the GPEI is responding to the COVID-19 pandemic.)
During this WIW, we are grateful for the longstanding support and dedication of our partners, including His Highness Sheikh Mohamed bin Zayed Al Nahyan, the Crown Prince of Abu Dhabi. At the Reaching the Last Mile Forum in Abu Dhabi in November 2019, global leaders pledged US$2.6 billion to eradicate polio – including His Highness’s pledge of US$160 million, which comes on the heels of pledges dating back a decade. This support has, for example, allowed for the delivery of more than 400 million drops of polio vaccine to protect the most vulnerable and hard-to-reach children in Pakistan and funded more than 5,000 full-time vaccinators in high-risk areas of the country.
Further, through the UAE-Pakistan Assistance Program (UAE PAP), the UAE is helping to build healthy communities and protect against polio through poverty eradication – including by delivering food aid, building water treatment plants and leading infrastructure projects.
While WIW encourages us to celebrate the progress we’ve made and highlight that #VaccinesWork, it also reminds us that continued commitment is key to ending polio once and for all. When the COVID-19 emergency subsides, we will come back stronger and faster in our mission to reach every child with the polio vaccine. These efforts are only made possible by our valued donors. This WIW, we are thankful to UAE leadership for their continued support in our efforts to #EndPolio.
It was a somber day when Ihsanullah was told that two of his youngest children will never be able to walk again. His two year old daughter Safia, and Masood, his five month old son, were both diagnosed with polio.
When they began running a high fever in December, Ihsanullah rushed them to the nearest hospital in the city of Tank, Pakistan. After a series of tests, doctors confirmed that both children had contracted polio. Further investigations revealed that neither child had been vaccinated during any previous routine immunization or polio campaign rounds.
Like many other parents in his village, Ihsanullah had never accepted the polio vaccine. “I had a negative opinion about vaccination from the start. Many people told me that the polio vaccine was made of haram[forbidden] ingredients and was part of a larger conspiracy to make Muslim children sterile,” he said.
A farmer and labourer by profession, 27-year-old Ihsanullah lives in a village named Latti Kallay in Khyber Pakthunkwa, Pakistan. Polio teams often face hesitancy from communities in Latti Kallay during campaign rounds, with many parents citing religion as the primary reason for refusing the polio vaccine. In Tank city and the immediate surrounding areas, six wild polio virus cases were reported in 2019.
Sadly, it sometimes takes a case of polio for communities to fully realize the importance of vaccinating their children. Asghar and Khadim, neighbours of Ihsanullah, told polio teams that they had started ensuring that their children are vaccinated, despite being staunch refusers of the vaccine previously.
Ihsanullah said, “It pains me to imagine that Safia and Masood will never be able to walk again. If I knew that this would be the outcome, I would never have stopped the polio teams from vaccinating my children. I deeply regret my decision, but I will make sure that my other children are vaccinated”.
For now, the COVID-19 pandemic has necessitated the temporary pause of polio vaccination campaigns. This leaves unvaccinated children who cannot access routine immunization services vulnerable to paralysis. The situation also underlines the vital importance of increasing trust in vaccines amongst parents, so their children are protected from polio no matter what happens.
Gohar Mumtaz, the Union Council Polio Officer of the district, has hope. He says that a routine immunization session with the community, conducted before the pandemic spread to Pakistan, seemed to be more popular than usual. “Although there is still hesitancy, the situation seems to be improving. People will understand the need to vaccinate and no child will suffer like Safia and Masood in the future.”
To overcome barriers to polio eradication, the Pakistan polio programme conducted a top-to-bottom review during 2019. Areas where improvement is required were identified, and innovations introduced. This is vital work, as there are many other children in Pakistan besides Safia and Masood whose futures have been marred by the poliovirus. Last year saw increased transmission of the poliovirus across all provinces with a total of 147 wild cases reported.
The COVID-19 pandemic has added an additional hurdle to defeating polio in Pakistan. It is vital that the programme makes up for lost time as soon as it is safe to conduct house-to-house vaccination activities again. Whilst the pandemic is ongoing, the programme continues to build trust with communities by providing information about COVID-19 as well as the poliovirus. Where routine immunization continues in health centres, polio personnel are emphasizing the importance of maintaining children’s vaccination schedules as far as possible.
In a time when our health feels especially precious, Ihsanullah, Safia and Masood’s story serves to remind us why vaccination is so important.