On both sides of the historical 2640-kilometre-long border between Pakistan and Afghanistan, communities maintain close familial ties with each other. The constant year-round cross border movement makes for easy wild poliovirus transmission in the common epidemiological block.
As a new tactic in their joint efforts to defeat poliovirus circulation, Afghanistan and Pakistan have introduced all-age polio vaccination for travellers crossing the international borders in efforts to increase general population immunity against polio and to help stop the cross-border transmission of poliovirus. The official inauguration of the all-age vaccination effort took place on 25 March 2019 at the border crossings in Friendship Gate (Chaman-Spin Boldak) in the south, and in Torkham in the north.
Although polio mainly affects children under the age of five, it can also paralyze older children and adults, especially in settings where most people are not well-immunized. Adults may play a role in poliovirus transmission, so ensuring that they have sufficient immunity is critical to simultaneously eliminating poliovirus from the highest risk areas on both sides of the Pakistan-Afghanistan border.
This is particularly important at the two main border crossing points – Friendship Gate and Torkham – given the extensive amount of daily movement. It is estimated that the Friendship Gate border alone receives a daily foot traffic of 30 000. Travellers include women and men of all ages, from children to the elderly.
Pakistan and Afghanistan first increased the age for polio vaccination at the border in January 2016, from children under five years to those up to 10 years old. The decision was in line with the recommendations of the Emergency Committee under the International Health Regulations (IHR) which declared the global spread of polio a “public health emergency of international concern”,
The all-age vaccination against polio at the border crossings serves a practical implementation of another recommendation of the IHR Committee: that Pakistan and Afghanistan should “further intensify crossborder efforts by significantly improving coordination at the national, regional and local levels to substantially increase vaccination coverage of travelers crossing the border and of high risk crossborder populations.”
As part of the newly introduced all-age vaccination, all people above 10 years of age who are given OPV at the border are issued a special card as proof of vaccination. The card remains valid for one year and exempts regular crossers from receiving the vaccination again. Children under 10 years of age will be vaccinated each time they cross the border.
Before all-age vaccination began at Friendship Gate and Torkham, public officials held extensive communication outreach both sides of the border to publicize the expansion of vaccination activities from children under 10 to all ages. Radio messages were played in regional languages, and community engagement sessions sensitized people who regularly travel across the border. Banners and posters were displayed at prominent locations.
Deputy Commissioner for Khyber District in Khyber Pakhtunkhwa province, Mr Mehmood Aslam Wazir, inaugurated the launch of All-Age Vaccination by vaccinating elderly persons at the Torkham border crossing. “Vaccination builds immunity and it is necessary for children to be vaccinated in every anti-polio campaign. The polio virus is in circulation and could be a threat to any child. The elders in our community could be carrier of the virus and take along the virus from one place to another, therefore, vaccination of every traveller, of all ages and genders, crossing Pakistan-Afghanistan border will be the key determinant to interrupt polio virus transmission in the region, and the world.”
The introduction of the all-age vaccination at border crossings is the latest example of cross-border cooperation between Pakistan and Afghanistan. The two countries continue to work closely together to ensure synchronization of strategies, tools and activities on both sides of the border.
In February:
1 case of wild poliovirus was reported in February 2019.
5.8 million children under the age of five were targeted during the February Supplementary Immunization Activities (SNIDs).
546 Permanent Transit Teams (PTTs) were operational across Afghanistan in February 2019.
In a control room at the World Health Organization (WHO) Regional Office for Africa in Brazzaville, the smart screen projects the South Sudan map with a scattering of red dots—and even more popping up every now and then. These red dots are geo-coded locations for every healthcare facility being visited by surveillance officers to document active case search in real-time as it happens.
By simply using an application on their smart phones, the surveillance officers send their reports, even without internet connection, to the centrally generated map. Here in the control room, public health experts can quickly analyze data, visualize surveillance gaps, and conduct active case searches for priority diseases and routine immunization assessments at health facility levels. This is a game changer.
“Since the advent of the mobile-based surveillance, it has made it possible to prioritize areas and the required interventions for immunization and surveillance,”, says Dr Atem Anyuon, Director General of the Primary Health Care Ministry of Health South Sudan. He also said that other stakeholders that support the EPI programme would have access and utilization of the mobile technology.
Bridging surveillance gaps through touch screens
Data collected by health workers and community informants from the field is aggregated on database servers, and then displayed on touch interactive screens. With just a touch, maps can be viewed, and charts and dashboards of data streaming in from the field can also be monitored.
Explaining the innovation, WHO Representative, Dr Olushayo Olu says, “Interacting with real-time data through the smart visualization screens helped us recognize gaps in surveillance and intuitively navigate the interactive maps of South Sudan”. Dr. Olu is optimistic that the platform will help inform actions to improve and support surveillance and other primary health services in the country.
Progress towards certification standard documentation
In South Sudan, the technology has made clear where there are gaps in surveillance of Acute Flaccid Paralysis (AFP) – a symptom of polio – in hinterlands without internet. It also makes it easier and more transparent for staff to report what they are doing. . One of the achievements for South Sudan has been the active identification of over 6,000 cases of priority diseases across all the counties, with 85% of the AFP cases validated through geo-coordinates.
Cutting cost of active surveillance
“For me, my enthusiasm about innovating on this has been the fact that we can collect data with geographic information in places that do not have any form of network coverage and it sends the information whenever the health worker gets an internet source”, Mr Godwin Akpan, Data Management Officer of the Regional Office for Africa says.
Akpan stresses that “There are the exciting possibilities of country teams having the freedom to slice and dice the data with various analytics on the smart screen; appropriate technology hitherto used for weather analyses by mega news conglomerates is being harnessed and is now available for use by countries in the African region – a first of its kind built around open source technologies at no recurrent cost except for the hardware.”
With the interactive smart screens, the Ministry of Health and WHO can now interactively analyze data from AVADAR (Auto visual AFP detection and Reporting), Esurv (electronic Surveillance), Immunization Campaign Monitoring, Mortality monitoring as well as the ‘Lots Quality Assurance’ survey.
The initiative is facilitated by the WHO Regional Office for Africa, with support from the Bill & Melinda Gates Foundation.
In February:
2 new cases of wild poliovirus cases were reported
1.5 million children were vaccinated in February 2019 at 355 Permanent Transit Points (PTPs) set up across the country
13.4 million children were vaccinated with oral polio vaccine
Thanks to the unbending resolve and resilience of women health professionals as they go door-to-door across villages and mountains administering vaccine in some of the most marginalized or remote communities, women are truly the backbone of the polio programme at the ground-level. We asked a few of these women about their most daunting and heartening moments in polio, and how they worked through them.
Julia Kimutai—Community Strategy Coordinator Nairobi, Kenya
For Julia Kimutai, a 38-year-old community strategy coordinator in Kenya, educating the public about the importance of vaccines is a constant project. As a specialist in dense urban areas with high rise buildings, Julia knocks on a lot of doors and is often greeted with refusals.
“To convince some mothers is not easy,” she says. “It has never been a smooth ride.”
But where some might just see a campaign-time encounter with skeptical parents as a one-off, Julia sees a long-term project.
“Where we have difficulties is where we double down our efforts to build relationships. We even go back when there is no polio campaign to try to talk with parents, emphasize why vaccination is important and try to do a lot of health education,” she says.
As a woman and as a mother, Julia believes she is uniquely qualified as she can relate, understand and convey the importance of polio vaccines to the numerous apprehensive mothers she meets daily.
“I am a good listener, a good communicator and patient. These tools help me daily as Polio Eradicator and a mother.”
A district polio officer with over two decades of experience in Banadir, Somalia, for Asha Abdi Dini, refusals are always heartbreaking. “My worst moment was seeing a family who had three girls and a son. They vaccinated their daughters but refused to allow the boy to take the vaccine. The boy got the polio and the girls survived.”
But Asha takes pride in the challenges she has been able to overcome since joining the polio programme.
“My best moment is seeing the same children I once vaccinated all grown up and bring their own children for vaccinations. It gives me immense hope and happiness,” she says.
Bibi Sharifa—Health Communication Support Officer, Islamabad, Pakistan
A continent away, for 39-year-old Islamabad district health communication support officer, Bibi Sharifa, a big part of the job is demonstrating how women can do difficult work and stand firm in the face of adversity.
“People often think that women are incapable, but they really couldn’t be more wrong. The women on our programme are extraordinary – they are strong, gentle, dedicated, humble, passionate, disciplined and fierce at the same time,” she says. “They are driven by the love of their children and their community, and despite the challenges they face, people should realize that women are like grass, not like trees: where trees can be uprooted by floods, grass can face the brunt of flood easily.”
In close collaboration with the Bill & Melinda Gates Foundation, WHO’s Regional Office for Africa is continuing to roll-out an innovative disease surveillance platform, enabling the real-time detection of suspected polio cases anywhere on the continent.
Thousands of health workers, volunteers and members of local communities across the continent have been equipped with geo-coded mobile phone technology, and trained to conduct regular and active surveillance visits to health centres across Africa. Professionals and volunteers are tasked to regularly visit local health clinics and actively check for the presence of any child with polio-like symptoms (known as acute flaccid paralysis – AFP), or to look for children in their communities presenting such symptoms. This information is subsequently fed back in real-time to national and regional authorities, enabling for rapid action and immediate dispatch of an investigative team as needed.
“This really is the future of disease surveillance,” comments Reuben Opara Ngofa of WHO’s African Regional Office in Brazzaville, who was instrumental in developing this innovative system and who recently returned from Burkina Faso where he helped roll out the system in remote areas. “Particularly in remote or hard-to-reach areas, we need to know immediately if we have polio circulating in the area, and this system allows for real-time information, which in turn allows for an immediate real-time response. If one of our informants identifies a child with polio-like symptoms anywhere, we will know about it immediately. We are really giving the poliovirus nowhere to run.”
In addition to polio, this system helps detect and respond to other vaccine-preventable diseases, such as measles, yellow fever and neonatal tetanus. Across west Africa, measles vaccination coverage is being assessed through this system, and a cholera outbreak in 2018 in Ethiopia was actively tracked. It is a clear example of the polio infrastructure adding value over and beyond merely eradicating polio.
Thanks to such innovations, and efforts of dedicated professionals and volunteers across Africa, the continent stands on the brink of a historic public health success: the certification of wild poliovirus eradication. In 1996, when Nelson Mandela launched the Kick Polio Out of Africa campaign, wild poliovirus paralysed more than 75,000 children every year, across every African country.
No wild poliovirus has now been detected since 2016, and this real-time GIS surveillance system will provide crucial additional surveillance data, to truly validate the absence of wild poliovirus. Data generated through this system will be critically evaluated by the independent African Regional Certification Committee on polio eradication, when evaluating whether the Region as a whole can be certified as free of wild poliovirus in early 2020.
Like many Pakistani women, Hafiza and Sahiqa start their days in the early morning, when other household members are still asleep. They tackle their domestic chores before beginning their official duties – as polio frontline workers.
“I get up by 5:00 am, if I am to prepare properly for a productive day. I need to manage my home chores before I can set out for my official work. I have to prepare breakfast, lunch, lunch boxes for my children and do the dishes. After that I clean the house and then I have to prepare my kids for school. After sending them to school, I leave for the office around 7:30 am,” Sahiqa explained.
Sahiqa (29) is from Quetta in Balochistan province and Hafiza (22) is from Islamabad. In their careers as Pakistan’s cadre of Lady Health Workers, they deliver house-to-house preventative and curative care to underserved communities, in particular women and children in urban and rural slum areas Locally recruited and community-based, these female health workers are also central to progress against polio in Pakistan’s complex environment.
Across Pakistan, thousands of women do the vital work of immunization in an environment that can be harsh, distressing and even dangerous. They balance this work with the demands of their own children and families, and they put their own needs last.
The women’s official workday starts at 8:00 am and is marked by interactions with the community every day. As part of their work, Lady Health Workers educate women about the benefits of exclusive breastfeeding, on better hygiene practices, supporting the advancement of women and children’s health and wellbeing. They knock on every door of their assigned areas to vaccinate children against polio during frequent immunization campaigns.
In Pakistan, women currently make up more than 56% of more than 260 000 frontline polio workers. Having women on the frontlines has been a game changer for polio eradication in Pakistan, given the trusted roles they have in communities and the fact that they are more likely to be allowed to take the crucial step across the thresholds of people’s homes and ensure access for all children to vaccines. Female polio frontline workers including vaccinators, campaign coordinators, supervisors and social mobilizers often work in extremely challenging circumstances to ensure children are protected against polio.
“I remember one chronic refusal family. It was such a difficult task to convince the women of the house to vaccinate their children. We engaged in many discussions and I explained to them that if the polio drops were not beneficial, would I give them to my own kids?
After a lot of convincing, I was able to persuade the women. I was so happy to have managed to convert a chronic refusal case and protect the kids in that house against polio,” Sahiqa said.
Despite multiple challenges, especially working in a conservative province like Balochistan, the health workers remain steadfast and intensely committed when it comes to achieving their goals. They have become creative problem solvers who are motivated by every refusal they convert. The challenges act as fuel and have helped them develop the skills they need to navigate the complexities of the job in this cultural context.
“While performing my job, remaining calm and controlling my emotions are the most difficult skills that I have drawn from these challenges. During this job, I learnt a lot how to avoid taking things personally as this helped me focus on the real objective. With the passage of time, I have realized the importance of maintaining firm boundaries in order to facilitate respectful communication with people,” said Hafiza.
There are different reasons why women in Pakistan make the choice to become polio frontline workers. Some have to support their families and some have to earn money for their studies. Many women take this job because it is the best opportunity to move ahead in life. The defining characteristic of most female polio frontline workers is a passion to serve humanity.
“I feel lucky to have my husband beside me, supporting me in every endeavour. He is also a polio worker and he feels that women have better access to the homes in the communities and can relate to the mothers therefore they have a definite advantage in gaining the trust of the homemakers in the community,” Sahiqa said.
The day is over, but their work is not
The women’s official duty ends with the setting sun, but at home domestic responsibilities await. They have to prepare dinner for the family and then help children complete homework. The idea of eight hours of uninterrupted sleep is a dream for them, but they sleep with the knowledge that they are doing important work, and doing it well.
Hafiza and Sahiqa are individual women, but they are also a reflection of every female worker who is part of the fight against polio. The polio eradication programme would not be where it is today without the contributions of hardworking women dedicated to ending polio.
Polio eradication efforts are as much rooted in the social realities as they are in the technological tools. The success of the Global Polio Eradication Initiative comes down to one simple action: the knock on the door, when the child’s caregiver greets the health worker.
Why do caregivers let vaccinators enter their homes? The caregiver’s decision to vaccinate is influenced by many moving parts: social, cultural, economic, and religious. Women health workers and leaders are able to transcend many of these boundaries as they are not only health workers; they are members of that community – someone’s neighbour, friend, aunt, cousin or grandmother.
Polio-endemic, at-risk, and outbreak countries regularly engage women as health officials in immunization activities, constituting about 68% of the frontline workforce. In Nigeria, 99% of frontline workers are women, followed by 56% in Pakistan and 34% in Afghanistan. But their strength in numbers is not the only reason why women are crucial to polio eradication efforts, they are, in fact, behavioural change agents.
Here’s a look at some of the resilient and inspiring women working to eradicate polio in their communities – in their own words:
If you ask the women who work in Somalia’s polio programme why they do what they do, most will tell you they do this to help Somali children, to build a stronger future for Somalia, and to support their own families. Somalia is a complex country with many cultural and institutional challenges for women who work outside the home. Perhaps, as a result, there is a sense of solidarity among the women to pull each other up and work together in the fight against polio.
From the senior member of the polio programme to the district-level polio officer (who chooses to remain anonymous for her own security), and for so many women in between, being part of the polio programme is not just a job, but a way to work together and support each other.
Dr Rehab Kambo—International Focal Point and Head of the Polio Programme, The World Health Organization, Garowe, Somalia
Dr Rehab Kambo wears two hats at The World Health Organization (WHO): International Focal Point and Head of the Polio Programme in the satellite office at Garowe, Puntland state of Somalia. After joining the polio programme, Dr Rehab set out to understand the context she was working in and one of the things she learned was about the strength of Somali women.
“It is easy not to notice that Somali women are stronger than men in their society, until you spend time with them,” she said.
For Dr Rehab, this realization was driven home on an early assignment. She and a colleague were conducting a surveillance review in a region known as Mudug. Dr Rehab had traveled to Galkacyo by road for eight hours during an active clan conflict, which was no easy feat. Movement was challenging, and the women had to travel with armed escorts. But they were determined, Dr Rehab explains, and they were on a mission.
The two visited transit points at the airport and health facilities to meet with Village Polio Volunteers, who serve the polio eradication initiative at the district level. Upon completing the mission, she and her colleague were elated. Dr Rehab looks back on this as one of the most satisfying – albeit stressful – experiences of her life as a polio eradicator.
Since then, Dr Rehab has taken on the challenge of two roles in one of the most operationally demanding regions in the world. For Dr Rehab inspiration comes easily from the women around her.
“In many instances, they are powerful, independent, and are decision-makers in their families,” said Dr Rehab of the Somali women. Even as a relatively privileged, educated woman, Dr Rehab admits there is a lesson in here for her, and for other women like her.
“Women are so strong, honestly. They can adapt to any role for the good of others,” she said.
Mira A—District Polio Officer, Somalia
Life in Somalia has been extraordinarily difficult since war broke out in 1991, and there is no doubt that it has been harder for women than for men. With an average fertility rate of 6.6 per woman, and high death rates in mothers – one out of every 12 women dies due to pregnancy complications – women are in need of timely and quality health services. A lack of education compounds the problem.
“Despite the challenges, women in Somalia have resiliently stood up to the task and engaged in small-scale businesses over the years to earn a living for their families,” said Mira A, a District Polio Officer in Somalia (we are not using her real name for security reasons).
For Mira A and women like her, taking work outside the home is a way to support not just their families, but themselves – and each other.
“Many women have no time to continue their education or look for other jobs, as they are so busy trying to earn money with their existing means,” she said.
When Mira A looks at the women around her, she sees that education is only part of the answer.
“There is a small sector of women who have managed to earn formal education, but even they do not earn money in most cases. They stay at home and look after their homes and children. Even they need to be empowered, even if it is just to help other women.”
Dr Ujala Nayyar dreams, both figuratively and literally, about a world that is free from polio. Nayyar, the World Health Organization’s surveillance officer in Pakistan’s Punjab province, says she often imagines the outcome of her work in her sleep.
In her waking life, she leads a team of health workers who crisscross Punjab to hunt down every potential incidence of poliovirus, testing sewage and investigating any reports of paralysis that might be polio. Pakistan is one of just two countries that continue to report cases of polio caused by the wild virus. In addition to the challenges of polio surveillance, Nayyar faces substantial gender-related barriers that can hinder her team’s ability to count cases and take environmental samples. From households to security checkpoints, she encounters resistance from men. But her tactic is to push past the barriers with a balance of sensitivity and assertiveness.
“I’m not very polite,” Nayyar says with a chuckle. “We don’t have time to be stopped. Ending polio is urgent and time-sensitive.”
Women are critical in the fight against polio, Nayyar says. About 56% of frontline workers in Pakistan are women. More than 70% of mothers in Pakistan prefer to have women vaccinate their children.
That hasn’t stopped families from slamming doors in health workers’ faces, though. When polio is detected in a community, teams have to make repeated visits to each home to ensure that every child is protected by the vaccine. Multiple vaccinations add to the skepticism and anger that some parents express. It’s an attitude that Nayyar and other health workers deal with daily.
“You can’t react negatively in those situations. It’s important to listen. Our female workers are the best at that,” says Nayyar.
With polio on the verge of eradication, surveillance activities, which, Nayyar calls the “back of polio eradication”, have never been more important.
Q: What exactly does polio surveillance involve?
A: There are two types of surveillance systems. One is surveillance of cases of acute flaccid paralysis (AFP), and the second is environmental surveillance. The surveillance process continues after eradication.
Q: How are you made aware of potential polio cases?
A: There’s a network of reporting sites. They include all the medical facilities, the government, and the hospitals, plus informal health care providers and community leaders. The level of awareness is so high, and our community education has worked so well, that sometimes the parents call us directly.
Q: What happens if evidence of poliovirus is found?
A: In response to cases in humans as well as viruses detected in the environment, we implement three rounds of supplementary immunization campaigns. The scope of our response depends on the epidemiology and our risk assessment.
We look at the drainage systems. Some systems are filtered, but there are also areas that have open drains. We have maps of the sewer systems. We either cover the specific drainage areas or we do an expanded response in a larger area.
Q: What are the special challenges in Pakistan?
A: We have mobile populations that are at high risk, and we have special health camps for these populations. Routine vaccination is every child’s right, but because of poverty and lack of education, many of these people are not accessing these services.
Q: How do you convince people who are skeptical about the polio vaccine?
A: We have community mobilizers who tell people about the benefits of the vaccine. We have made it this far in the program only because of these frontline workers. One issue we are facing right now is that people are tired of vaccination. If a positive environmental sample has been found in the vicinity, then we have to go back three times within a very short time period. Every month you go to their doorstep, you knock on the door. There are times when people throw garbage. It has happened to me. But we do not react. We have to tolerate their anger; we have to listen.
Q: What role does Rotary play in what you do?
A: Whenever I need anything, I call on Rotary. Umbrellas for the teams? Call Rotary. Train tickets? Call Rotary. It’s the longest-running eradication program in the history of public health, but still the support of Rotary is there.
In January:
4 new cases of wild poliovirus cases were reported in January 2019.
1.5 million children were vaccinated in January 2019 at 353 Permanent Transit Points (PTPs) set up across the country.
39.4 million children were vaccinated during January National Immunization Campaign (NIDs).
In January
1 case of wild poliovirus was reported in January 2019.
5.6 million children under the age of five were targeted during the January Supplementary Immunization Activities (SNIDs).
524 Permanent Transit Teams (PTTs) were operational across Afghanistan in January 2019.
Pakistan’s polio programme relies on the efforts of thousands of specialized workers, but there is one group almost everyone relies on: the drivers.
In the endgame of eradication, reaching zero transmission requires a vast network of expertise— from epidemiologists to community advocates to data managers and health workers. But without drivers, many of these people would not be able to do their work.
Polio eradication entails wide-ranging nationwide vaccination campaigns. In Pakistan, this means targeting more than 38 million children under the age of five. Reaching every single child without an organized fleet of vehicles is almost impossible. Polio programme drivers do not plan activities in operations centres, but they have a real on-ground impact in the fight against polio.
“ I think whether you are a polio eradication officer, data personnel, technical staff, a consultant, a member of the communication team or a driver, every single employee is playing a very significant role in polio eradication efforts.”
“It doesn’t matter whether you’rein the driver’s seat or the passenger seat, driving is an unavoidable and essential part of the polio programme, especially here in Pakistan, where the push for eradication is at such a sensitive and critical point. I have spent the last 20 years as a driver with WHO’s polio programme, always with the same focus: saving Pakistani children from this disease and securing a better future for them.”
“For poliofield officers, duty starts around 8 am, but the driver’s duty starts early in the morning whether they are traveling directly to field or to the office. I personally feel that when I am in the field, I am responsible for the safety of my assigned vehicle as well as that of the officer.”
“I joined in 2002 and since then I have learned, I am working for the welfare of future generations.At work, I apply the “safety first” approach to every part of my job. I think, I am not only driving but I also act as a guide and security guard for my field officer. Because I drive with different field officers at different places, before the commencement of field work I orient my officer about the social norms, customs and security situation of the area. I also advise them to remain close to the vehicle. It is very essential to remain close to the vehicle for a possible quick escape in case of some emergency situation.
“The thing I enjoy as a driver with the polio programmeis the satisfaction of my passenger: the field officer. When my field officer is satisfied, I am satisfied, and for this I have worked to enhance my skills.”
“For the last 16 years, I have played a significant role in polio eradication in Pakistan. My level of responsibility as a driver is very high. Polio eradication is a programme that requires strong teamwork. While performing my duty with different field officers, I assist them in finding local vaccination teams and convincing the community of the importance of vaccination, and I clear any hurdles so they can do their jobs during case investigation, campaign monitoring and LQAS.
“When my officer covers refusals during campaign monitoring, it gives me the most satisfaction as I feel that we have saved a child from permanent disability. When there is some refusal I actively assist my officer to counter that refusal. I also advocate within my localcommunity and try to satisfy them about the efficacy of the vaccine.”
“I have been a driver for the polio programmefor the last 14 years. I think whether you are a polio eradication officer, data personnel, technical staff, a consultant, a member of the communication team or a driver, every single employee is playing a very significant role in polio eradication efforts.
“I have a strong wish to see Pakistan polio free. Although I am not directly involved in eradication activities, indirectly I am contributing tobetter implementation and successof routine immunization efforts by safely transporting field officers to their assigned duty areas. I am proud that I am a part of hardworking team who are trying to defeat the polio virus.”
In December
4 new cases of wild poliovirus cases were reported.
1.6 million children were vaccinated in December 2018 at 381 Permanent Transit Points (PTPs) set up across the country.
39.8 million children were vaccinated during December National Immunization Campaign (NIDs) from 10-13 December.
In December
0 cases of wild poliovirus were reported.
3.2 million children under the age of five were targeted during the December Supplementary Immunization Activities (SNIDs).
429 Permanent Transit Teams (PTTs) were operational across Afghanistan in December 2018.
The Endgame Plan through 2018 brought the world another year closer to being polio-free. While we had hoped to be finished by now, 2018 set the tone for the new strategic plan, building on the lessons learned and mapping out a certification strategy by 2023. 2018 was also marked by expanded efforts to reach children with vaccines, the launch of innovative tools and strategies, critical policy decisions and renewed donor commitment to the fight.
Circulation of wild poliovirus (WPV) continues in the common epidemiological block in Afghanistan and Pakistan. However, both countries steadily worked to improve the quality of their vaccination campaigns in 2018 through National Emergency Action Plans, with a particular focus on closing any immunity gaps to put the countries on track to successfully stop WPV in the near future. Given the priority on polio eradication, WHO Director General, WHO Regional Director for the Eastern Mediterranean and President, Global Development at Bill & Melinda Gates Foundation started off the new year with a four-day visit to meet the heads of state and have a first-hand experience of the on-the-ground eradication efforts in both the countries.
In August, Nigeria marked two years since detecting any WPV. With continuing improvements in access to the country’s northeast, as well as efforts to strengthen surveillance and routine immunization, the entire African region may be eligible for being certified WPV-free as early as late this year or early 2020. What’s more, the world has not detected type 3 WPV since 2012 and the strain could be certified eradicated sometime this year.
Program innovation
The programme is constantly developing new ways to more effectively track the virus, vaccinate more children and harness new tools to help end the disease for good.
In Nigeria and the surrounding region, health workers launched new tools to enable faster, more comprehensive disease surveillance. e-Surve, a smartphone app, guides officers through conversations with local health officials, offering prompts on how to identify and report suspected cases of disease. Then, with the touch of a button, responses are submitted to a central database where health officials can analyze and track outbreaks across multiple districts in real-time.
Beyond surveillance, health workers worked tirelessly to bring the polio vaccine to the remote communities of Lake Chad. Dotted with hundreds of small islands, the lake is one of the most challenging places on earth to deliver health services. Vaccinators must travel by boat on multi-day trips to deliver polio vaccines to isolated island villages, using solar-powered refrigerators to keep their precious cargo cool. In 2018, vaccination campaigns on the lake reached thousands of children for the first time – children who would otherwise have gone unprotected.
The programme also took important steps in developing new tools including, novel oral polio vaccine (nOPV), if studies show to be successful, could provide a safer form of OPV that provides the same level of protection without the small risk of vaccine-derived polio in under-immunized populations.
Battling circulating vaccine-derived poliovirus
In 2018, the Democratic Republic of the Congo, Niger, Nigeria, Papua New Guinea, Kenya, Somalia and Mozambique experienced outbreaks of circulating vaccine-derived polio (cVDPV). Although these cases are still rare – and only happen in places where immunity is low. The polio eradication initiative has two urgent tasks: eradicate WPV quickly as possible and stop the use of OPV globally, which in tandem will prevent new cVDPV strains from cropping up.
The program uses the same proven strategies for stopping wild polio in responding to cVDPV cases. These strategies, coupled with the rapid mobilization of resources on the ground, can bring outbreaks under control.
In December, an international group of public health experts determined that the 2017 cVDPV2 outbreak in Syria has been successfully stopped. This news follows 18 months of intensive vaccination and surveillance efforts led by the GPEI and local partners in conflict-affected, previously inaccessible areas. In Papua New Guinea, the programme carried out 100 days of emergency response this past summer and is continuing to vaccinate and expand surveillance across the country.
Bringing an end to ongoing cVDPV outbreaks remains an urgent priority for the program in 2019.
New policy decisions
At the World Health Assembly in May, Member States adopted a landmark resolution on poliovirus containment to help accelerate progress in this field and ensure that poliovirus materials are appropriately contained under strict biosafety and biosecurity handling and storage conditions. The programme also finalized a comprehensive Post-Certification Strategy that specifies the global, technical standards for containment, vaccination and surveillance activities that will be essential to maintaining a polio-free world in the decade following certification.
Recognizing the ongoing challenge posed by cVDPVs, the Global Commission for the Certification of Poliomyelitis Eradication (GCC) met in November and recommended an updated process for declaring the world polio-free. This plan will start with the certification of WPV3 eradication, followed by WPV1, and include a separate independent process to validate the absence of vaccine-derived polio.
Comprised of members, advisers, and invited Member States, the 19th IHR Emergency Committee met in November. The Committee unanimously agreed that poliovirus continues to be a global emergency and complacency at this stage could become the biggest hindrance. “We have the tools, we need to focus on what works, we need to get to every child,” commented Prof. Helen Rees, Chairperson of the Committee. “The reality is that there is no reason why we should not be able to finish this job, but we have to keep at it.” “We have achieved eradication of a disease once before, with smallpox,” Rees concluded. “The world is a much better place without smallpox. It’s now more urgent than ever that we redouble our efforts and finish this job once and for all as well.”
In 2018, the GPEI took major steps in adopting a more gender-responsive approach and strengthening gender mainstreaming across its interventions. The GPEI Gender Technical Brief highlighted the programme’s commitment to gender equality and included a thorough analysis of various gender-related barriers to immunization, surveillance and communication.
The programme introduced new gender-sensitive indicators to ensure that girls and boys are equally reached with polio vaccines, to track the timeliness of disease surveillance for girls and boys, and to monitor the rate of women’s participation as frontline workers in the endemic countries. The GPEI continues to regularly collect and analyze sex-disaggregated data and conduct gender analysis to further strengthen the reach and effectiveness of vaccination campaigns.
Donor countries made new financial contributions to the programme in 2018. Polio-affected countries also demonstrated continued political commitment to eradication efforts. The Democratic Republic of the Congo signed the Kinshasa Declaration committing to improve vaccination coverage rates in sixteen provinces throughout the country, and Nigeria approved a $150 million loan from the World Bank to scale up immunization services and end polio.
Looking ahead: 2019 and beyond
Over the last five years, the programme has been guided by the 2013-2018 Polio Eradication & Endgame Strategic Plan, helping to bring the world to the brink of polio eradication. This spring, the programme will finalize a new strategy –GPEI Strategic Plan 2019-2023– which will aim to sharpen the tools and tactics that led to this incredible progress. In 2019, the GPEI will also launch its first-ever Gender Strategy to further guide its gender-responsive programming and to increase women’s meaningful and equal participation at all levels of the programme.
Success in the coming years will hinge on harnessing renewed financial and political support to fully implement the plan at all levels, with our one clear goal in sight: reach every last child with the polio vaccine to end this disease once and for all. Echoing similar sentiments, Chairs of the effort’s main advisory bodies issued an extraordinary joint statement, urging all to step up their performance to end polio. 2019 may very well be the watershed year that the world will finally eradicate polio, thanks to the global expertise and experience over 3 decades.
A new circulating vaccine-derived poliovirus type 2 (cVDPV2) outbreak has been confirmed in Mozambique. Two genetically-linked circulating vaccine-derived poliovirus type 2 (cVDPV2) isolates were detected from an acute flaccid paralysis (AFP) case (with an onset of paralysis on 21 October 2018, in a six-year old girl with no history of vaccination, from Molumbo district, Zambézia province), and a community contact of the case.
As polio is a highly infectious disease which transmits rapidly, there is potential for the outbreak to spread to other children across the country, or even into neighbouring countries, unless swift action is taken. Global Polio Eradication Initiative and partners are working with country counterparts to support the local public health authorities in conducting a field investigation (clinical, epidemiological and immunological) and thorough risk assessment to discuss planning and implementation of immunization and outbreak response.
In January 2017, a single VDPV2 virus had been isolated from a 5-year old boy with AFP, also from Zambézia province. Outbreak response was conducted in the first half of 2017 with monovalent oral polio vaccine type 2 (mOPV2).
Read our Mozambique country page to see information on cases, surveillance and response to the developing outbreak.
In November:
There were no wild poliovirus cases reported.
1.6 million children were vaccinated in October 2018 at 390 Permanent Transit Points (PTPs).
21.9 million children were vaccinated in 94 districts of the country during November SNID campaign from 12-15 November.
Since polio was confirmed in Somalia in late 2017, health authorities have led a complex response to twin outbreaks of circulating vaccine-derived poliovirus type 2 and type 3 (cVDPV2 and cVDPV3), paying special attention to high-risk populations: nomads, internally displaced people (IDPs), and people living in peri-urban slums and rural areas.
So far, five of Somalia’s 12 infected children are from nomadic communities, and another four are from internally displaced families living in urban areas. To boost immunization among eligible children in these populations, vaccination activities have placed a special focus on reaching these communities.
Somalia has a rich culture of people leading pastoral lifestyles, raising livestock and moving with them as the seasons and the weather change. Nomadism has a long history in Somalia and nomads have a special place in Somali society: almost a third of Somalia’s people are nomads. However, they do not observe formal international borders – just like the poliovirus. For health workers, this context poses a significant challenge: How can you be sure you have vaccinated every last child when so many children are on the move?
For health workers, this means searching for polio symptoms in more than 900 health facilities across the country, as well as nutritional centres, camps for IDPs, and key sites along Somalia’s borders. At transit points, along borders and at water collection points, polio teams work to vaccinate children moving in and out of areas experiencing conflict or with limited access to health services. In high-risk areas, the Somali Government, WHO and UNICEF hire local vaccinators – people known and trusted by their communities – and when additional security is necessary, polio partners provide it.
Gaining high-level political goodwill
Even in an emergency, cross-border collaboration is not always easy to come by. In the Horn of Africa outbreak, regional collaboration moved into high gear in September, when health ministers from across the region and representatives from the Intergovernmental Authority on Development (IGAD) countries came together in the Kenyan town of Garissa to reiterate their commitment to ending polio.
One of the event’s key messages was around the risks posed by the easy and frequent mobility of communities across borders. Kenya’s national polio immunization ambassador, former UN Person of the Year and polio survivor, Harold Kipchumba, spoke directly to the pastoral communities in the region.
Kipchumba highlighted their focus on vaccinating animals, and urged parents in these communities to use the same vigour to vaccinate their children against polio, so they are able to serve as future herders for their families.
A regional response to support high-risk populations
The Technical Advisory Group, an independent body of experts that monitors outbreaks and offers guidance, recommended that countries in the region strengthen their coordination. In response, the Horn of Africa Coordination Unit coordinates joint responses among HoA countries – work that includes monitoring current outbreaks, and collaboratively planning, mapping, conducting immunization campaigns and communicating with various audiences. This ensures that countries work together in partnership rather than in silos, viewing the outbreak as one epidemiological block.
At regional and district levels, teams have spent the last few months building records of every settlement in their area, by lifestyle (nomad, IDP, peri-urban slums, rural). The highest priority: locating special populations – internally displaced persons, refugees, nomadic families, people living in informal settlements in urban areas and communities living in access-compromised areas – in order to reach them with vital polio vaccine.
A vital step in reaching more children, particularly those on the move, has been to move away from paper records and use electronic tools to collect data on children reached and missed during campaigns. This gives data specialists and decision-makers timely, accurate information, allowing them to analyze data in real time and flag areas with where high numbers of children are missed, so teams can revisit these households the following day.
Getting vaccines to the doorstep is not the only challenge for polio eradication teams in Somalia. Parents and caregivers also need information to ensure their children are vaccinated – something Kipchumba spoke to. On rare occasions, vaccinators meet families unconvinced of the need for vaccinations, particularly when the family has a newborn child or a sick child. In the lead up to every campaign, teams of social mobilizers, sometimes joined by influential Islamic leaders or scholars, visit communities to alert them of dates of polio immunization campaigns and the benefits of vaccination. Here, too, special attention is paid to nomadic communities, as polio teams liaise with elders from these communities in order to learn more about these communities and their needs, and to inform community members in appropriate ways about immunization dates and benefits of vaccination.
In the last week of October, Djibouti’s Ministry of Health, working with WHO, UNICEF and other partners, successfully carried out the country’s first polio National Immunization Days (NIDs) since 2015.
While Djibouti has not had a case of polio since 1999, the recent outbreaks of polio in neighbouring countries in the Horn of Africa, and the low levels of routine immunization coverage in some areas in the country, are indications that Djibouti is still at risk if poliovirus spreads through population movements. Other countries in the Horn of Africa are already cooperating to stop the ongoing outbreak and to reduce the risk of spread, and especially considering that Djibouti is on a major migration route in the Horn of Africa, it makes a lot of sense for Djibouti to join in this coordinated response.
For Dr Ahmed Zouiten, the acting WHO Representative (WR) in Djibouti, this context demanded action.
“I prefer to deal with a campaign for prevention than to have to deal with an outbreak of polio,” he said.
With that in mind, an NID planned for 2019 was brought forward and carried out over 23-26 October. The target was 120 000 children under five years of age, a number suggested by Djibouti’s last census, in 2009. Two strategies were proposed: one approach, where children would be vaccinated at fixed points (health facilities) and a complementary door-to-door approach using two-person teams (a vaccinator and a registration person).
In the days and weeks before the NID, all partners, including the government, WHO and UNICEF, used a variety of communication channels – from outdoor signage to radio spots – to ensure that communities were informed not just of the risks of polio, but also of the importance of protecting children from vaccine preventable diseases.
The campaign’s official launch ceremony was held at the Youssouf Abdillahi Iftini Polyclinic in Balbala neighborhood, Djibouti City, in the presence of Djibouti’s Minister of Health, WHO and UNICEF representatives, and other partners. Over the course of the following days, vaccinators surpassed targets, vaccinating all children under five they encountered living on Djibouti territory, regardless of their origin, including nomadic populations, refugees and migrant children.
Although final numbers are still being tabulated through independent monitoring mechanisms, initial results suggest high coverage of the target population. This means vaccinators reached the estimated target number of children, and more, such as newer cohorts of children not accounted for in earlier estimates. Catching these children helps to further inform immunization estimates for any further campaigns.
For Dr Zouiten, a result like this is something to celebrate.
“Today, our children are on their way to being better protected, and we are launching a second campaign in the near future to follow up on that,” he said.
“Before, we had some worries; we thought that the circulation of poliovirus in the region posed a risk. Now with this first vaccination campaign, we know we are on the right path to ensure the children of Djibouti are protected. These results weren’t easy to achieve, but were made possible through collaboration between the Ministry of Health, the partnership between WHO, UNICEF and others.”
Given the high risk of importation of poliovirus, the Government of Djibouti, WHO and UNICEF are not taking any chances: plans are in the works for a second and third NID to roll out in 2019. With an outbreak in the region, it is critical for nearby countries to strengthen their own immunity levels and ensure routine immunization and disease surveillance systems are strong enough to detect any virus circulation. Despite the cost and effort of staging national immunization activities, in this case, all partners agree: an ounce of prevention really is worth a pound of outbreak response.
In the wake of a polio outbreak confirmed on June 26 2018, the Government of Papua New Guinea declared polio a national health emergency. It was imperative that all children under the age of five be vaccinated, even those living in the most inaccessible regions of the country.
As part of the outbreak response, a team from Madang Provincial Health Authority, supported by WHO, travelled for over half a day by road and helicopter to reach the Hagahai people who live in the highlands of Madang province in Papua New Guinea, which is one of the most geographically isolated places in the world.
Ever wondered what it is like to be on the forefront of the fight against polio? Watch and learn how the team made their way to the remote mountain top to deliver vaccines.
Left: Shire gives child two drops of the oral polio vaccine to protect them against lifelong paralysis Right: Shire works with vaccination teams to prepare cold boxes to carry polio vaccines
I have spent nearly my whole career working on eradication programmes – first smallpox, then polio. Eradication has been a rewarding career for me because I am so curious to know what is happening in the world. Every time I see a disease that we have worked so long to stop returning, I become so unhappy and know I need to work to stop it.
I worked for the smallpox eradication programme back in the 1970s. I was an epidemiologist – this means that my job was to track the disease and plan how we could stop it.
We used to hold vaccination campaigns at night because then we knew everyone would be at home, and we wouldn’t risk missing a single person. As our cars pulled up out of the dark, people would peer out of their houses to see what was happening. Somalis are very curious! As we brought them the vaccine, occasionally someone would make trouble, but mostly people were pleased to see us.
Somalia was the last country where smallpox was found in the whole world. When I knew we had really ended it in 1977, I was so happy. My name was printed there on the certification document – it was something to be proud of. We had freed the world from smallpox!
I remember one of my friends calling me in 1997 to tell me we were going to eradicate another disease, and that we had to look out for something called ‘AFP’. I thought to myself, what is this ‘AFP’? I hadn’t heard of it. They explained to me that it means acute flaccid paralysis – and that it was the symptom of a disease called polio.
Then one day in 1999, I received a call asking if I would come and work for the second eradication programme in my single lifetime. They said, “If you are ready, we will make you a coordinator. We don’t know if there is polio in Somalia or not, but we want you to come and see.” I jumped at the chance.
We started to search, looking for AFP cases, to collect stool samples and then to send them to the laboratory for testing. And soon, we had confirmation that polio was in Somalia. As soon as we found cases, lots of people came from inside and outside Somalia to help.
By 2002, we found the last case of indigenous polio, and thought the game was won. I even joked to my friends saying, what will we do now that polio is eradicated? They said to me, no – we still have polio in Nigeria, Egypt, Pakistan, many other countries – another case will come. We have to be prepared to stop it if it comes.
And true enough, we had an outbreak in 2005, and again in 2013. Each time we stopped it. Last year, we found circulating vaccine-derived poliovirus type 2. Vaccine-derived polio causes paralysis just like wild polio, and we must eradicate it too.
We started to organize ourselves and held two vaccination campaigns. But then we found another virus – circulating vaccine-derived poliovirus type 3. So now, we are responding to two outbreaks that need different vaccines at the same time. If we miss cases and miss getting vaccines to all children, we can’t stop polio. It is hard, but we will end these outbreaks just as we ended wild polio before.
Eradicating polio has been very difficult – more difficult than it was to end smallpox. I suffered – me and my wife were even kidnapped once. But I am always motivated to keep going. My motivation was never my salary – to stay alive, I need to work. I must know what is going on in my country, if my people are safe. From morning until night, my job is to make sure activities can go on peacefully. My family are my true reason for committing my life to eradication. I have seven children, and 30 grandchildren; I never once missed getting any of them vaccinated. Never.
I am sure that we will finish this job. When we eradicate polio, I will be so happy – I will have been involved in the certification of the second human disease ever to be eradicated. I feel so lucky to have spent my life working for these two eradication programmes; I am proud to tell stories to my grandchildren of my life’s work.
Eradicating polio won’t take a miracle. It is a job. It needs a lot of hard work to end an outbreak. There is no other way – the only way is to work hard, to find cases, and to respond. We hope that in the coming months we will make it. I do believe we will make it. Inshallah.
In June 2017, some of the first circulating vaccine-derived poliovirus type 2 (VDPV2) cases were reported in Deir Ez-Zor governorate, in eastern Syria, confirming an outbreak of polio. Since then, 74 cases were reported, with the most recent case reported on 21 September 2017.
Despite being a high-risk country with large scale population movements, inadequate health infrastructure, and accessibility issues, the outbreak response was successfully carried out. Health workers reached out to children to raise immunity levels, vaccinate children, and stop the outbreak, regardless of the location or socio-political climate.
An official outbreak response assessment was carried out by experts on global health, virology, and epidemiology, which concluded that the outbreak could now be closed.
“(Disease) Surveillance is stronger today than it was 18 months ago, when the initial cases were detected…so, as we celebrate what is a remarkable achievement in stopping this outbreak, amid very challenging circumstances, we must not lose sight of the risks posed by continued circulation of virus in other parts of our Region,” said Chris Maher, Manager for Polio Eradication in the WHO Eastern Mediterranean Region.
