A frontline worker is vaccinating a child against polio. WHO Afghanistan/R Akbar
In November, polio vaccination teams across Afghanistan targeted 5.3 million children under the age of five in high-risk provinces. The vaccination campaign came on the heels of several newly reported cases. Afghanistan has 19 documented cases of wild poliovirus in 2018, as of November. Confirmation of even one polio case anywhere signals remaining vaccination coverage gaps which must be filled to achieve eradication.
The targeted vaccination campaign took place from 5-9 November, and with support across the board from healthcare workers, communities, religious clerics, and the government. “The Ministry of Public Health and health partners are committed to ending this disease,” said Dr. Ferozuddin Feroz, Minister of Public Health.
Afghanistan is one of the three remaining endemic countries in the world along with Pakistan and Nigeria. The endemic countries are intensifying their efforts by making sure they fully implement the strategies in their national polio emergency action plans.
Read more about the details of Afghanistan’s vaccination campaign here.
Related Resources
A nation-wide immunization campaign helped in eradicating polio in India. WHO/2011
Eradicating polio in India was a feat of dedication, commitment and simply doubling down on immunization activities. Given India’s vast population, tropical climate in many parts of the country, and other environmental challenges, it would be easy to imagine that if polio couldn’t be stopped, India would be the place to fail.
Simply put: it was a challenge. After all, India constituted over 60% of all global polio cases as recently as 2009.
However, in 2014, India was officially declared polio-free, along with the rest of the South-East Asia Region. Thanks to the singular commitment of the Indian Government at all levels, partners of the Global Polio Eradication Initiative, notably WHO, Rotary International and UNICEF, polio was tackled head-on. India has not had a case single case of wild polio virus since 2011.
India had long been considered one of the most difficult geographical locations to eliminate the disease. Success in India really changed the game, and now serves as an example that eradication of polio is indeed possible when the world marshals political will and commits adequate resources to the cause that affects everybody worldwide.
Today, the world is close to making public health history when it comes to polio – as it was when in 1980 small pox was officially eradicated. The goal of reaching a polio-free world is well within reach.
Tune in to listen to the podcast as the UN Dispatch tells the story of how, against all odds, India wiped out polio, and some of the lessons learned along the way.
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In September:
There was one new case of wild poliovirus (WPV1) reported.
39.3 million children were vaccinated during September National Immunization Day (NID) campaign.
1.7 million children were vaccinated in September 2018 at 382 Permanent Transit Points (PTPs) set up across the country and its borders.”
In October
4 new cases of wild poliovirus were reported in October 2018.
26 385 children under the age of five were targeted during the October recovery campaign.
377 Permanent Transit Teams (PTTs) were operational across Afghanistan in October 2018.
Chief Imman of Dutsen wai Sheck Zakaria Mohammed Sani sending message on RI and ANC during Eld-Kabir Prayer. UNICEF Nigeria
Malam Musa Abubakar was an ardent opponent of polio vaccination and other health services, not allowing his children to be immunized or his wives to receive antenatal care or other health services.
“I used to chase off immunization officers whenever they came to my door because I believed there was a hidden agenda behind it, and I was also uncomfortable allowing my wives to go to the hospital,” admitted Abubakar who hails from Zaria in Nigeria’s north-central Kaduna State.
Abubakar’s views changed, however, once Muslim clerics began to explain to the community the importance of allowing women and children to access health services and immunizations, along with the dire consequences of rejecting immunization services.
Delivering life-saving messages
Malam Ibrahim _Kaduan south RFP vaccinating a Child of NC house holdm at T-wada, Kaduna South LGA. UNICEF Nigeria
Religious, socio-cultural, and safety concerns are among the main barriers to polio vaccination and other health services in most of northern Nigeria.
United Nations Children’s Fund (UNICEF) has engaged 228 religious leaders in 11 northern Nigerian states, particularly in Muslim communities, to mobilize caregivers against social norms that prevent families from vaccinating their children. Muslim and Christian clerics deliver life-saving messages during sermons and other religious gatherings to dispel negative attitudes toward vaccinations and other health services.
Collaboration with religious leaders has not only supported polio eradication efforts but has also brought about further benefits in the fight against infant and maternal mortality through awareness campaigns.
“We have a duty to ensure people can live healthy lives”
Speaking at an annual meeting of 228 religious leaders held in Abuja in September 2018, Dr. Anis Siddique, UNICEF Chief of Communication for Development, described female and male religious leaders as game changers and encouraged them to create demand for immunization.
Sheik Abubakar Gumi, a renowned Muslim thought-leader and cleric, said that cooperation with religious leaders is creating positive change.
“Up until a few years ago, people in Muslim-majority communities stayed away from health centres, rejected polio vaccines and other routine immunizations even if they were brought to their doorstep due to misconceptions, suspicions, and socio-cultural norms,” explains Sheik Gumi. “But this changed with the engagement of religious leaders, who have succeeded in mobilizing people against behaviours that have put the lives of women and children at risk.”
Seeing respected religious scholars endorse immunization, others have also followed suit. Haruna, who leads Friday prayers at a mosque in Kaduna, speaks to over 1000 men every week about the importance of women and children accessing health services.
These collective efforts have brought about shifts in attitudes and knowledge as an average of 20 000 men who attend weekly Friday prayers across the mosques in northern Nigeria receive resounding messages on polio immunization and antenatal care-related health services.
“I used to be non-compliant but was convinced by Sheik Gumi about the dangers of rejecting immunization and other health services that are specifically provided to prevent women and children from dying of preventable diseases. As religious leaders we have a duty to ensure that all people can live healthy lives,” says Haruna.
Pakistan’s routine immunization programme Expanded Programme on Immunization will carry out a nationwide measles vaccination campaign targeting around 31.8 million children aged 9-59 months from 15 to 27 October to respond to an ongoing measles outbreak in Pakistan. Over 30 000 measles cases have been reported this year, compared with around 24 000 cases in 2017.
Pakistan typically encounters a measles outbreak every 8 to 10 years, and the Federal Ministry of Health works proactively to stop these outbreaks with regular vaccination campaigns. Although the Polio Eradication Initiative and the Expanded Programme on Immunization are separate entities, they work together to improve immunization outcomes in Pakistan. Achieving strong essential immunization coverage is a critical step in bringing Pakistan closer to ending polio, and once this goal is reached, in maintaining polio-free status.
Many of the areas at highest risk for polio are also at high risk for measles. During the upcoming measles campaign, the polio programme will lend its human, physical and operational resources, knowledge and expertise to achieve the highest possible measles immunization coverage across the country.
Reaching more children through stronger collaboration
The collaboration between polio and routine immunization programmes has made a significant difference in vaccination efforts across dense urban environments as well as scattered rural settings. A key factor for success has been the polio programme’s highly-skilled workforce of community vaccinators, front-line health workers and social mobilizers.
During every round of country-wide polio vaccination campaigns, around 260 000 front-line health workers vaccinate more than 38 million children under the age of 5 across Pakistan. With vital on-the-ground experience in some of the most challenging settings, they are determined to ensure that the lessons learned in polio are transferred to other health interventions.
“Our front-line workers have built strong rapport in their respective communities,” said Dr. Rana Safdar, coordinator of the National Emergency Operation Centre (NEOC) for polio eradication and member of the National Measles Steering Committee.
“They understand the dynamics of the population, even as they relate to children, not only at the district level but also at the Union Council and village level. This indigenous knowledge coupled with community trust can definitely play an instrumental role for other health interventions.”
Unlike polio eradication activities, measles immunization is not carried out from door-to-door but at fixed centres at health facilities as well as through outreach sessions within communities. Children are mobilized to the vaccination sites where trained healthcare professionals administer the injectable measles vaccine. The deep local knowledge polio workers have developed and the trust they have built with their communities is vital in mobilizing caregivers to take their children for measles immunizations at nearby vaccination sites.
“The strong collaboration between the two programmes has helped us vaccinate more children. Our joint efforts are geared towards reaching every last child and they have shown significant progress so far. We hope that our synergized efforts during the upcoming measles campaign will lead us to reach every child in the target population with measles vaccine,” said Dr. Tahir Abbas Malik, from the Pakistan polio programme.
“For polio, these coordinated efforts have paved the way for increasing the coverage of persistently missed children, especially those who are on the move or reside in hard-to-reach areas. Similarly, integrated micro planning, monitoring and reporting of children who have not received essential immunization have been instrumental for achieving gains for routine immunization through enhanced coverage,” said Dr. Tahir Abbas Malik.
To mark the 100 days since the Government of Papua New Guinea launched the Emergency Response to the Polio Outbreak, the National Department of Health, with support from WHO, UNICEF and other partners released a report on the key accomplishments and highlights from of the response operations.
The 100 Days Report is dedicated to the thousands of front line polio workers who braved challenges and worked long hours to ensure that children in Papua New Guinea are protected from polio.
In September
3 new wild poliovirus (WPV1) cases were reported in September 2018.
In the September Sub-National Immunization Days, 5.6 million children under the age of five were targeted.
484 permanent transit points (PTPs) were operational across Afghanistan during September 2018.
For full update please click on pdf below.
Pakistan polio eradication programme has achieved significant progress in recent years, thanks to renewed government commitment and revitalized community ownership. However, in cities like Karachi, poliovirus continues to be detected.
Working to overcome the virus once and for all, the polio programme an emergency action plan in January 2018. Since then, the geographical scope of the virus has been noticeably reduced. Much of this progress is thanks to religious leaders like Imam Qari Mehboob, who has spent years building trust and demand for polio vaccination in some of the most difficult areas of the city.
Gulshan-e-Buner is in the eastern corner of Karachi. The town includes some of the most impoverished and high-risk populations of the city. Playing in the streets, playgrounds and compounds that wind up and down the hilly landscape are around 2200 boys and girls under five years old. The places where they learn to crawl, walk, and run are perfect hiding spots for the paralysing poliovirus, but the last detection in the environment was in June 2016. No child in Gulshan-e-Buner has been paralysed by polio since 2014. In a community where vaccine refusal has sometimes caused problems, this represents a dramatic transformation.
Gulshan-e-Buner is one of the high-risk areas of Karachi where the polio programme first began community-based vaccination. Religious leaders helped to identify and recruit female vaccinators to reach every child with vaccines, and the area seemed well on the way to becoming polio-free. Then in 2012, an attack on health workers caused vaccination activities here to stop. In the years since, the commitment of religious leaders to ensure security, restore access, and build community trust has been crucial to defeat the virus.
Iman Qari Mehboob is 50 years old, a migrant from Khyber Pakhtunkhwa like most of his neighbours. He calls the community to prayer five times a day, and teaches many of the youngest children in the town. A father of four children, he is devoted to keeping them and all the other children in his community safe from the poliovirus. His support of the polio programme has helped increase vaccine trust, boost uptake of routine immunization services, and spark conversations about the vaccine.
During every polio vaccination campaign, Qari Mehboob goes from house to house with vaccination teams to check for any unvaccinated children. He speaks to parents who refuse the vaccine for their child, reassuring them that it is safe and effective. He conducts his work under the guidance of the National Islamic Advisory Group for Polio Eradication (NIAG), which educates religious leaders about polio eradication and the unique and important role they can play in protecting all Pakistan’s children from polio.
Under the guidance of NIAG, religious leaders are trained on the basics of social mobilization, communication, health, and hygiene. They also learn about the religious justifications for polio vaccination, including examining the arguments and fatwas of influential religious scholars.
Reflecting on his training, Qari Mehboob says, “The toughest job [for the NIAG trainers] is to convince religious clerics because their denial and doubt is deep rooted, but the collective Fatwa [scholarly verdict] of prominent scholars helps a lot”.
Since his training, Qari Mehboob has organised community engagement sessions to raise awareness about the dangers of the poliovirus. He often makes vaccination a central theme during his sermons at Friday and Eid prayers.
“I face less resistance because most of the people here know me personally and they rely on me because of my status as a religious cleric.” he says.
Qari Mehboob also uses the power and platform of his mosque to amplify his voice. He means this literally – sometimes he can be found using a loudspeaker. That’s so that mothers working inside compounds and homes can hear his messages, as well as the fathers who attend prayers. He doesn’t just speak about polio eradication, but also educates his community about personal hygiene, routine immunization and importance of education in Islam.
To thank him for his work, the provincial polio eradication programme team gave Qari Mehboob a clock during a Mosque promotional activity a few years ago. Below the time lies a message emphasising the importance of vaccination. Now displayed prominently on the wall of the mosque, the gift reminds parents why the polio vaccine is one of the best gifts that they can give to their children.
Back out in the streets of his town, Qari Mehboob laughs with local children as he checks their finger marking to make sure that they are vaccinated.
Discussing his motivation, he says, “These children are my own children. So I must protect them from any harmful disease - especially from a crippling disease like polio.”
At the end of the day’s campaign, Qari Mehboob offers tea and cookies to members of the provincial polio eradication programme team.
Since he joined the programme, vaccine refusals in Gulshan-e-Buner have dropped by 50%, and far more children receive their full polio vaccine doses on time.
Reflecting on the impact of his work, Qari Mehboob returns to his desire to keep all children safe. “I feel an extreme level of contentment after I contribute my part in the programme,” he says.
In a rural village in Nigeria, a group of women knock on the door of new mother Hauwa Abubakar. She emerges from within, exhausted from the routine of feeding, sleeping, and caring for a little one. But she has extra reason than most to be tired.
A few months ago, she became mother to triplets, two baby girls and one baby boy.
The women visiting her are from her local community, but today they have come in their roles as polio vaccinators.
Realizing that they are there with vaccines, Hauwa picks up her young son, and carries him to another room. She closes the door, and returns to her daughters, ready to present them for their polio vaccinations.
The health workers ask Hauwa why she hid her son – he is just as vulnerable as his sisters, and the vaccine is the only way to keep him safe from polio paralysis.
“He is my only son,” she explains. “He will grow up and continue my family lineage. As for my girls, I’ll give them away to another family when they turn 18.”
“Boys or girls, your children all need polio immunization. Please don’t discriminate when it comes to matters of health,” says the lead health worker, as she puts two drops of polio vaccine into each of the girls’ mouths.
“You never know who your daughters will become one day, and you never know what disease you are protecting your son from.”
After a little more discussion, Hauwa is reassured. She fetches her son, and soon he too is protected from the virus.
Gender and polio eradication
Hauwa’s perspective is not unusual in communities where there is hesitation about the need to vaccinate. In communities where boys are more valued, and there is uncertainty about the need for vaccination, they may not be given the polio vaccine alongside their sisters. Sadly, this leaves them vulnerable to polio paralysis, whilst girls grow up protected from the virus.
Understanding that the world can only become polio-free if all children are vaccinated, the polio programme is developing a gender strategy which recognizes the way that gender impacts access to immunization, and also considers the valuable role of women health workers.
Dr Usman Adamu, the Incident Manager at the Nigerian National Emergency Operations Centre for Polio Eradication, explains how these things are related.
“All team members performing house-to-house for the polio campaign must be women. This is because we want to reach all eligible children with polio vaccines irrespective of whether children are inside or outside the house. Having a female team member makes it easy to reach these children in the household [where male vaccinators cannot enter]. ”
Polio workers are locally recruited, and women vaccinators often have a preexisting relationship with the mothers they visit with vaccines. This means that they are uniquely placed to answer questions and reassure them of the safety of the vaccine for boys and girls. With extra training, many women vaccinators also provide mothers with important information about other health interventions, including maternity health.
Keeping boys and girls safe
The GPEI gender strategy will help guide endemic countries like Nigeria to respond to gender related barriers to immunization. A first step has been the developing of several gender-sensitive indicators which country programmes use to track gender as a determinant of health.
The team lead of the WHO Immunization Cluster, Dr Fiona Braka, explains, “These gender-sensitive indicators measure the equal reach of girls and boys in vaccination campaigns, the doses of polio vaccine received by girls and boys, the timeliness of disease surveillance for girls and boys and women’s participation as front-line workers in polio-endemic countries.”
By recognizing the impact of gender on immunization, the polio programme can better deliver a vaccine to every baby.
For Hauwa’s triplets, the most important thing is that all three are well on their way to being protected from the virus.
In August
-Intensified eradication efforts are continuing in Afghanistan, in close cross-border coordination with Pakistan.
-Efforts are focusing on reaching children in hard-to-reach areas, and among mobile population groups.
-Subnational surveillance sensitivity continues to be strengthened.
For full update please click on pdf below.
In the Democratic Republic of the Congo, emergency response has been ongoing since 2017 to overcome outbreaks of circulating vaccine-derived poliovirus, caused by low rates of routine immunization. In the battle to close the outbreak, health workers, partners of the Global Polio Eradication Initiative, Governors of affected provinces, and the Ministry of Health are working together to vaccinate every child. In a context with weak health systems and other high-profile health and humanitarian emergencies, these united efforts are crucial to boost population health and keep all young children safe from paralysis.
In Tanganyika province, where poliovirus was first detected in September 2017, outbreak response is focused on reaching all vulnerable populations with the safe, effective oral polio vaccine. Health infrastructure is weak in the province, and it has taken concerted efforts to reach many children. Here, mothers with their babies queue for polio immunization activities in Manono district, organized with the support of WHO, UNICEF and partners.
Despite several campaigns, immunity gaps still remain. Continuing cases from several virus strains in the country show that the battle to protect every child from paralysis is far from over. Here, a nurse carefully places vaccines vials back in a cooler during immunization activities in Manono. It is critical that the polio vaccine is kept cool, a considerable challenge in warm locations far from the nearest vaccine storage facility.
A small boy is vaccinated against polio after waiting in line with his mother. The Democratic Republic of the Congo has some of the lowest vaccination rates worldwide, and it is hoped that the lessons learned in overcoming this and other health emergencies will help strengthen the country’s health system for the future, and prevent other outbreaks.
A community mobilizer tells a woman in a village in Manono about the polio vaccination campaign that has just begun. Community mobilizers, usually local people trained by UNICEF and partners, are a critical part of efforts to ensure that every child is protected from the virus. Going house to house, they speak to parents about the dangerous poliovirus, and answer questions about the vaccine. Often, they also provide other health service support, including child and maternal health advice.
A girl has her little finger marked after being vaccinated against polio. All children under the age of five are being targeted in vaccination campaigns in the affected districts.
Amongst the communities here, there are children whom the virus has already reached. Remy Muyombi was previously an opponent of vaccination. Since his three-year-old son Justin was affected by polio paralysis, he has become a strong advocate of the campaigns ongoing in his district. So far in 2018, there have been eleven confirmed cases of polio paralysis due to the outbreak. In 2017, 22 children were paralyzed.
A community health worker crosses a shallow stream with his bike to reach the most distant children in Manono health zone. Many communities here live hours from the nearest road, far from any route that a car could easily traverse.
After a household is visited with vaccines, health workers mark the home with chalk to show that the children there have been immunized. They also collect paper records of vaccination, to feed back into a central monitoring and evaluation system coordinated by WHO.
Community mobilizers speak to a mother in Kalunga site for internally displaced people in Tanganyika Province. Regular movement of people in the Democratic Republic of the Congo complicates outbreak response, as there is a real threat of virus spread. The programme works specifically with moving and displaced populations to boost immunization rates, and collaborates with other UN agencies to gather up-to-date information on population movements and the wider humanitarian situation in the country.
A girl is vaccinated against polio in Manono. With each campaign, the polio eradication programme is looking to protect more children, and get closer to ending the outbreak. More polio immunization activities are planned for the coming months, building on commitment from the government of the Democratic Republic of the Congo and provincial governors. Working with other programmes, and in complex contexts, the polio eradication teams continue their work to keep every child safe from polio paralysis.
After more than 25 years on the hunt for polio, it’s easier to list the things the World Health Organization’s Chris Maher hasn’t seen than the things he has. He began his career with WHO five years after the global health community vowed to eradicate polio, which was then found in over a hundred countries. Since then, Maher has progressed to spearhead on-the-ground operations for the global polio eradication initiative, a partnership that has seen the disease beaten back by 99%. In a ceremony in May 2018, the Australian Government awarded him the Order of Australia, recognizing his immense contributions to the fight against a disease that has gone from paralyzing more than 350 000 children every year in 1988, to fewer than 22 cases worldwide today.
In 1993, Maher had several years of experience in public health, but none in polio-endemic countries. “I don’t think I’d ever seen an active polio case,” he recalled. Upon joining the WHO immunization team in a region that spanned from Mongolia to the Pacific Islands, polio was suddenly at the top of his agenda.
Maher and his colleagues worked as disease detectives, stalking the wild poliovirus through hard-to-reach communities in south-east Asia. From immunizing small communities on the Pacific Islands to taking on massive campaigns targeting millions of children in China, the complexity made his head spin.
The Philippines was the first country to go polio-free on Maher’s watch, seeing its last case that year.
Tracking unimmunized children through a population maze
It was here that Maher came face to face with polio’s full force of devastation, after a Khmer nurse at a district health clinic invited him home to meet her son. Maher and a colleague followed the woman to a house on stilts in a flooded field, where a quadriplegic teenager lay on a rattan bed.
“I realized very early on, he had polio. It was typical of the kind of polio that had no rehabilitation whatsoever”, Maher said.
Maher recalls being struck by the young man’s intelligence and his interest in the world, despite his isolation. As polio destroyed his body, his mother bestowed constant care.
“While she was working every day, somehow she had managed to look after him, to provide for him. As an example of motherly love I had never seen anything like that in my life.”
By the 2000s, it seemed that the most challenging country to eradicate polio was India. With its vast population and sprawling slums, in Maher’s words, “If technically we couldn’t do it, India would be the place we’d fail.”
Maher recalls Bihar, India as “the most extraordinary place that I ever worked on polio.” Eighty million people live in the state. Widespread illiteracy, a lack of infrastructure and high levels of population movement compounded the complexity of polio eradication there.
Despite the daunting challenges, Maher and his colleagues developed systematic plans to administer vaccine to all children across the country, taking a critical step in a journey to eradication. By the end of 2011, India was polio-free.
The risk of doing something different
At the start of the global push to eradicate polio, those involved in the operation would sometimes encounter skepticism from those who thought it simply couldn’t be done. The scale of the project, the size of activities and the time, energy, effort and cost involved had never been seen before.
Today, wild polio is endemic in three countries: Afghanistan, Pakistan and Nigeria. Immense efforts to battle the virus into extinction in these places are ongoing. Outbreaks of vaccine-derived polio virus (VDPV) add complexity to the end goal. Conflict, low routine immunization and population movement in the most at-risk areas complicate things further. Some of the approaches Maher and his eradication colleagues take to navigate these and myriad other challenges are astonishing – feats of logistics, diplomacy and detection that would not be out of place in a textbook.
“We’ve learned a lot about reaching every community, the most difficult access places, we’ve learned a lot about the importance about communicating what we are trying to achieve, to bring communities along with us in what we were doing. We’ve learned that there are certain things that are too big to do yourself. You need to build coalitions, you need partnerships to be able to make something happen, and the broader that partnership is, the greater the likelihood that you are going to be able to achieve something significant,” he said.
For Maher, the real risk is not that polio won’t be defeated, but that the world might one day forget how it was done. He sees the lessons learned during eradication as critical to the global health community.
“It would be a terrible pity if we lost that, if after eradication we kind of collectively heaved a sigh of relief and said, ‘well thank goodness that’s over, let’s do something else now’.”
In April 2016, the polio programme embarked on a massive, coordinated effort to withdraw Sabin type-2 from routine use, through a synchronized switch from the trivalent formulation of the oral poliovirus vaccine (tOPV) to the bivalent form (bOPV). Over a two-week period, 155 countries and territories successfully made this change, marking the largest and fastest vaccine rollout in history.
Referred to as simply “the switch,” this global undertaking was a major programmatic achievement, but it was also a necessary step on the road to eradication. That’s because, in rare cases, the live, weakened virus contained in OPV can mutate and spread, resulting in cases of circulating vaccine-derived polioviruses (cVDPVs). The vast majority of these cases are caused by just one of the three components contained in tOPV (Sabin type-2 virus), so switching to a bivalent form that doesn’t contain this component was an attempt to significantly minimize the risk of further cVDPV2 cases – a decision that was endorsed by the global health community. Further, with Sabin type-2 responsible for 40% of vaccine-associated paralytic polio (VAPP) occurrences – a much rarer phenomenon at 2-4 cases per 1 million ‒ there was even stronger justification for the switch.
To assess whether the switch was successful, a group of researchers from Imperial College London, the World Health Organization and the Bill & Melinda Gates Foundation analysed stool and sewage samples from 112 countries collected in the first 15 months after the switch. The results, published in The New England Journal of Medicine, show that VDPVs and Sabin type-2 excreted into the environment after vaccination disappeared rapidly after the switch, shrinking to a much smaller geographic area.
These findings validate the GPEI decision to withdraw tOPV and demonstrate that the switch achieved its desired goal of reducing VDPVs and VAPP. This research also provides important evidence that the complete withdrawal of OPV after eradication of all wild polioviruses will eventually eliminate the risk of VDPVs, provided high immunity and effective surveillance are maintained. Eradication is simply not compatible with continued use of OPV.
The study also showed, however, that while some outbreaks of VDPV were expected post-switch, the number and magnitude of some of these outbreaks in different geographies has proven more difficult to control than expected. Type-2 VDPV outbreaks outside of Africa have been responded to with monovalent type-2 OPV (mOPV2) and controlled. However, outbreaks in the Horn of Africa, DR Congo and Nigeria have been very difficult to bring to a rapid close.
VDPV outbreaks emerge in areas with very low population immunity, due to low immunization coverage. Factors which enable them ‒ insecurity and resulting inaccessibility, weak health systems, and poor campaign performance – are the same that need to be addressed to stop their transmission. While the programme is aware of these risk factors and has proven experience and strategies to respond to them, the longer outbreaks persist, the harder they can be to stop.
The key to stopping these outbreaks will be to increase the focus on improving the quality of vaccination campaigns in accessible areas. In inaccessible areas, we need to use all available means to negotiate access and implement vaccination campaigns. Achieving high quality campaign activities will give us the best chance to stop all types of poliovirus for good and prevent any child from being paralysed by the virus ever again.
“Please wait, I’ll soon be with you,” says Nasiru, the father of six children, as he disappears into his house in Gagi Makurdi settlement in Nigeria’s northwestern State of Sokoto.
Within minutes, Nasiru reappears, proudly displaying immunization cards with the record of the vaccines given to his youngest three children. It is unusual for fathers in this conservative part of Nigeria to readily know the whereabouts of these documents. Tending to children and ensuring that they stay healthy is usually a mother’s job.
“Take a look at the cards. My children Fidausi and Fatima have completed all their required immunization, whilst my youngest, Nana Asmaiu, is well on course to complete his,” he says.
Nasiru is a champion for immunization, but he wasn’t always so enthusiastic.
20 000 community mobilizers
It was Hauwa Ibrahim, a 46-year-old UNICEF-trained Volunteer Community Mobilizer, who persuaded Nasiru that the vaccine was safe and effective. She is part of a 20 000-strong network of community mobilizers who work across twelve Nigerian states like Sokoto, where some communities have been resistant to polio vaccination.
As recently as 2012, Nigeria used to account for half the world’s polio cases. Today, with help from women like Hauwa, no wild poliovirus has been detected in the country since August 2016. There are still many immunity gaps in Nigeria – as underlined by an outbreak of vaccine-derived virus currently ongoing in the country – but in the villages where VCMs like her work, these gaps are beginning to close.
Using a simple register, Hauwa goes house to house in Gagi Makurdi to record all children below the age of five, as well as women who are pregnant. It is the same register that Hauwa used to track the pregnancies of Nasiru’s wife – Zara’u – and she now uses it to find out who manages the routine immunization schedules of the three youngest children in the household.
Strengthening routine immunization
This forms part of the polio programme’s work in Nigeria to strengthening routine immunization, building on the infrastructure developed to eradicate the virus.
Upon her first visit, Hauwa was determined to convince Nasiru that vaccination against polio and other diseases is important – and that he should take the children to the health facility.
“My culture does not allow a wife to go outside of the compound, so when Hauwa insisted that we take our children to the health facility for vaccines, I had no way but to go myself. Else, Hauwa would not give up,” Nasiru explains. Whilst he travels with his children, Zara’u takes care of their older siblings at home.
By recruiting locally influential women like Hauwa from communities where some parents are vaccine-hesitant, and training them to be advocates for child health, vaccination rates are improved throughout their neighbourhoods. In some areas, more than 99% of parents now accept the polio vaccine for their child.
“Hauwa resides in this settlement and I trust her; I trust that the advice she is giving is in the best interest of my children,” says Nasiru.
He also notes, however, that he is often the only man at the health facility.
Engaging all fathers
Hauwa hopes that by encouraging more fathers to take on the parental responsibility of completing their children’s routine immunization schedule, immunization coverage will increase across Sokoto. Greater vaccine acceptance and awareness means that children are more likely to receive a life-saving polio vaccine, and other vaccines, whether through routine immunization or through door-to-door vaccination.
Already, the trust that she has built amongst parents in Gagi Makurdi has helped surmount many of the barriers that deny children immunization and other health services. In Nasiru and Zara’u’s compound, nearly all children are now protected against polio and other vaccine-preventable diseases.
Only their baby, Nana Asmaiu, has yet to have all his vaccinations – and Hauwa will soon visit his household to support Nasiru and Zara’u, and ensure he gets them.
Long distances, an ever-changing environment and minimal infrastructure are only a few of the barriers that the Lake Chad Task Team face as they conduct polio vaccination and surveillance activities in response to wild poliovirus detected in Nigeria in 2016. Overcoming these hurdles isn’t easy, but innovations ranging from geographical information systems (GIS) technology to boat-side vaccination are going far to ensure that every child is reached with lifesaving vaccines.
“I have heard of several more islands that have appeared since the dry season began”, says a local official as he discusses plans for a vaccination campaign about to be held near Bol, the main lake-side town in Chad. Unique climate conditions contribute to fluctuating water levels, and land is built up and destroyed within weeks. Now, new information is recorded using geographical information systems (GIS) technology, increasing the accuracy of regional vaccination plans, and ensuring that health workers visit every community with vaccines.
Travelling via speedboat reduces the journey time to islands from days, to hours. The team have invested in dedicated vessels for polio eradication activities, freeing them to travel at a moment’s notice to investigate a case of acute flaccid paralysis, or deliver vaccines. These stable, tough boats are specially chosen for long distance journeys.
Arriving on an island, the team supervise the activities of community-based vaccinators, ensuring that every child receives two drops of polio vaccine, and that their finger is stained purple to distinguish from those children not vaccinated. Vaccination activities happen in markets, villages, and nomadic settlements. Recruiting women and men to work in their local communities increases vaccine trust and acceptance. This is one of the key lessons learned over the course of the global polio eradication programme.
As temperatures soar, it’s critical that the polio vaccine is kept cool, an immense challenge in places where there is little or no electricity. A game changer for the team has been the introduction of dedicated vaccine refrigerators, some solar powered, painstakingly transported to and installed in several island villages. This means that vaccines are kept cold week to week, reducing the amount that must be transported by the team for each campaign, and limiting vaccine waste.
“Seeing how healthcare is so important, especially for mothers and children, I was inspired”, says Ahmad, an IT expert. During each campaign, he travels to distant villages to train local health workers on new technology to ensure high quality vaccination campaigns. Using specially-designed mobile phone applications, the team helps ensure that every household is visited by vaccinators.
“Can you tell me how to recognize the symptoms of a potential polio case?”, asks Dr Adele. She records the answer given by Robert, who is the coordinator of a small island health centre, on a mobile phone used as part of electronic disease surveillance (also known as Integrated Support Supervision). Conducting regular disease surveillance monitoring allows the task team to ensure that every case of acute flaccid paralysis has been properly reported. At the same time, they reinforce best practice for disease surveillance. This has the added benefit of ensuring that the team maintains a close relationship with health workers, many of whom live days’ journey from the nearest hospital.
Calling out in French, Arabic, and local dialects, the team speak to parents in passing boats and wooden pirogues, “We’re vaccinators, let us see your child’s finger mark!”. Drawing alongside every vessel as they journey to and from villages, the polio eradication team ensure that all travelling children have received two drops of the safe, effective oral polio vaccine. Families journeying across the lake are often headed to markets, where unvaccinated children could potentially spread the virus as they play. Before they continue on their way, the team diligently vaccinate every child without a stained finger.
No wild poliovirus has been detected since September 2016, after outbreak response began in the Lake Chad Basin. Vaccination rates are higher, whilst investment in polio eradication operations and infrastructure has helped to strengthen the wider health system in the lake. The tools and strategies of the Task Team are defeating polio, and leaving a strong legacy that other health programmes can follow.
In July:
There were no new cases of wild poliovirus (WPV1) reported.
10.5 million children were vaccinated against poliovirus during case response campaigns by more than 73 000 dedicated frontline workers.
Teams at transit points and borders successfully vaccinated 1.7 million children.
This is southern Afghanistan. A place characterized by a rich, diverse, but often complex history. Enveloped by mountains, this part of the country has seen years of conflict which have left hospitals under-resourced and health services shattered. Children face many challenges – as well as conflict and poverty, southern Afghanistan has the highest number of polio cases in the world.
In this difficult environment, the virus can only be defeated if every child is vaccinated.
Afia (not her real name), who is nineteen years old, is one of over 70 000 committed polio workers in Afghanistan, supported by WHO and UNICEF. Last month, she and her colleagues vaccinated 9.9 million children and educated thousands of parents about vaccination across the country.
The polio eradication programme comprises one of the biggest female workforces in Afghanistan: a national team, all fighting polio. Some women work as vaccinators, whilst others, like Afia, are mostly engaged in education and social mobilisation efforts. The polio programme gives women culturally-appropriate opportunities to work outside the house and engage in their community, speaking to parents about the safe, effective polio vaccine, and answering their questions. Often, women vaccinators offer other kinds of health advice, including recommendations for good child and maternal health.
To be a good vaccinator and educator, women must be committed to better health for all, with strong communication skills. They must also be organized to ensure that every child is reached during the campaign.
Afia says that if she wasn’t eradicating polio, her parents would expect her to give up her education and get married. Her younger sisters look up to her, excited to work in the polio eradication programme when they are old enough.
Her job is very important to protect all children. Afghanistan is just one of three countries – the others are Nigeria and Pakistan - that have never interrupted poliovirus transmission.
Women can vaccinate children who might otherwise miss out. Culturally, male vaccinators are unable to enter households to administer vaccine, causing difficulties if young children are asleep or playing inside. Their freedom to enter homes and give the vaccine to every child is one reason female polio workers are so critical.
Afia started work at 7 am, and is now walking home ten hours later with a young boy she has just vaccinated. Her purple burka stands out against the sand as she goes home to tell her parents and siblings about her day.
Afia feels positive about the future of polio eradication in Afghanistan: “We have a duty to protect our children, and I won’t stop working until every child is protected.”
Women have a right to participate in all aspects of polio eradication. Removing barriers to women’s full participation at all levels is a key goal for the Global Polio Eradication Initiative (GPEI). To learn more, see the gender section of our website, and read the GPEI ‘Why Women’ Infographic.
Molvi Hameedullah Hameedi is a prominent religious scholar in a mountainous rural area of Killa Abdullah district, one of the poorest districts in Balochistan province, Pakistan. With a close connection to his community, who are mostly Pashtuns, he delivers the sermon each week during Friday prayers, and runs a religious seminary.
He is also a determined supporter of routine vaccination for all children, and an advocate for better health.
This might come as a surprise if you met Molvi Hameedullah just a year or two ago. For most of his life, he did not believe in the safety and effectiveness of the oral polio vaccine, the key tool of polio eradication.
“I was a religious scholar who was very sceptical of non-governmental organizations and the polio vaccine,” he reflects.
“After reading anti-vaccine books and papers, I began following the work of anti-vaccine campaigners. Soon, I came to consider it my religious duty to spread awareness against the polio vaccine.”
“But it all changed when I was invited to a two-day International Ulema conference in Islamabad where religious scholars from all over Pakistan and other Islamic countries were invited to debate polio vaccination.”
The conference Molvi Hameedullah attended was hosted by the Islamic Advisory Group for Polio Eradication (IAG). The IAG was launched in 2014 by leading Islamic institutions including Al-Azhar University, the International Islamic Fiqh Academy (IIFA), the Islamic Development Bank (IsDB) and the Organization of Islamic Cooperation (OIC).
For Molvi Hameedullah, attending the conference marked the beginning of a change in perspective. “At the conference, I was given an opportunity to discuss my apprehensions towards polio vaccine. The talks I had motivated me to further research the pro-polio vaccine stance, and I started meeting with religious scholars in Karachi to debate polio vaccination.”
“Through talking to these people, I was getting a completely different picture to what I had believed earlier.”
By educating religious leaders and scholars about the poliovirus, and explaining religious justifications for vaccine acceptance, the IAG and its national equivalent equip people like Molvi Hameedullah with the tools to act as health advocates. The same skills that help scholars engage with parents about the polio vaccine are applicable for wider health, including improving routine immunization, hygiene practices, and maternal and child health.
After the conference Molvi Hameedullah was offered support by other vaccine-promoting scholars.
“I received a book from a religious support person working for polio vaccination in my area. Included were dozens of fatwas from highly esteemed madrassahs and religious teachers. I was initially sceptical, so I telephoned the madrassahs who had written them. To my surprise, all the fatwas were genuinely issued by them, and they also urged me to support vaccination wherever I called.”
Today, Molvi Hameedullah teaches similar fatwas as a member of the Provincial Scholar Task Force under the National Islamic Advisory Group. Most Task Force members have an honorary position, and are not paid a salary. Instead, the local government facilitates their transport and communication needs during immunization campaigns. Of his new role Molvi Hameedullah says, “I was faced with a different problem. I had been working against polio vaccination for many years, and now felt that I had done a great damage to the children and parents of my community. I felt it was now my absolute religious duty to negate all that I had taught before. I decided to step forth, and started working in the community voluntarily to promote vaccination.”
Religious refusals in Molvi Hameedullah’s area have declined. He has begun supporting other ways of ensuring that every child receives a vaccine, including by recruiting women vaccinators.
He acknowledges that the work he does now is not easy. He and his fellow scholars sometimes face challenges from those accusing them of having a political agenda, and changing beliefs informed by years of cultural and religious tradition takes time and patience. But he vows to continue his new mission until eradication.
There have been no cases of polio in the area of the district that Molvi Hameedullah covers since he joined the Provincial Scholars Task Force. Looking ahead, he is determined not to stop until all of Pakistan is polio-free.
