GPEI-From island to island with vaccines in Lake Chad

Dr Adele vaccinates children from her canoe, after travelling for hours to the most remote islands on the lake. © WHO Chad

When the sun rises in the health district of Bol, in Chad, Dr Adele’s day begins. Launching her canoe into the reed-filled waters of Lake Chad, and taking a look at the map, she readies herself for the long journey ahead. In four to six hours time she will arrive at a remote island, where there are children never before reached with vaccines.

Dr Adele Daleke Lisi Aluma works in one of the most challenging areas of the world in which to vaccinate. In Bol, 45% of children live on difficult-to-access, remote islands, where geographical barriers, violence, insecurity, and poverty mean people usually do not receive health or other government services.

Her job is to overcome these barriers, seeking out every last child for vaccination, whilst using her experience to ensure that the programme makes the best use of resources to reach the most children, every time.

Planning the route

A first step for every campaign is to plan the route. Studying maps, and comparing information, Dr Adele and her team find the most efficient way to reach the multiple islands that must be visited by vaccinators.

“The team often plans campaigns to take place at the same time as the weekly market, to vaccinate children when they are with their mothers buying and selling necessities,” she says.

To increase acceptance of the vaccine, a few days before each campaign, Dr Adele and her colleagues telephone village elders and leaders, explaining why protection against polio and other vaccine-preventable diseases is so important.

This helps to improve the programme’s reach. In the past, vaccinators sometimes travelled long distances over many days to islands where there are very few children. This meant wasted vaccine, as vaccinators were not able to keep the spare vaccines cold enough on the return journey to be used for other children. Today, better planning, as well as the purchase of solar refrigerators for vaccine storage, helps to solve this issue.

“To maximise a vaccination session, we need to make sure our field operations are efficient and effective, minimizing missed opportunities” she says.

The journey

For Dr Adele, avoiding insect bites often proves one of the biggest challenges of the job. © WHO Chad

Lake Chad is made up of waterways filled with reeds, trees, and wildlife: not a flat stretch of water. To get to the islands, Dr Adele uses a paddle canoe, deftly navigating the difficult terrain for hours at a time. The teams need to be careful – while steering straight and keeping the vaccines cold, they must also watch out for insect bites – and even hippos.

Despite the challenges, she finds a huge sense of achievement in her work.

“Reaching a difficult to access village gives me every time a sense of motivation to continue.”

Arrival

Upon reaching an island, Dr Adele begins vaccination. The majority of children in remote island villages have received less than three doses of oral polio vaccine, leaving them vulnerable to the virus. One by one, Dr Adele works to protect them.

Dr Adele is driven in her work by her experience of a close family member with polio. Previously, she conducted immunization and epidemiological surveillance for polio in the Democratic Republic of the Congo and in Haiti, as part of a career that has taken her all over the world.

The results

With each campaign, Dr Adele vaccinates hundreds of children, but she also looks for signs of the virus.

On a recent trip to the islands, she and her team discovered a child with acute flaccid paralysis, a potential signal of polio, who had not been reported to the polio surveillance network. While the child didn’t have polio, this underlines the crucial need for the programme to continue to access these difficult to reach places, vaccinate children, and encourage communities to report any suspected polio cases.

Dr Adele is already helping to strengthen surveillance through training community members in each village to recognise the signs of a potential polio case.

She is also planning her next journeys: “We plan to return soon to supervise and accompany vaccination teams in the island areas.”

To reach the remotest communities in Lake Chad, this is what it takes.

Dr Adele Daleke Lisi Aluma and her colleagues wade through Lake Chad to vaccinate the hardest-to-reach children. © WHO Chad

For more stories about women on the frontlines of polio eradication

Children show their inked fingers - a sign they have been vaccinated against polio. © WHO/Afghanistan — Children show their inked fingers – a sign they have been vaccinated against polio. © WHO/Afghanistan

In eastern Afghanistan, one family is helping to vaccinate every last child in their community

Zahed, his daughter Sahar, and son Mohammad all work together. But they are not working for themselves, they are working to eradicate polio.

The family lives in an indigent village in eastern Afghanistan with a diverse community. It is close to the border with Pakistan and many residents are returnees from Pakistan, families displaced by insecurity and nomads passing through. With a population that is often on the move, it is a community with high risk of poliovirus transmission – making it extremely important to vaccinate every child.

Zahed’s family are well-known. Each month, they knock on doors giving free vaccinations and educating their community about the virus.

Although sometimes they don’t have doors to knock – only tents. Known in Afghanistan as Kuchis, nomads are particularly vulnerable to polio, because they move seasonally and often miss vaccination campaigns. Historically underrepresented and often neglected, they are also isolated from health services.

Nomads at risk

Laden with water jugs, cooking equipment and clothes, the Kuchi travel with their livestock and move between provinces depending on the climate. Their goats, sheep and camels are often exchanged or sold for grain, tents and other essential items. There are an estimated two million nomads in Afghanistan.

Over 120 nomad families with 194 children under the age of five recently arrived in Zahed’s village from shelters along the Kabul River. They come in the winter because it offers warmer, more fertile ground for their animals to graze. They return to Kabul and Bamiyan during the spring, when the land is more arable.

To eradicate polio in Afghanistan, every child must be vaccinated – including the nomads. And this is exactly what Zahed’s family are doing. They go to each tent, and ensure every child is protected against polio. Last week, Zahed’s 20-year-old son Mohammad vaccinated 719 children, including nomads. “My community are happy with my service. I’m young, and it is a privilege to make a difference,’’ says Mohammad.

The family is not only protecting children, they are also contributing to community cohesion and bridging divides between nomads and residents. The challenge, however, is continuing to vaccinate nomads when they are on the move.

The motivation of Zahed’s family is impressive, but it is not always easy. A handful of people in the village reject the vaccine because they think that it is unsafe or not halal – permissible in traditional Islamic law. But watching an entire family working to eradicate polio helps break misconceptions. At the start of each vaccination campaign, Mohammad gives one of his own children the vaccine to prove that it is safe.

Becoming advocates

Zahed’s family have turned almost all the families who were refusing the polio vaccine into advocates for vaccination. Mohammad was already a prominent member of the community and was previously given a ‘Turban’ – headwear used to recognize a person who makes decisions on behalf of their community and country – to honour his relentless work to improve water, sanitation and development in his village. Now his role as a polio eradication ambassador is developing trust and increasing acceptance of the vaccine.

In 2017, three polio cases and 14 positive environmental samples were reported in eastern Afghanistan. A positive sample indicates that the polio virus is present, and that children with low immunity are at risk of contracting the disease. The first polio case of 2018 was also reported in eastern Afghanistan, making it an urgent priority location for nationwide eradication.

In the village, polio has almost been eradicated. But this is not enough for Zahed’s family. As they prepare for their next vaccination round, they are determined not to stop their work until everyone in their community – wherever they are from – is safe from polio.

The discovery of wild poliovirus in Borno and Sokoto states in Nigeria in 2016 after more than two years without any reported cases prompted a multi-country response in neighbouring countries of the Lake Chad basin, covering Cameroon, Central Africa Republic, Chad, Niger and Nigeria. Since the outbreak response started, coordinated vaccination campaigns have been taking place in all five countries, reaching tens of millions of children. This year, campaigns are planned for March, April and October – all of them synchronized between the neighbouring countries.

In Chad, vaccination activities for polio and other diseases are being carried out in priority districts, supplementing regional campaigns which aim to target the hardest-to-reach children.

A bold sign in the camp for internally displaced persons makes it clear where people can come to be vaccinated against yellow fever. WHO/NIGERIA

As he climbs out of his car and walks across to the entrance of Bakassi camp for internally displaced persons in Borno, northern Nigeria, Dr Terna Nomwhange is met by a familiar sight. Standing at the gates, greeting a tired, dusty family laden with possessions, is a team of polio vaccinators. As families arrive at this sea of shelters following a long, hard journey, these people offering polio vaccines are the first sign that they have reached a place of protection.

Not only are families in northern Nigeria facing insecurity, a humanitarian crisis and the threat of polio, but since September they have also been at risk from an outbreak of yellow fever. By early January 2018, a total of 358 suspected cases had been reported in 16 states, with 45 deaths recorded for 2017. In Borno, the ongoing conflict means that the health infrastructure on the ground to respond to the outbreak is limited to local government and the polio eradication infrastructure.

At the camp gates, the polio vaccinators give two drops of vaccine into the mouth of every child; but they also tell the parents where to go to get their yellow fever vaccination. As Dr Terna, who works for the WHO Nigeria polio eradication programme, walks further into the camp, he catches sight of the distinctive blue that signifies the uniform of a polio volunteer community mobilizer. As she emerges from the door of a shelter, he hears her reminding the family within to get their children vaccinated against polio, but also for the whole family to be vaccinated against yellow fever.

With weakened health system in parts of north eastern northern Nigeria, the infrastructure that is already on the ground to stop polio is providing the volunteers needed to support the yellow fever vaccination campaign. More than eight million people are being targeted with yellow fever vaccines in the states of Borno, Zamfara Kwara and Kogi states in 2018.

Vaccinating adults

By providing both polio and yellow fever vaccinations, the polio infrastructure protects everyone – the young children vulnerable to polio, as well as the whole population at risk of yellow fever. WHO/NIGERIA

Regular polio vaccination campaigns reach children under five years of age with polio vaccines, as this age group is the most vulnerable to the virus. But reaching everyone between nine months and 45 years to protect them against yellow fever takes creative thinking. People who would not usually be vaccinated have to be mobilised to come to health clinics where they can receive that one shot of yellow fever vaccine that infers life-long protection.

This is where the polio infrastructure comes in. To prepare for the launch of the yellow fever vaccination campaign that took place at the beginning of February, polio experts supported the preparations by developing detailed microplans, mapping each community so that every individual can be vaccinated. Volunteer community mobilisers, well versed in educating communities about the risks of infection, used their skills to warn populations of the high mortality rates associated with yellow fever.

Surveillance

Volunteer community mobilizers for the polio programme spread awareness of the importance of polio and yellow fever vaccinations. WHO/NIGERIA

The polio surveillance system in Borno is already on high alert to identify any case of polio, even in conflict affected areas. “Surveillance remains everyone’s number one priority,” says Dr Terna. “While the polio infrastructure is doing everything it can to find any trace of polio, it is killing two birds with one stone by keeping an eye out for yellow fever as well. This is a win-win situation to stop both diseases.”

While surveillance focal persons move house to house, they are also raising awareness about the symptoms of yellow fever. When a potential case is found, the polio infrastructure is being used to collect blood samples and transport them to the national laboratory down the reverse cold chain, keeping samples at the correct temperature for testing.

Collaboration

“What makes this campaign special is not just the fact that the strong polio infrastructure is helping to control other diseases, but also that it underscores what can be achieved with intersectoral collaboration and partnership,” said Dr Wondimagegnehu Alemu, WHO Country Representative to Nigeria. “Without the polio eradication infrastructure, a campaign of this scale would not have been able to take place.”

“Everyone is pulling in one direction – the government, partners and volunteers within communities – to protect any and every vulnerable person against polio and yellow fever,” says Dr Aliyu Shettima, Polio Incident Manager at the Emergency Operations Centre (EOC) in Maiduguri.

Support for immunization to the Federal Government of Nigeria through the World Health Organization is made possible by funding from the Bill & Melinda Gates Foundation (BMGF), Department for International Development (DFID), European Union (EU), Gavi, the Vaccine Alliance, Global Affairs Canada (GAC), Government of Germany through KfW Bank, Japan International Cooperation Agency (JICA), Korea Foundation for International Healthcare (KOFIH), Measles and Rubella Initiative (M&RI) through United Nations Foundation (UNF), Rotary International, United States Agency for International Development (USAID), United States Centers for Disease Control and Prevention (CDC) and World Bank.

Vaccinating every child, every time Haroon, 3, was vaccinated for the second time in two weeks. WHO / Tuuli Hongisto

In Afghanistan, frontline health workers explain to parents why the polio vaccine must be delivered multiple times

“It’s easy for the others, they are young and strong!” laughs Hamida. She has just climbed hundreds of steps to the top of a long and steep staircase on the side of one of Kabul’s many hills. Together with her colleagues Mohib and Khalid she works as a part of a polio team vaccinating children in their community. Today, the team started at 8 am, and they have now been walking up and down the hill for three hours. No wonder she is tired.

So far, the group has visited 50 families and vaccinated 110 children. They have 30 more to go today, and, in the next three days, they will visit a total of 233.

The team’s role is not only to vaccinate the children but to also to educate people about the life-saving polio vaccine and its importance. It is not always an easy job.

“Last time we visited was only two weeks ago, so some parents have been asking why we are visiting again. I have explained to everyone that the vaccine is beneficial for the children and that children need to be vaccinated every time we visit to be protected.”

It is the first day of a vaccination campaign, which aims to immunize over 6 million children against polio in Afghanistan.

Today, thankfully, all families have accepted the vaccine from this team.

Last push to eradicate polio in Afghanistan

Afghanistan is one of the last countries in the world where wild poliovirus still circulates, and has the highest number of children paralyzed by the virus.

In 2017, there were a total of 14 cases and, so far in 2018, there have been three confirmed cases. In recent months, the virus has been found circulating in southern and eastern regions.

WHO Afghanistan polio programme manager Dr Hemant Shukla is confident that with stepped-up efforts, the circulation can be stopped. “Afghanistan has stopped transmission in the past in all areas, but not at the same time. We are confident that by following correct strategies, focusing in the right areas and by coordinating our efforts with neighbouring Pakistan, we can stop the transmission”.

To answer to the challenge, the Polio Eradication Initiative has stepped up efforts to detect any viruses in the environment. The programme is taking special steps in the eastern and southern regions to reach all children with the vaccine every time the vaccinators pass by, as these are very high risk areas for polio transmission, with people moving in and out of neighbouring Pakistan. Special outreach tactics are concurrently aiming to reach and immunize ‘mobile populations’, such as nomadic people, who are at high risk of contracting polio.

The oral polio vaccine is effective as it not only protects children from contracting the virus, it also prevents them from carrying it in their intestines. Several doses – spaced apart – need to be given to build sufficient immunity, especially in areas where poor nutrition can weaken immune systems.

During the low transmission season, the Polio Eradication Initiative conducted two campaigns – in January and February – in order to vaccinate children in high risk and very high risk districts in quick succession so that the vaccine would have a maximum effect.

In March, 10 million children across the whole country will be vaccinated – that’s every single child under the age of five years.

In Kabul, one by one the team marks their tally sheet with numbers and ages of the children and takes note whether all the children of the household were present.

One of the children vaccinated today is three-year-old Haroon, who stands outside his family’s home. His mother Nadia peeks through the gate. She has six children, and Haroon is her youngest.

“Haroon was just vaccinated two weeks ago, but I know it is important to vaccinate children every time”.

The team marks this household vaccinated for today.

In four weeks, Nadia will open up her door when the vaccinators knock again.

Children living in Raqqa, Syria, were immunized to rapidly raise population immunity, and stop the virus in its tracks. ©WHO Syria

The year’s end offers the chance to reflect on the polio programme’s milestones and challenges in 2017, and look ahead to what we can achieve in the coming year. 2017 saw the fewest wild polio cases in history — a total of 17 cases, or a 50% reduction from the year before—with these cases occurring in just two countries: Afghanistan and Pakistan. Yet the need to reach every last child is more important than ever, as demonstrated by surveillance gaps in Nigeria and outbreaks of vaccine-derived polio in Syria and the Democratic Republic of the Congo.

From programme strategies that helped protect progress and overcome obstacles, to commitments from donors and partners, 2017 demonstrated the resolve required to achieve a polio-free future. Accelerating progress in the new year and ending polio for good will require maintaining these political and financial commitments as well as building upon the programme’s efforts to find the virus wherever it exists.

Rooting out the virus

Throughout 2017, developments in disease surveillance – both in humans and in the environment – allowed the programme to better hone in on the virus and identify its remaining hiding places.

The drive to vaccinate every last child continued at the Afghanistan-Pakistan border. ©WHO / S.Ramo

For example, in Afghanistan, blood tests helped pinpoint which children have been reached and where gaps in immunity persist, allowing health workers to launch targeted vaccination responses. In Sudan, a pilot study used a new method of quality control to help ensure that stool samples arrive at the lab in the right condition for testing. And throughout the Eastern Mediterranean Region, environmental surveillance networks were expanded and strengthened.

These innovations are building robust, sensitive surveillance networks around the world that pick up every trace of the virus and enable the programme to develop targeted immunisation responses before polio has the chance to paralyse children.

Our surveillance teams worked to root out the virus in its remaining hiding places. ©GPEI

Overcoming challenges

The year also came with new challenges, including outbreaks of circulating vaccine-derived polio in Syria and the Democratic Republic of the Congo, where conflict has ravaged the health infrastructure. In these communities, and others where polio still exists, difficult terrain, conflict and highly mobile populations can all stand as hurdles to vaccinating children. Yet the polio programme continues to find new and effective ways of delivering vaccines.

Over 450,000 children were vaccinated against polio in Kabul, Afghanistan, in December 2017. ©WHO / Tuuli Hongisto

For example, in Afghanistan, a collaboration with a mobile circus is sharing important messages about polio vaccination with hard-to-reach populations, including those living in camps for internally displaced persons. In Pakistan, campaigns based at border crossings and train stations vaccinated children on the move who might otherwise have been missed by traditional methods. And in Syria, dedicated workers are delivering vaccines at transit points and registration centres for internally displaced persons. Thanks to these strategies, more than 255,000 children have been vaccinated in Deir Ez-Zor, 140,000 were reached in Raqqa and the programme continues to work to reach every child.

The mobile circus passed on vital health care and social messages, encouraging full immunization of every child. UNICEF Afghanistan / Ashley Graham

Renewed commitment to end the disease

Complementing these programmatic innovations were political and financial commitments that highlighted polio eradication as a priority for global health leaders. These included:

In May, the World Health Assembly reiterated the importance of eradicating polio and strategically transitioning the programme’s assets, and the G20 Health Ministers recognized the contribution of the polio infrastructure in helping countries face health emergencies during their first-ever meeting in Berlin.
At the Rotary International Convention in June, health leaders gathered and pledged US$1.2 billion to end polio. Just months later, the UK demonstrated its own longstanding commitment to eradication with a $130 million pledge.
At the G7 Health Ministers meeting in November, leaders once again affirmed their dedication to polio eradication as part of their broader commitment to strengthen health systems.

A child is vaccinated in Afghanistan during the September 2017 campaign. ©WHO / S.Ramo

Looking ahead to 2018

Next year, country programmes will need to continue working to ramp up surveillance, particularly in Nigeria, and reach children everywhere with vaccines. Cross-border coordination between Pakistan and Afghanistan, which has already had a huge impact in reducing cases, will continue to be critically important to stopping transmission.

At the same time, the global community is beginning to solidify plans for keeping the world polio-free once eradication is achieved. Countries are developing strategies for transitioning the infrastructure and tools that they currently use to fight polio. And the GPEI is working with global stakeholders and partners to develop the Polio Post-Certification Strategy, which will define the activities needed to keep polio from returning after the virus is eradicated.

If the remaining endemic countries continue to do all that they can to stop the virus, and if the global community continues to meet the level of political and financial commitment needed to make and keep children everywhere polio-free, 2018 will bring the world’s best opportunity yet to end the disease.

In Somalia, a Member State of the Organization of Islamic Cooperation, Minister of Health Dr Fawziya Abikar Nor (right), and Dr Ghulam Popal, WHO Representative for Somalia, vaccinate a child against polio. ©WHO / A.Wolasmal

The Organization of Islamic Cooperation has celebrated the efforts of its Member States to eradicate polio and is working to ensure that eradication remains at the top of national health agendas. In a resolution passed at the sixth session of the Islamic Conference of Health Ministers, held in Jeddah in early December, the Organization of Islamic Cooperation recognized the importance of ensuring that all children are consistently reached and vaccinated with the polio vaccine. It also highlighted the critical roles of Government leaders and the Islamic Advisory Group in the effort to put an end to the crippling disease.

The Jeddah Declaration

In the Jeddah Declaration, signed by representatives from all Member States, the Organization of Islamic Cooperation reiterated health as one of the basic rights of every human being and reaffirmed their belief that “… the right to health must be at the core of the global agenda.” They reiterated their support to polio eradication and to the full implementation of the Polio Eradication and Endgame Strategic Plan, and recognised the efforts of their Member States to stop transmission. In particular, members were called upon to support the work of the remaining polio endemic countries – Afghanistan, Nigeria and Pakistan – and for the Islamic Advisory Group to continue their work to support the Global Polio Eradication Initiative. The resolution issued at the end of the conference also called upon Member States and other donor entities to provide the necessary financial support that would allow the Islamic Advisory Group to continue its work.

High level support in action in Somalia

Just days after the commitment of member states was reemphasised, the Minister of Health of Somalia Dr Fawziya Abikar Nor showed her commitment to eradication by attending a polio vaccination campaign, alongside Dr Ghulam Popal, WHO Representative for Somalia. High level government commitment has been one of the most important components of eradication in some of the most challenging countries around the world.

Crowds gather as Minister of Health Dr Fawziya Abikar Nor, and Dr Ghulam Popal, WHO Representative for Somalia attend a polio vaccination campaign following the declaration. ©WHO / A. Wolasmal

A boy getting vaccinated against polio in school during a campaign in Lahore, Pakistan in May 2018. © WHO EMRO / Anam Khan

With polio at the lowest levels in history in Pakistan, the country is about to launch an all-out and hopefully final assault on the disease in 2018. To help these emergency efforts, the Government of Germany announced today an additional € 2 million in financial support, to Pakistan’s national emergency action plan. Germany is a longtime supporter of the Global Polio Eradication Initiative (GPEI) with contributions totaling more than US$ 550 million to the effort, not including a recently announced additional pledge of € 19.9 million to Nigeria’s polio eradication effort for 2018. For its engagement in polio eradication, including in fostering global commitment, Germany has on numerous occasions been internationally recognized at the highest levels. Chancellor Angela Merkel is a past recipient of Rotary International’s prestigious Polio Champion Award.

The Global Polio Eradication Initiative partners would like to extend their profound gratitude to both the Government of Pakistan and Germany for their collaboration and for their tremendous support and engagement in the effort to eradicate polio globally.

A WHO worker oversees vaccination campaigns in Raqqa, Syria, following the polio outbreak. © WHO Syria

Amidst conflict and humanitarian crisis in Syria, health workers are battling to end the current polio outbreak. Since the World Health Organization announced the outbreak on 8 June 2017, 70 cases have been confirmed, with 67 in Deir Ez-Zor governorate, two in Raqqa and one in Homs.

Vaccinating children

WHO and UNICEF are supporting the Government of Syria and local authorities to end the outbreak. Two mass vaccination campaigns have taken place, thanks to dedicated health care workers on the ground, striving to reach resident, refugee and internally displaced children. Despite the challenges of holding vaccination campaigns in a conflict zone and effectively reaching displaced populations from infected areas, more than 255,000 have been vaccinated in Deir Ez-Zor, and more than 140,000 in Raqqa.

Contingency plans for an additional vaccination campaign are being put in place to reach children under the age of five with monovalent oral polio vaccine type 2 in the infected zones and areas hosting high risk populations, particularly recently displaced families from Deir Ez-Zor.

Two different vaccines are being used to ensure that population immunity against polio is rapidly increased. The monovalent oral polio vaccine type 2 is being used to rapidly increase immunity against type 2 polio. To boost immunity against type 2 and also provide protection against types 1 and 3, the inactivated poliovirus vaccine is also being provided to children aged between 2 and 23 months in high risk areas.

Preventing spread of polio

While all hands are on deck to stop polio, outbreak response teams are also working hard and adapting complementary strategies such as vaccination at transit points and registration centres for internally displaced persons from infected zones, to prevent spread of the virus to other parts of the country. The inactivated poliovirus vaccine is being used strategically in high risk areas, especially where there are high numbers of internally displaced families.

In order to reduce the threat of polio spreading to the countries surrounding Syria, vaccination activities have been carried out in Iraq, Lebanon and Turkey. These activities are aiming to reach both Syrian children and those from local communities to limit the possibility for the virus to spread across international borders.

Searching for the virus

Knowing where the virus is at all times is crucial to stop the outbreak. Surveillance is ongoing across the country, with doctors, community members and vaccinators on the alert for any child with potential symptoms of polio. The surveillance system is operating well, despite the challenges of transporting stool samples from children with symptoms to laboratories for testing.

Plans are also in place to begin environmental surveillance in Syria by the end of the year. This will enable laboratories to identify the presence of polio in sewerage to provide early warning.

The information from disease surveillance being used to inform where and when vaccination campaigns need to take place.

Vaccine derived polio

The current outbreak in Syria is caused by circulating vaccine derived poliovirus type 2, a very rare virus that can occur when population immunity against polio is very low. In Syria, conflict and insecurity have compromised community access to immunization services, which has allowed the weakened virus in the oral polio vaccine to spread between under-immunized individuals and, over a long period of time, mutate into a virulent form that can cause paralysis. The only way to stop transmission of vaccine-derived poliovirus is with an immunization response, the same as with any outbreak of wild polio. With high levels of population immunity, the virus will no longer be able to survive and the outbreak will come to a close.

A mother helps to reduce outbreak risk by allowing her child to be immunized. © WHO

“I was told that if the child was vaccinated against polio, he could one day become a great footballer like Drogba and Yaya Toure…Today, they have not yet become like Drogba and Yaya, but they are in good health.”

– Awa B., mother of five children, Côte d’Ivoire

Today, the countries most vulnerable to poliovirus outbreaks are those where the barriers to effective immunization are most acute. In high-risk countries like the Central African Republic and Côte d’Ivoire, populations are hard to access and persuading communities of the need to vaccinate can be difficult.

For polio workers in these countries, it is important to reduce outbreak risk through strategies that involve local people, and which are receptive to the local surroundings and culture. Not every child will grow up to be a champion footballer, but by persuading parents of the importance of immunization, they can grow up active and healthy, protected from the debilitating effects of polio.

The risk of polio outbreak

The Central African Republic and Côte d’Ivoire are both considered outbreak risk countries due to their difficult political and security situations, weak health-care systems, and regular cross-border population movement.

Geographically close to Nigeria, one of the last three polio endemic countries, the Central African Republic is currently at risk of virus spread from Borno state where there was a poliovirus outbreak in 2016. In 2011, Côte d’Ivoire experienced an outbreak of wild poliovirus type 3, also originating from Nigeria.

A child is vaccinated against polio in the Central African Republic. November 2017 © UNICEF CAR

Outbreak prevention is a central part of the strategy to end polio, as the spread of the poliovirus through under-immunized populations could make eradication more of a challenge. In high risk countries where delivering vaccine can be difficult, different methods must be used to comprehensively immunize every last child.

Getting the local community involved

In Côte d’Ivoire, a round of National Polio Vaccination Days officially began on October 28^th in Ebimpé, marked by a ceremonial gathering of vaccination partners alongside key members of the local community. Speaking at the event, the Minister of Health and Public Hygiene, Dr Raymonde Goudou Coffie, described the need to vaccinate every last child as a mission for everyone: “Traditional leaders, heads of households and communities need to be involved in this initiative.”

This is a powerful method of engagement – making sure that parents and local leaders, as well as health workers and volunteer vaccinators, are involved in the fight against poliovirus.

No one approach fits all

Vaccinators also understand that no single approach will fit every situation. Instead, the Global Polio Eradication Initiative partners and field workers must work hard to understand how best to communicate the risk of polio outbreaks to different communities.

For instance, to reach parents working in Nana Mambere prefecture of the Central African Republic, local radio station SIRIRI hosted a panel based radio discussion to mark the recent vaccination campaign. Featuring medical professionals and local politicians, the panel addressed community worries around vaccine, urging every parent listening to take their young children to be immunized.

The day before the October campaign in Côte d’Ivoire, an advance team of volunteer vaccinators in Grand-Bassam began vaccinating at the local weekly market. Knowing the routine of local women, they anticipated that there would be some children visiting the market with their mothers who might not be reached later in the week – making this gathering of the community too good an opportunity to miss.

Health workers mobilize communities in Côte d’Ivoire, September 2017. © Rotary International — Health workers mobilize communities in Côte d’Ivoire. September 2017 © Rotary International

Having an understanding of the communities targeted in campaigns, whether of their worries around vaccination, or even parents’ weekly schedules, is crucial to effectively reduce the risk of a polio outbreak.

Providing broader benefits

In Côte d’Ivoire, Dr Bamba Souleymane, Departmental Director of Health in Grand-Bassam, noted the quantity of different health interventions that his team was attempting to successfully deliver. Alongside the polio vaccine, the volunteers were distributing impregnated mosquito nets, de-worming medication, and vitamins.

Such combined efforts use the GPEI’s well-established infrastructure to deliver a variety of desirable health benefits in communities, not polio vaccine alone. In places where the health infrastructure can be weak, the polio programme’s ability to reach remote children can be a big advantage for many reasons.

For Awa, the dream of her son becoming a champion footballer was a persuasive reason to take him to be vaccinated. For others, receiving different health benefits or hearing information via radio are compelling reasons to vaccinate their children.

Lowering the chance of an outbreak is never a straightforward process, but instead requires understanding parents, children, and communities.

The best vaccinators and campaign planners are able to spot opportunities to keep campaigns relevant, access groups in different ways, and ensure that coverage is sustained.

This way, we can successfully protect every last child.

Mother Hadiza holds her 2-year-old daughter Hafsat as she receives oral cholera vaccine (OCV) at a health camp in Maiduguri, in Nigeria’s conflict-affected north-eastern state of Borno. Hafsat will receive vital vaccinations against polio, cholera and measles and other routine immunization antigens with support from UNICEF-trained network of Volunteer Community Mobilisers, a workforce established to support the polio eradication effort. © Unicef

In Nigeria’s north-eastern Borno state, children displaced by ongoing conflict are being reached with essential immunization and health care services, thanks to a strong network of Volunteer Community Mobilisers established by the polio eradication programme.

Two-year-old Hafsat Khalifa waits patiently in line with her mother, Hadiza. Hadiza is one of many women who’ve brought their young children to receive vital immunization at the local health camp in Maiduguri. Hafsat knows she needs to open her mouth wide when it’s her turn to receive the oral cholera vaccine just like she did when vaccinated with the Oral Polio Vaccine. She displays the confidence of a seasoned pro, although in reality this is the first year she has received any health services, having been born into an area of conflict. Along with these two vaccines, Hafsat will receive other much-needed health care during today’s visit.

Humanitarian crisis

Hafsat is one of many thousands of children affected by the humanitarian crisis in north-eastern Nigeria. The conflict has resulted in a surge in internally displaced persons, with limited access to medical care, leaving millions at risk of life-threatening diseases. Since four cases of wild poliovirus type 1 were detected in Borno in August 2016, an outbreak response for polio has been a top priority. But it has been carried out hand in hand with broader humanitarian efforts to meet the health needs of vulnerable populations.

Benefits beyond polio eradication

UNICEF’s vast network of volunteer community mobilisers have not only played a vital role in ensuring that children like Hafsat receive OPV and other health services every time they are offered, but are leveraging the skill-set they’ve gained from their expanded training to impact child and maternal health far beyond polio.

In addition to receiving the oral cholera vaccine today, Hafsat’s nutrition status will be assessed at the health camp, and children identified as malnourished will be referred for receiving therapeutic food. This important network of polio vaccinators, with years of experience in reaching children with polio vaccines, has made a huge difference in halting the spread of cholera and meningitis outbreaks in Nigeria in 2017. They are also helping create awareness and generate demand for the upcoming campaign against measles.

The reach of this network even extends to protecting children before they are born. Volunteer community mobilisers provide critical antenatal care for pregnant women that can save the lives of mothers and babies alike. And this year, for the first time ever in an emergency humanitarian setting, antimalarial medicines have been delivered on a mass scale alongside the polio vaccine, reaching 1.2 million children in a campaign in August.

For families in Nigeria’s north-east, many who have fled their homes in the face of ongoing violence, this life-line to access essential services is critical to ensuring their children can grow up protected from vaccine-preventable diseases.

Polio worker Imran Khan vaccinates a child at Karachi Cantonment Railway Station ©WHO/J. Muhammad

Dressed in a blue uniform, carrying a vaccine carrier on his shoulder, Imran Khan is a polio vaccinator working at Karachi Cantonment Railway station. “I make sure no child under five travelling by train is missed during the immunization campaign,” he says. Apart from vaccinating children, Imran also sensitizes their parents on the importance of vaccination and threats posed by the crippling disease.

Vaccinating children inside trains is a unique initiative introduced in Pakistan’s Sindh province which is connected with the rest of country through a railway network that transports millions of people every day. Passengers include people travelling to visit family and communities living on the border between Pakistan and Afghanistan as well as seasonal migrants and displaced populations. With many of these people moving between areas where polio continues to circulate, the threat of the virus continuing to survive as it moves from place to place via this human network is one of the biggest challenges the programme is facing. Reaching children on the move with the polio vaccine is therefore critical for stopping the virus.

Currently there are more than 500 permanent transit points across the country, where vaccination teams work to vaccinate all children under the age of five as they cross district, provincial and national borders. The strategy to vaccinate children inside trains themselves was started in Pakistan’s Sindh province in January 2017. Since then, during each vaccination campaign, polio workers vaccinate children travelling on the popular rail route between Karachi and Hyderabad, Sindh’s two biggest cities, which was selected for the project implementation.

“During campaign days, I travel from Karachi to Hyderabad on a daily basis. Along with other team members, we visit all the train compartments to vaccinate each and every eligible child”, says Imran Khan with passion in his voice.

Team of vaccinators get on a train at Karachi Cantonment Railway station ©WHO/J. Muhammad

According to Dr Nawab Khan, High Risk Mobile Population coordinator with Pakistan’s Polio Eradication Initiative: “To maintain and increase population immunity against polio in Pakistan, reaching children through public transport routes is an effective outreach strategy. It plays an important role in interrupting the transmission of poliovirus and represents a great opportunity to vaccinate children missed during door-to-door immunization campaigns.”

More than 24 thousand children have been vaccinated inside trains running between Karachi and Hyderabad since the project started.

It is thanks to the use of innovative strategies such as this one that the Pakistan Eradication Polio Programme has come so close towards achieving a future in which polio no longer endangers children, families, and communities. The progress can be seen in the declining number of wild poliovirus (WPV) cases in Pakistan: from 306 cases in 2014, to 54 in 2015, and 20 in 2016. As of October 2017, the total number of WPV cases reported in Pakistan stands at five.

A child in Nigeria is given a dose of antimalarial medication alongside a polio vaccine in a coordinated campaign. © WHO/P. Utomi Ekpei

The people working to end polio are helping broader humanitarian response efforts in north-eastern Nigeria. With malaria currently claiming more lives than all other diseases put together, a campaign was launched in October to reduce the malaria burden among young children in Borno state by delivering antimalarial medicines. At the same time, community health workers protected children against polio.

“The current campaign marks the first time that antimalarial medicines have been delivered on a mass scale alongside the polio vaccine in an emergency humanitarian setting,” said Dr Pedro Alonso, Director of the Global Malaria Programme, in an interview with WHO on the campaign and the broader humanitarian situation in Borno. “This integrated campaign with WHO’s polio and health emergency teams is an example of unprecedented collaboration to tackle the leading cause of death in a displaced population.”

The humanitarian crisis in north-eastern Nigeria has resulted in a surge in internally displaced persons, with limited access to medical care, leaving millions at risk of life-threatening diseases. In August 2016, four cases of wild poliovirus type 1 were detected in Borno; the outbreak response has been carried out hand in hand with broader humanitarian efforts to meet the health needs of vulnerable populations.

WHO’s well developed network of polio vaccinators, with their years of experience in reaching children with polio vaccines, is making a real difference to the drive against malaria. The polio programme in Nigeria has a vast infrastructure and hundreds of staff on the ground and they are coordinating efforts to make sure that families affected by the crisis have access to other healthcare services.

As a result, the campaigns have reached 1.2 million children with polio vaccines and antimalarial medicines, as shown through a WHO photo story. “I think we will imminently be able to show significant impact,” said Dr Matshidiso Moeti, Regional Director for Africa, reflecting on the encouraging results of the joint campaign.

Malaria campaign saving young lives in Nigeria: Interview with Dr Pedro Alonso, Director of the WHO Global Malaria Programme

Photo story: Integrated campaign tackles malaria and polio in north-eastern Nigeria

Polio workers join the cholera battle in northeast Nigeria

Between campaigns, polio workers bring broad benefits

Abdullah Khalid marks a child’s finger with indelible ink at the Torkham border between Afghanistan and Pakistan in September 2017. © WHO/S.Ramo

Malik is one of the hardworking vaccinators making sure that even children on the move are protected against polio.

The poliovirus knows no borders, making children on both sides of the border between Afghanistan and Pakistan vulnerable to contracting the debilitating disease. This is why, placed strategically along the border, 19 WHO-supported vaccination posts reach children on the move as they cross between countries, ensuring that all children under the age of 10 receive two drops of the oral polio vaccine to protect them from polio.

One of these teams is led by Malik, who has worked for the polio eradication programme for 14 years.

“I wanted to join the eradication programme when I heard that polio is a contagious disease that affects children. I wanted to serve children and our community. I learned about polio on the TV and radio and the health workers who came to our home to share information about the virus.”

Protecting children on the move

Malik started working as a vaccinator and has now worked as a team supervisor for the past 10 years.

“I am proud when we can reach every child and when I see my team vaccinating children, making sure that no child is missed. This makes me very happy,” he says.

Cross-border vaccination teams are crucial in the fight against polio. The Torkham border between Afghanistan and Pakistan, in eastern Nangarhar province, is one of the busiest border crossings in Afghanistan. Currently 38 WHO-supported vaccinators work in three shifts, operating 24 hours a day, 7 days a week.

“Today I started my work at 5.30 am. When we arrive at work in the morning, I gather the team together and we go through any issues that arose in the previous shift. We revise the schedule of the day and I assign teams to their specific locations. We have three locations at this border where we vaccinate all children coming to Afghanistan and those who are leaving.”

Abdullah Khalid and his team approach a truck at the Torkham border vaccinate all children arriving to Afghanistan. © WHO/S.Ramo

Checking for signs of polio

Since January 2017, WHO and partners have vaccinated over 44 000 Afghan children under the age of 10 crossing the border to Afghanistan from Iran and Pakistan. Over 25 000 of these have been vaccinated at the Torkham border’s so called “zero point” – the first point where Afghan refugees and returnees returning from Pakistan arrive.

“We focus a lot of finding cases of acute flaccid paralysis, sudden onset of floppiness in the limbs that is a sign of polio. We check children in all the vehicles that arrive at the border and work hard not to miss any potential polio cases,” Malik says. “When the trucks park here, we talk to the parents and ask about any possible cases of paralysis in the family. We also educate them about the importance of vaccines and tell them about the routine immunization services that are available free-of-charge in Afghanistan’s health facilities.”

Building trust

Most caregivers crossing the border to Afghanistan accept the polio vaccine but challenges remain.

“Sometimes we see parents who refuse to vaccinate children. We try our best to convince them to vaccinate by telling them more about the benefits of the polio vaccine and how polio cannot be cured. Those who refuse to vaccinate their children often don’t understand what the vaccine is or how it is essential for protecting their children,” Malik says.

Despite difficulties and his demanding work in a challenging environment where the security situation can shift quickly, Malik and his team are determined to continue the fight against polio.

“Afghanistan is still polio-endemic and the virus is deadly,” he says as he leads his team to approach another truck that crossed the border into Afghanistan. “I want to deliver these crucial services, serve my community and protect vulnerable children.

News Category: Vaccination campaigns

Planning the route

The journey

Arrival

The results

For more stories about women on the frontlines of polio eradication

Rooting out the virus

Overcoming challenges

Renewed commitment to end the disease

Looking ahead to 2018

The Jeddah Declaration

High level support in action in Somalia

Vaccinating children

Preventing spread of polio

Searching for the virus

Vaccine derived polio

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Humanitarian crisis

Benefits beyond polio eradication

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Planning the route

The journey

Arrival

The results

For more stories about women on the frontlines of polio eradication

Vaccinating adults

Surveillance

Collaboration

Watch more in the polio eradication animation series

Rooting out the virus

Overcoming challenges

Renewed commitment to end the disease

Looking ahead to 2018

The Jeddah Declaration

High level support in action in Somalia

Vaccinating children

Preventing spread of polio

Searching for the virus

Vaccine derived polio

Read more

The risk of polio outbreak

Getting the local community involved

No one approach fits all

Providing broader benefits

Humanitarian crisis

Benefits beyond polio eradication

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