The Pakistan polio snapshot gives a monthly update on key information and activities of the polio eradication initiative in Pakistan.
September updates include:
No new cases of polio reported since the August update – the total for 2017 is five
The first country-wide immunization campaign of the current low season for poliovirus transmission took place – 38 million children under 5 years were vaccinated.
According to independent post-campaign monitoring, the September National Immunization Days has been one of the best campaigns this year.
The September campaign set the foundation for eradicating the virus from the last remaining areas of Pakistan.
The Afghanistan polio snapshot gives a monthly update on key information and activities of the polio eradication initiative in Afghanistan.
In September:
No new cases wild of poliovirus were reported.
Two new WPV1 positive environmental samples were reported in Kandahar province.
National vaccination campaigns were carried out across all 34 provinces, aimed at reaching over 9.9 million children under 5 with oral polio vaccine OPV.
Permanent transit teams successfully vaccinated 1,131,231 children against polio, and cross-border teams vaccinated 101,784 children.
Afghanistan is closer than ever to eradicating polio. Through this photo essay, discover 10 innovative approaches that are bringing Afghanistan closer to ending polio, for good.
WHO Afghanistan/S.Ramo
1) Giving children a second shot at protection
During vaccination campaigns, healthcare workers knock on every door around the country to deliver polio vaccines. But when a child is not at home to receive the vaccine it can mean that they are left vulnerable to the poliovirus. To address this problem, vaccinators now return to any household where a child was missed to give them a second shot at protection a few days after the campaign has taken place. In this photo, Zahra marks the pinky finger of a child after vaccinating her during a picnic in a women’s garden in Kabul on a Friday re-visit.
WHO Afghanistan/S.Ramo
2) Keeping all eyes on the virus
Even in areas where conflict makes it challenging, a network of people across Afghanistan are on the alert for the poliovirus. Over 28 000 people including volunteers, health workers, teachers, religious leaders and traditional healers look for signs of polio, such as floppy or weakened limbs and a fever. This network of committed individuals has grown nearly 20% over the past year.
WHO Afghanistan/S.Ramo
3) Expanding environmental surveillance
As well as looking for the symptoms of polio, Afghanistan continues to step up the hunt for the poliovirus in the environment. Currently, water samples are taken from 20 sites in nine provinces to be tested in the laboratory. Four new environmental sampling sites have been established in 2017 and sampling frequency has been doubled in high-risk areas in the south. This helps determine how the virus is spreading around the country and to find it even before it can cause paralysis so that campaigns can be held to stop it.
WHO Afghanistan/S.Ramo
4) Vaccinating children on the move
Afghanistan has deployed 42 vaccination teams at 18 border crossing points with Pakistan and the Islamic Republic of Iran. Every month, these teams vaccinate on average more than 105 000 children under 10 years of age crossing the border. In 2016 alone, the teams vaccinated over a million children against polio.
Since January, over 42 000 children returning to Afghanistan from Pakistan have received the oral polio vaccine and 18 000 children have been vaccinated with the inactivated polio vaccine at UNHCR and IOM reception sites near the border. In addition to vaccination, teams collect information on where the families are headed to ensure that they receive the follow up doses they need to ensure that they are fully protected.
WHO Afghanistan/S.Ramo
5) Reaching children in inaccessible areas
Permanent transit teams help to reach children in inaccessible areas with vaccines. Currently 387 permanent transit teams, up from 163 in 2016, are stationed in strategically selected locations such as informal border crossings, busy transport hubs, major market places, health facilities and entry/exit points of inaccessible areas. The teams vaccinated over 10 million children in 2016.
WHO Afghanistan/S.Ramo
6) Training frontline health workers and engaging women
The success of polio eradication depends on the single moment that a healthcare worker knocks on the door of a child who needs the vaccine. All polio frontline workers, over 65 000 Afghan men and women, have been given training to help them engage families and vaccinate every last child. The polio programme has also been working to employ more women; the countrywide proportion of female vaccinators is 12%; however, in the urban areas the proportion of female polio workers has already reached 45%. This can help reach more children in more traditional areas of the country.
WHO Afghanistan/R. Akbar
7) Validating and revising microplans
Comprehensive microplans are at the core of successful vaccination campaigns, mapping where communities and households are located in each area and how many children live there. Before every campaign, each local microplan is updated using new technology and local knowledge. This process results in finding previously unreached villages and children as well as in streamlining workloads of vaccination teams, supervisors and district coordinators.
WHO Afghanistan
8) Reaching nomadic groups
Special strategies are in place across the country targeting nomadic groups based in Afghanistan as well as nomads who enter Afghanistan from Pakistan and move widely in the country before returning to Pakistan. Their routes, seasonality and places of settlements are known and the dates of special campaigns targeting the children of nomadic groups are adjusted accordingly. Special Permanent Transit Teams are deployed along the major movement routes in the Southern and Western regions, and nomadic settlements are included in supplementary immunization activity microplans across the country.
WHO Afghanistan/J.Jalali
9) Engaging religious leaders
Religious leaders have become increasingly involved in polio eradication efforts in Afghanistan in the last years, spreading messages about the benefits of polio vaccines during Friday sermons and convincing caregivers in their communities to vaccinate children. So called “mobile mullahs” visit refusal families to talk about Islam’s support to vaccines.
WHO Afghanistan/J.Jalali
10) Stepping up cross-border collaboration
The virus moves between Afghanistan and Pakistan unchecked by the border, meaning that the countries need to work together as one unit to stop it. The polio programmes in both countries have intensified coordination, with more regular communication and information sharing about population movements. Vaccination campaigns are held at the same time and if any case of acute flaccid paralysis is found, both countries are informed so that efforts can be scaled up in that area.
The Afghanistan polio snapshot gives a monthly update on key information and activities of the polio eradication initiative in Afghanistan.
August updates include:
One new case of wild poliovirus was reported, bringing the total number of cases to 6 in 2017
National vaccination campaigns were carried out across all 34 provinces, aimed at reaching over 9.9 million children under 5 with oral polio vaccine OPV
Over 155,000 children were reached in IPV-OPV campaigns across 8 districts in the Southern region
Vaccinators visiting an IDP camp in Raqqa. Photo: WHO Syria
Three mass immunization rounds have been carried out in Deir Ez-Zor and Raqqa governorates, Syria, in response to an outbreak of circulating vaccine-derived poliovirus type-2 (cVDPV2). The latest round, targeting resident, refugee and internally displaced children less than five years in Deir Ez-Zor concluded 28 August.
“The detection of circulating vaccine-derived poliovirus indicates that there has been low population immunity in affected areas for a considerable period of time,” said Chris Maher, manager of WHO’s regional polio eradication programme based in Amman, Jordan. “WHO is working with all parties on the ground to ensure access to and vaccination of all children under five in these areas, to put an end to this outbreak as quickly as possible,” he said.
As of the end of August, 39 cases of cVDPV2 have been confirmed in Syria ‒ 37 cases from Deir Ez-Zor governorate, and 1 case each from Raqqa and Homs governorates. All three governorates are affected by active conflict.
“Conflict and inaccessibility continue to hamper efforts to raise population immunity levels in areas across the country. These same factors that paved the way for the outbreak of wild poliovirus in Syria in 2013,” said Maher. “We are using the same approaches to achieving access that were successfully used in responding to the 2013 outbreak, and working together with all partners to make sure that children can be reached with vaccine,” he added.
In addition to ensuring access for vaccination teams, innovative methods have been used to increase response reach and effectiveness. The advertising of campaigns through bakeries, and engagement of a local ice cream factory to assist with the daily freezing and refreezing of ice packs for vaccinator cold boxes, are examples.
“Vaccinators on the ground in Deir Ez-Zor and Raqqa continue to face difficult circumstances, but their efforts show clear dedication to protect children against this preventable disease,” said Maher. “We must maintain this high level of commitment and drive,” he said.
Deir Ez-Zor has carried out two mass immunization rounds in July and August while Raqqa has carried out one. The second round for Raqqa is planned for after the Eid holiday.
Inactivated polio vaccine (IPV) is being given to targeted children in each of the second rounds along with the oral vaccine to maximize individual and community protection.
“These local polio vaccination campaigns represent a significant step that has culminated in the close cooperation between WHO, UNICEF and local health partners to reach all targeted children under five in Ar-Raqqa and Deir Ez-Zor governorates,” said Elizabeth Hoff, WHO Representative in Syria.
“Despite security challenges, WHO is committed to ensure the distribution of polio vaccines and the implementation of the local campaigns as planned with a view to achieving sound wellbeing and growth for children with a special attention given to the affected governorates,” Hoff added.
In addition to supporting the response, WHO and partners are also working with neighboring countries to enhance immunization and disease surveillance activities in high-risk areas.
Circulating vaccine-derived poliovirus can occur in rare instances when population immunity against polio is very low. In these settings, the weakened virus found in the oral polio vaccine can spread between under-immunized individuals and over 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.
In July and August, vaccination campaigns were held in Deir Ez-Zor and Raqqa governorates to stop an outbreak of circulating vaccine-derived poliovirus type 2 (cVDPV2).
Photo: WHO Syria
In preparation for the campaigns, polio vaccine was transported long distances to reach Deir Ez-Zor and Raqqa governorates. Careful storage and temperature controls were required to ensure vaccine quality was maintained as it travelled in high temperatures across rugged terrain.
Photo: WHO Syria
This picture shows monovalent oral polio vaccine type 2 (mOPV2) arriving in Deir Ez-Zor in good condition. Both mOPV2 and inactivated polio vaccine (IPV) are being used in the response. The first vaccination round in Deir Ez-Zor, which ran from 22 to 26 July 2017, aimed to reach 328,000 children under 5. The first round of vaccinations in Raqqa ran from 12 to 17 August, and aimed to reach 120,000 children.
Photo: WHO Syria
In the lead up and during the campaigns, social mobilizers used a range of approaches to ensure high levels of community awareness of campaign activities. One such approach was the inclusion of information about the campaigns in bread packages.
Photo: WHO Syria
Social mobilizers also travelled from house to house during the campaign to talk to families about polio vaccination activities, and the importance of the polio vaccine to protect their children from the potentially paralytic disease.
Photo: WHO SYria
A child in Raqqa receiving mOPV2. The objective of the campaign is to protect every child and rapidly raise population immunity to stop the virus in its tracks.
Photo: WHO Syria
This health worker is giving mOPV2 to a child in a camp for internally displaced people in Raqqa. More than 10,000 internally displaced children were included in Raqqa campaign plans.
Photo: WHO Syria
These children from a camp in Raqqa show off their finger markings, to demonstrate that they have been vaccinated against polio during the campaign.
Africa’s last case? Two-year-old Yafanna Mamma, held by her mother, Yagamallam, in a photo captured by the polio case investigation team. Photo: GPEI
The photo shows a little girl in a blue dress, resting against her mother’s shawl, a tiny green heart hanging from her ear.
It is just over 12 months since two-year-old Yafanna Mamma became Nigeria’s most recently-reported case of wild poliovirus. But this anniversary provides little cause for cheer – last year, Nigeria was about to celebrate two years without any cases, only for four infants to arrive from deep inside conflict-affected territory, in the remote north-eastern state of Borno, paralyzed by polio. Yafanna was the last of them, arriving in the northern Nigerian outpost of Monguno malnourished and sickly.
The discovery of polio in these children underlines the challenges facing the polio eradication programme – and many other health and development initiatives – working in conflict zones. Amidst the ongoing humanitarian crisis in North-Eastern Nigeria, at least 200,000 children are estimated to still live in inaccessible areas, where insecurity is a constant threat. All humanitarian activity, including vaccination campaigns and disease surveillance, is made all the more difficult across these areas, and there is a significant risk that poliovirus continues to hide undetected, spreading among unvaccinated children in the area.
Yafanna’s paralysis was a lesson that when vaccination and disease surveillance efforts pose such a challenge, finding no polio cases does not mean that there is no virus.
Yafanna’s family – father Ali, mother Yagamallam and their two surviving sons – are a living example of the consequences of conflict on the health of families. Their small village, Zanari, is four hours’ walk into inaccessible territory north-east of Monguno, with no health centre and irregular access to vaccination campaigns.
“Since 2014, there is no health facility,” Ali says softly, seated beside his wife in the WHO-UNICEF joint office in Borno’s capital, Maiduguri. “The closest facility is in Monguno town and walking it takes many hours.”
They made that walk, carrying their infant daughter, two weeks after she had fallen sick with a high fever and they soon noticed she could no longer stand. When they arrived in Mongonu a worried doctor quickly referred them to Maiduguri, where they attended a health facility in a camp for internally displaced people.
“At the health facility they asked us to bring stool samples from our daughter, they gave us medicine, and after we went back home. The fever got better, but she stayed paralyzed.”
After two weeks, the military arrived, guarding a medical team which confirmed that little Yafanna, who had never received any doses of oral polio vaccine, had been found by the poliovirus.
“We had heard of this disease,” Ali says, looking down at the table. “But we didn’t know what it could do. Before the insurgency, vaccinators would visit us with a motorcycle. But after the insurgents came the vaccination teams stopped coming.”
The polio eradication programme is working hard in Nigeria to reach every child with the vaccine, and to find the virus wherever it is hiding. Vaccinators are steadily reaching more children, using strategies such as engaging and collaborating with local communities, vaccinating in camps for internally displaced people, and in different locations like markets and transit points. But there is still much work to do.
Little Yafanna never walked again. Three short months later after her paralysis, she contracted another disease – possibly whooping cough – and on 27 December 2016 after three days of coughing and fever, she died.
Ali now has been engaged to talk with the community about the threat of polio, and the importance of vaccination. “I pray that we can honour her life by making her the last polio case in all of Africa. So that her name is remembered. So that her life is remembered.”
Throughout Kabul, on the many long, grey blast walls that line the city’s roadways, a splash of colour is helping to mobilize caregivers to vaccinate their children against polio.
Afghan NGO The Art Lords, supported by UNICEF, are in the process of painting 250 murals up to 30 feet high and 100 feet wide on high-visibility walls, portraying men and women vaccinating children against polio, accompanied by the slogan ‘Two drops of polio vaccination for every child, up to 5 years of age’.
The project started by Kabul but its popularity has seen it extended to priority cities across the country, with city officials, hospitals and schools approaching the polio programme to ask if their walls can be next.
The Art Lords typically take two days to complete the mural, starting at night by projecting an image against the wall and tracing it with pencil, before returning the next day to add colour. Children regularly join in to help with the painting.
See the video here on how The Art Lords are adding colour to the effort to eradicate polio from Afghanistan.
Photo – WHO
Reaching children with polio vaccine can be notoriously difficult and dangerous. In fact, polio transmission and outbreaks in some areas can be directly related to inaccessibility. When we talk about inaccessibility, many people think about insecurity. And that is definitely a critical factor in some areas, for example in Borno, Nigeria, or Syria at the moment. But in most areas, other elements contribute to the difficulties faced by vaccinators in reaching every child with the vaccine. For example, children living in dense urban neighbourhoods or children who are part of nomadic or mobile communities are often hard to reach.
In some parts of the world, significant environmental and geographic challenges make it difficult for vaccinators to reach children. It is important for health workers to be aware of these different physical barriers when planning vaccination campaigns, as each requires different strategies to make sure we reach even the hardest to reach child.
Many countries working to vaccinate their children against polio have a dry season and a wet or rainy season. When the rains come they can be relentless, altering the landscape and the environment dramatically. For example, rivers that are easily crossed can become torrents of rushing water, impossible to traverse or to even see across. Populations can be suddenly cut-off for months at a time, and reaching them with vaccines becomes much more difficult. The polio programme must then adapt to the local physical landscape and come up with solutions. One of the last hideouts of wild poliovirus in India was the floodplain of the Kosi River in Bihar state; the virus was stopped here by careful planning of vaccination campaigns, mapping of temporary settlements and increasing the number of personnel on the ground.
Infrastructure factors can affect access: children can live in extremely remote locations in places where there are no roads or easy means of transport. In parts of the Democratic Republic of the Congo, some settlements are deep in dense forests, and are not clearly mapped or identified. Says Mohammed Mohammedi, polio eradicator since 1997, “In some countries, we simply might not even know where exactly these places are or if children live there, not to mention the challenge of actually reaching such remote environments. Rains can turn dusty roads in to muddy swamps. Cars and other vehicles risk getting stuck in the mud, causing significant delays to operations.” The polio programme overcomes such challenges with both old-fashioned means – muscle power to dig out vehicles from the mud or donkeys to transport vaccines – and new tools such as satellite imagery to find human habitations or airlifting in vaccine with helicopters.
Mohammedi advises, “For the environmental factors, forward planning is key. We try to schedule vaccination campaigns right before the rainy season starts, and right after it finishes.” The rainy season often coincides with ‘high season’ for polio, with increased transmission during these wetter months, so the pre-rainy season campaigns are critical to make sure children are protected, even when populations become cut off from vaccinators. In some places, vaccines are pre-positioned ahead of the rains, so that local health workers can continue to operate in those areas once regular access is cut off.
“We need to focus on leaving no child unvaccinated,” reminds Mohammedi, “no matter how difficult it is to reach them. This means we need to first identify all the factors that are hampering access, and then respond with tailored strategies that specifically address each situation.”
The programme has years of experience responding to a whole host of inaccessibility factors, and is constantly using this knowledge to make sure every child is immunized against polio.
Read more in the Reaching the Hard to Reach series
This little girl is Kapia. She lives in a small village, surrounded by jungle, in a remote part of the countryside. There are no medical doctors in her village. The nearest clinic is hundreds of kilometres away. And she has just received two drops of polio vaccine, protecting her from the potentially paralytic disease.
A few days ago, health workers arrived in her village with one simple goal – to immunize every child under five against polio. Kapia’s village is one of many hundreds of settlements, villages, towns and neighbourhoods that will be visited by vaccinators with this same simple goal, to reach every child with the polio vaccine.
While the goal is simple, achieving it is much more complex. Vaccination campaigns need to reach hundreds of thousands of children over large areas of land, often involving difficult environmental, cultural and political challenges. A huge amount of detailed information gathering and planning is needed to ensure every piece of the campaign puzzle is first discovered and then analysed and slotted in to place to ensure every child is immunized against the disease.
Enter the microplan.
The foundation of every successful vaccination campaign is a comprehensive microplan, which captures in great detail all the different, yet interrelated components of the campaign.
The first piece of the microplanning puzzle involves discovery – finding out about communities in the vaccination area, how many children live in in the area, and where they are located. This informs a range of other planning and logistical elements of the campaign.
Health workers use a wide variety of resources to gather the most accurate and detailed information possible about communities, to make sure all children are reached with the vaccine. This includes working with the communities themselves, as well as NGOs on the ground and government to make sure even the most remote settlements and hard to reach children are reached in the vaccination campaign. This must take into account groups that are mobile, such as nomads, the internally displaced, or migrant workers’ families. Where are these groups, how many children do they have who need vaccine, what are the routes they use and the transit points through which they pass?
When all these puzzle pieces have been revealed, health workers can start putting them together, building on each piece of information to create the whole microplan picture – a comprehensive and detailed plan for the campaign.
In the microplan, every community is listed, along with estimated number of children, and important areas in each community where children can be reached: whether playgrounds, water collection points, markets or government clinics. Communities are also plotted on maps, along with distances, population spread, landmarks, population movements and seasonal and environmental specifics, such as floods and challenging roads.
This information is also used to calculate the amount of vaccine needed for the campaigns, the logistics for getting the vaccine to where it needs to go, and the number of health workers, vaccination teams and supervisors needed to carry out the work.
Once all of this is established, vaccinators can be identified who are appropriate for that community, and detailed activity plans can be created, allocating vaccination teams to cover specific mapped areas on specific days. Special plans are also made for vaccination teams to vaccinate at major transit points, and to cover hard to reach populations, such as nomadic populations or people living in areas with disputed borders.
Each team is provided with a team microplan, which includes the number of houses and children to be reached, and a detailed description and map of each area to be covered including start point, route to be taken, end point, important landmarks and special sites, like schools and playgrounds, that should be covered to ensure all children receive the vaccine. This functions as a systematic guide to vaccinators as they carry out their work.
Other detailed plans are made covering vaccine distribution and logistics, social mobilization and communications plans, and reporting plans.
Slotted together, every small piece of information and planning combines to give a highly detailed picture of the forthcoming campaign, leaving no situation to chance or guesswork. This ensures every child like Kapia, no matter how remote or hard to reach, receives the protection they need against polio.
The Pakistan polio snapshot gives a monthly update on key information and activities of the polio eradication initiative in Pakistan.
July updates include:
No new cases of polio reported – the total for 2017 remains 3
The Federally Administered Tribal Areas marked one year without reporting a case – down from a high of 179 cases in 2014
Small-scale vaccination campaigns were carried out in July in the core polio reservoirs and other high risk areas, aiming to reach 10.1 million children
The Afghanistan polio snapshot gives a monthly update on key information and activities of the polio eradication initiative in Afghanistan.
July updates include:
One new case of wild poliovirus was reported, bringing the total number of cases to 5 in 2017
Vaccination campaigns were carried out across 28 provinces, aimed at reaching 6.5 million children under 5 with oral polio vaccine OPV
Smaller campaigns aimed to reach 104,000 children with IPV & OPV in Kabul City and Khak-e-Safed district of Farah province, and 43,000 children with OPV in Paktika province
Fifty-seven year-old Khalida, a striking figure on her four-wheeler motorbike, is a supervisor of one of the female vaccinators’ teams in Karachi, Pakistan’s largest city.
“I have been working as a supervisor for three years, but I have been associated with polio vaccination campaigns for many years as volunteer,” she explains. The community in the area where Khalida works is mostly from Pakistan’s tribal areas in the north-west of the country, and distrustful of outsiders. Traditionally, this mistrust involved not accepting vaccination. Today, all families in the area accept polio drops.
Khalida had worked in different jobs but wasn’t satisfied until she was offered a job of polio team supervisor. Her influence in the area has been critical to overcome myths about vaccination and build knowledge and trust.
Having women like Khalida working on the frontlines is a game changer for polio eradication. The fact that she is well known and trusted in her community means that mothers and fathers are more likely to allow her and her team to take the crucial step across the thresholds of their homes to vaccinate their children. The Pakistan Polio Programme’s emphasis on local, motivated, full-time, community-based female vaccinators has been improving immunization coverage figures. Across the country, the proportion of vaccinated children increased from 85% in August 2016 to 92% in May 2017, according to independent post-campaign monitoring.
In my community, the number of polio cases has decreased drastically. The progress is visible with the naked eye. We hold rigorous polio campaigns which are being carried out frequently in the area to reach every child multiple times with vaccines and keep them safe against paralysis. In this regard the contribution of the frontline health workers I supervise is remarkable, as they work hard to ensure each and every child is protected from this crippling disease.
Polio eradication is very important to have a healthy generation; as healthy generations, these children will be able to better serve the country – Khalida
For Khalida, vaccinating children against polio is a true mission. “Since I began working to end polio, I feel like I am a soldier. Just as an army fights to protect a country, similarly I fight against a virus which is disabling our beloved children. I will fight against this crippling disease until the virus is permanently eradicated and our beloved children are fully protected”.Khalida’s work spans a large area, with temperatures in the summer reaching 40°C, making the work of vaccinators very challenging. To provide supervision to the polio teams under her care, Khalida uses a motorbike specially designed for her for this very purpose – it has four wheels and is capable of crossing the rocky terrain and getting her where she needs to go at top speed. The sight of Khalida coming into a settlement on her motorbike has become a well-known, welcome sight.
Pakistan is one of only three last polio endemic countries, along with Afghanistan and Nigeria. The number of cases has declined dramatically in the past years: from 306 in 2014 to 20 in 2016. As of June 2017, the number of polio cases reported in Pakistan was three.
A child receives two drops of polio vaccine during the May vaccination campaigns in Lahore, Pakistan. WHO Pakistan/Anam Khan.
At the end of May 2017, more than 38 million children under the age of 5 were vaccinated against polio in Pakistan. During the campaign, over 250,000 trained polio workers went from house to house across the length and breadth of the country to vaccinate children against the crippling disease.
This was one of five country-wide vaccination campaigns that took place during the 2016/2017 “low season” for poliovirus transmission. From October to May when temperatures are low in Pakistan, the virus remains less active, giving polio eradication experts the opportunity to get ahead of the virus.
The end of the May polio campaign marked the start of the “high season” for poliovirus transmission. The ability of the poliovirus to infect children increases in high temperature and during heavy rainfall. As a result, viral circulation is expected to be higher from June to September.
Reaching more children
With steady gains in the proportion of children vaccinated during the 2016/2017 low season, the May campaign achieved an overall goal of vaccinating 92% of the targeted children, according to independent post-campaign monitoring. The highest vaccination coverage rates were observed in Khyber Pakhtunkhwa (KP), Sindh and the Federally Administered Tribal Areas (FATA), some of the highest risk areas of the country, with rates increasing from 84% to 95% in KP and 77% to 93% in Sindh in the last nine months.
A polio vaccinator marks the door of a house to show that the children living there were not home when he called, so that they can be vaccinated by campaign monitors the next day. WHO Pakistan /Anam Khan.
However, more work is needed to bring vaccination rates up to 95%, the level identified as that needed to stamp out the virus for good. FATA remains the only region consistently over 95% in the last three campaigns, with Balochistan, Islamabad, Azad Jammu, Kashmir and Gilgit Baltistan not reaching the benchmark.
With the high season underway, Pakistan is well-positioned to respond to these remaining gaps and challenges. The current situation remains the best we have ever seen in the country, with the virus geographically limited. The number of cases has declined from 306 in 2014 to 53 in 2015, and to 20 in 2016. So far this year, the number of polio cases reported in Pakistan is three (compared to 13 the same time last year). However, this progress means that there is more to lose than ever before. The low season campaigns put the polio programme in a better position with which to fight the virus through the high season.
Poliovirus in the environment
While the number of new wild poliovirus cases remains record low, the environmental surveillance system indicates the virus remains a serious threat to children, with the proportion of samples being tested positive for poliovirus reaching 18 per cent as of May this year compared to 10 per cent as of May 2016. In particular, the environmental presence of the virus has increased in the Quetta block, Karachi and the twin cities of Islamabad-Rawalpindi. The programme is systematically addressing and responding to these challenges by focusing on reaching missed children and continuously improving campaign quality to remove every last hiding place of the virus.
A father and daughter proudly show off the purple dot of ink on her little finger to show that she has been vaccinated against polio in the May campaign. WHO Pakistan/Anam Khan.
Preparing for the next low season
Government leadership is fully committed to the National Emergency Action Plan (NEAP), implemented via focused Emergency Operations Centers at National and Provincial levels, with emphasis on evidence-based decision making, a one-team approach between all of the partners of the GPEI and the government, highlighting the essential role of front-line workers at the center of the polio eradication effort, effective oversight of performance management and accountability, and coordination across the common Afghanistan-Pakistan epidemiological block. As eradication moves into the final stage, seamless cross-border coordination with Afghanistan, that has had four polio cases so far this year, becomes ever more critical to success in both countries.
Late August marks the beginning of the Hajj season – the annual pilgrimage of Muslims to Mecca – bringing together people from all over the world. While a holy time of pilgrimage, this also presents health risks as people are coming together from many countries where they may have been exposed to different infectious diseases.
The Ministry of Health of Saudi Arabia has issued health requirements and recommendations for entry into Saudi Arabia during the Hajj season, including requirements relating to polio vaccination. Regardless of age, all travellers from certain, specified countries must show proof of vaccination against polio within the last twelve months, and at least four weeks before departure. All travellers from these countries will also receive one dose of oral polio vaccine on arrival in Saudi Arabia.
These requirements apply to travellers from the following countries:
WHO African Region
Cameroon, Central African Republic, Chad, Democratic Republic of the Congo, Equatorial Guinea, Ethiopia, Guinea, Kenya, Liberia, Madagascar, Nigeria, Niger, Sierra Leone, South Sudan
WHO Eastern Mediterranean Region
Afghanistan, Iraq, Pakistan, Somalia, Syrian Arab Republic, Yemen
WHO South-East Asian Region
Myanmar
WHO Western Pacific Region
Lao People’s Democratic Republic
WHO European Region
Ukraine
.
.
.
.
.
A doctor greets a Syrian child in a refugee camp, where children are vaccinated against polio and other diseases. Photo: WHO
In recent years, the global drive to eradicate polio has seen the virus cornered in fewer places than ever before. Yet polio’s final strongholds are some of the most complicated places in the world to deliver vaccination campaigns. Insecurity and conflict are some of the challenges to delivering vaccines, as well as populations on the move, testing terrain and weather, and weak health systems.
In 2013, polio outbreaks in Central Africa, the Horn of Africa and the Middle East paralysed hundreds of children. The Global Polio Eradication Initiative (GPEI) developed strategies to deliver vaccines and stop the virus, even when access seemed impossible. All three of these outbreaks were put to an end just a year later, by not letting the complexity of the situation undermine the quality of vaccination campaigns.
The valuable lessons learned by the GPEI in tackling these outbreaks are now being used to end polio in the final polio endemic countries – Afghanistan, Nigeria and Pakistan – as well as to stop a newly-detected circulating vaccine-derived polio outbreak in Syria.
Challenges to immunization in emergencies
Disruptions to routine immunization systems and mass displacement caused by conflict can rapidly reduce population immunity, making individuals much more vulnerable to polio outbreaks. Polio eradication relies on being able to repeatedly access over 95% of children with vaccines. Yet emergency settings can interrupt systems that gather data about a population, functioning health facilities, health care personnel, vaccine supplies, cold chains to keep vaccines safe, power supply, financial resources, population demand for vaccines, and disease surveillance. When these factors are at play, the GPEI calls on past experience and adopts new approaches to reach every last child.
Lessons learned in conflict zones
Community acceptance and trust
When there are barriers to access, the first step is to have community trust and acceptance of vaccination. Every community and context is different and calls for a targeted approach to communicate exactly why immunization campaigns need to take place. The polio eradication programme identifies and trains vaccinators from local communities, engages religious figures to support the campaign and gets local leaders on board to advocate for, plan and implement vaccination efforts. The polio programme has seen time and time again that when securing access is a challenge, the answer often lies in the very communities we are trying to reach.
In Pakistan, a number of Religious Support Persons have been recruited based on the guidance of the Islamic Advisory Group for polio eradication, to address concerns of local communities about polio vaccinations in some challenging areas of the country. This has resulted in enhanced community acceptance of immunization, with refusal rates of less than 1.5%, as well as broader child welfare interventions.
Opportunistic vaccination campaigns
When different forces make populations periodically inaccessible, vaccination schedules can be interrupted and leave pockets of people unprotected against polio. In these situations, health authorities try to reach children in whatever ways are possible. Transit points can be set up around insecure areas, to vaccinate children as they enter or leave; vaccinators work with local leaders to track and reach populations on the move; communities within the inaccessible areas can store and deliver vaccines themselves; and brief periods of calm can be used to bring vaccines and other essential health services into villages through a health camp.
In Pakistan, over 350 transit points have been set up in recent years along borders and near areas with access challenges. This is one of the innovative approaches that have reduced the percentage of children missed on vaccination campaigns from 25% in 2014 to 5% in 2017.
Negotiated access
In the most challenging situations, when all other approaches are not able to overcome the severity of vaccination challenges, the programme has negotiated access by engaging non-state actors, governments, religious figures and local leaders. Reiterating the humanitarian principle of “neutrality,” the GPEI works with all parties to a conflict to highlight the importance of vaccination campaigns, and secure agreements to access targeted communities for specific periods of time.
In the past, negotiating access to conflict zones was comparatively simple to today. In the 1980s, days of tranquillity were first used in the Americas, through negotiation with two groups – often the government and the opposition group. In many areas where polio persists, there are many different actors and groups engaged in conflict, so negotiation is more complex. It includes identifying who is appropriate to negotiate with in any given district or area, and, importantly, finding appropriate negotiators. Often, third party partners such as the International Committee for the Red Cross are engaged to negotiate operations of vaccination campaigns in security-compromised areas, and in areas where vaccination bans have been imposed by local authorities.
Conflict and insecurity continue to pose significant challenges to eradication. Our best chance of ending polio for good in conflict zones lies in learning from these lessons and adhering to the principles of neutrality in health.
Read more in the Reaching the Hard to Reach series
A circulating vaccine-derived poliovirus type 2 (cVDPV2) outbreak has been confirmed in the Deir-Ez-Zor Governorate of the Syrian Arab Republic. The virus strain was isolated from two cases of acute flaccid paralysis (AFP), with onset of paralysis on 5 March and 6 May, as well as from a healthy child in the same community.
Outbreak response plans are being finalized, in line with internationally-agreed outbreak response protocols, including plans for targeted vaccination campaigns to rapidly raise population immunity. An initial risk analysis has been conducted, finding low overall population immunity levels in the area but solid levels of disease surveillance. Active searches are being conducted for additional cases of acute flaccid paralysis. Surveillance and immunization activities are also being strengthened in neighbouring countries.
Although access to Deir-Ez-Zor is compromised due to insecurity, the Governorate has been partially reached by several vaccination campaigns against polio and other vaccine-preventable diseases since the beginning of 2016. Most recently, two campaigns have been conducted in March and April 2017 using bivalent oral polio vaccine (OPV). However, only limited coverage was possible through these campaigns. Syria also introduced two doses of inactivated polio vaccine in the infant routine immunization schedule in 2018.
The detection of the cases demonstrates that disease surveillance systems are functional in Syria. The polio programme is working with local authorities and organisations on the ground to respond immediately, using proven strategies. In 2013-2014, Deir-Ez-Zor was the epicentre of a wild poliovirus type 1 (WPV1) outbreak, resulting in 36 cases at the time. This outbreak was successfully stopped; the now-detected cVDPV2 strain is unrelated to the WPV1 outbreak.
Circulating VDPVs are extremely rare forms of poliovirus, mutated from strains in the oral polio vaccine (OPV) that can emerge in under-immunised populations. OPV has been a critical tool in eliminating 99.9% of polio cases worldwide, and while cVDPV is rare, the GPEI is actively working with countries to eradicate both vaccine-derived and wild polio. The same strategies that are eliminating wild poliovirus also stop cVDPV – it remains critical that all countries maintain strong disease surveillance and ensure all children are vaccinated.
Young mothers waiting to vaccinate their children receive information on exclusive breastfeeding from a polio-funded Volunteer Community Mobilizer. @ UNICEF/R. Curtis
“Are you watching me?” “Yes, ma’am.”
“Are you seeing me?” “Yes ma’am.”
Along two rows of benches under the awning of the Chikun Primary Health Centre in northern Nigeria’s Kaduna State, about 50 young mothers sit still, their babies swaying on their laps. All eyes are fixed on Lidia, the assured polio social mobilizer who is not delivering polio vaccine, but showing the women how to correctly breastfeed.
Lidia is a grandmother, a one-time community midwife now employed with Nigeria’s polio eradication programme as a UNICEF-supported Volunteer Community Mobilizer (VCM). During the monthly polio vaccination campaigns, she goes house to house with the vaccination team, opening doors through her trusted relationship with the mothers, tackling refusals where they occur and tracking any children missed in the campaigns through her field book containing the names and ages of all children in her area. But it is between campaigns where Lidia’s full worth is realized.
Trust
Helen Jatau, a supervisor in this Local Government Area, supervises 50 VCMs and five first-level supervisors. She is convinced the health care polio frontline workers provide between campaigns provides benefits beyond the surface value – it establishes trust. “When we bring different things to the mothers, it helps the community live better and even accept us more, because we are giving more than just polio vaccines.”
Between polio vaccination campaigns, mobilizers like Lidia track pregnant women and ensure the mothers undertake four Ante-Natal Care visits, including immunization against tetanus. They advise mothers-to-be to give birth at the government health facility, provide them with the first dose of oral polio vaccine, facilitate birth registration and connect them to the routine immunization system. In houses and at monthly community meetings, the mobilizers also provide information on exclusive breastfeeding, hand washing, the benefits of Insecticide Treated Bed Nets, Routine Immunization and the polio vaccination campaign.
Ante-Natal Care
VCM Charity Ogwuche stands before the mothers at the health centre and peels over the pages of a colourful flip book. “Breastmilk builds the soldiers inside your child,” she shouts. “It will save you money. You don’t need to find food for your child to eat. You don’t need to find water: 80% of breastmilk is water. It will protect your child.”
Adiza, a young mother holding her first child, Musa, carries a routine immunization card including messaging on breast feeding and birth registration. “Aminatu talked to me about antenatal care. She asked me to get the tetanus shot, and today she has brought me here to receive routine immunization for my baby. I am really grateful. If she wasn’t here I wouldn’t be here. I wouldn’t know about it. She is the only one who tells me about this.”
Charity is proud of her work. “The women are so familiar with me, it makes me happy. They call me Aunty. I provide most of the health information for them. Really there is no other in our community. They are very young mothers and they need me.”
Birth registration
Aminatu Zubairu, in her trademark blue VCM shawl, displays the birth registration cards she will carry back to mothers in her village. @ UNICEF/R.Curtis
Every Tuesday is birth registration day. Once, hardly a soul turned up to register their newborns, but today, a long line of VCMs are standing clutching handfuls of registration forms, waiting to register the newborns within their catchment area.
Aminatu Zubairu, wrapped in the trademark blue hijab of the VCM, explains how all social mobilizers must come from their own community, and how that familiarity breeds the trust that has enabled her to register hundreds of children in her area. “I go to their houses and ask if they had the birth registration. If they say no I take all the information. Now I will register them and get the certificate of birth and carry it to their house to give back to them. In a month I can do 50 of these. This year there are plenty of newborns.”
Danboyi Juma, the district’s Birth Registration Officer, believes birth registrations have increased by 95% since VCMs assumed responsibility for the service. “They are helping us so much because they go house to house,” he says. “They have increased the number of birth registrations in this area by so much – oh, that’s sure.”
Routine Immunization
Jamila and her baby Arjera, who was vaccinated for the first time, following the persistent efforts of her VCM Rashida Murtala. @ UNICEF/R.Curtis
Despite stifling heat, on this Tuesday, there are more than 50 mothers and several fathers sitting on benches, waiting for their turn to have their babies vaccinated. More than 80% of them carry the cardboard cards given to them by VCMs to remind them their baby is scheduled for routine immunization.
Jamila, a young mother wrapped in a white shawl around her orange head-dress, is bringing her six-month-old baby Arjera to be vaccinated for the first time. Her VCM, Rashida Murtala, badgered her for months before Jamila finally accepted.
“Oh, she refused and refused,” Rashida says. “She’s fed up with me visiting. I went to see her today and finally she followed me. I’m happy to see her here.”
Jamila smiles. “She has been disturbing me every day that I have to take this child to the health centre. I know she’s right, so today I followed her.”
Priscilla Francis, the Routine Immunization provider who vaccinates young Arjera, believes VCMs are key to strong vaccination coverage in Chikun district. “There is much improvement in attendance since the VCMs started. They are well trained. They do a good job of informing mothers to come. If we lost them we would lose our clients – no doubt. When they come we tell them to come back, but no one else is going to their house to bring them.”
Hassana Ibrahim, a Volunteer Ward Supervisor, knows her mobilizers are important. “I have 10 VCMs, five in this ward. Non-compliance used to be a big problem but not now. Now with the routine immunization, the community sees they are providing a package of health care and now people comply with the polio vaccination.”
Naming ceremonies
New mother Naima with newly named Jibrin and her friends and family was happy to welcome her VCM to immunize children at her son’s naming ceremony: “She is my friend.” @ UNICEF/R.Curtis
Following the routine immunization session, the VCMs fan out to attend the naming ceremonies of newborns in their catchment area. Naming ceremonies provide an important opportunity to vaccinate lots of children, as family gathers around to celebrate. On average, they attend 10 naming ceremonies a month. Today we visit Naima, the young mother of a 7-day-old boy, who as per tradition has just been named Jibrin by his grandfather. Naima is surrounded by her sisters, family and village friends, who cook and eat with them, and their 68 children under five. Within minutes, the VCM has walked among them all, vaccinating them as they sit waiting with their mouths open to the sky like little birds.
Naima is happy to see her trusted VCM, and encourages her to vaccinate the children. “I know her well,” she says. “She taught me to go for ante-natal care, to deliver at the hospital and to go for immunization. She is the only health care worker who comes. We are from the same community. She is my friend.”
A child in west Africa receives polio vaccine. Photo: WHO.
More than 190 000 polio vaccinators in 13 countries across west and central Africa will immunize over 116 million children over the next week, to tackle the last remaining stronghold of polio on the continent.
The synchronized vaccination campaign, one of the largest of its kind ever implemented in Africa, is part of urgent measures to permanently stop polio on the continent. All children under five years of age in the 13 countries – Benin, Cameroon, Central African Republic, Chad, Côte d’Ivoire, Democratic Republic of Congo, Guinea, Liberia, Mali, Mauritania, Niger, Nigeria and Sierra Leone – will be simultaneously immunized in a coordinated effort to raise childhood immunity to polio across the continent. In August 2016, four children were paralysed by the disease in security-compromised areas in Borno state, north-eastern Nigeria, widely considered to be the only place on the continent where the virus maintains its grip.
“Twenty years ago, Nelson Mandela launched the pan-African ‘Kick Polio Out of Africa’ campaign,” said Dr Matshidiso Moeti, WHO Regional Director for Africa. “At that time, every single country on the continent was endemic to polio, and every year, more than 75 000 children were paralysed for life by this terrible disease. Thanks to the dedication of governments, communities, parents and health workers, this disease is now beaten back to this final reservoir.”
Dr Moeti cautioned, however, that progress was fragile, given the epidemic-prone nature of the virus. Although confined to a comparatively small region of the continent, experts warned that the virus could easily spread to under-protected areas of neighbouring countries. That is why regional public health ministers from five Lake Chad Basin countries – Cameroon, Central African Republic, Chad, Niger and Nigeria – declared the outbreak a regional public health emergency and have committed to multiple synchronized immunization campaigns.
UNICEF Regional Director for West and Central Africa, Ms Marie-Pierre Poirier, stated that with the strong commitment of Africa’s leaders, there was confidence that this last remaining polio reservoir could be wiped out, hereby protecting all future generations of African children from the crippling effects of this disease once and for all. “Polio eradication will be an unparalleled victory, which will not only save all future generations of children from the grip of a disease that is entirely preventable – but will show the world what Africa can do when it unites behind a common goal.”
To stop the potentially dangerous spread of the disease as soon as possible, volunteers will deliver bivalent oral polio vaccine (bOPV) to every house across all cities, towns and villages of the 13 countries. To succeed, this army of volunteers and health workers will work up to 12 hours per day, travelling on foot or bicycle, in often stifling humidity and temperatures in excess of 40°C. Each vaccination team will carry the vaccine in special carrier bags, filled with ice packs to ensure the vaccine remains below the required 8°C.
“This extraordinary coordinated response is precisely what is needed to stop this polio outbreak,” said Michael K McGovern, Chair of Rotary’s International PolioPlus Committee . “Every aspect of civil society in these African countries is coming together, every community, every parent and every community leader, to achieve one common goal: to protect their children from life-long paralysis caused by this deadly disease.”
The full engagement of political and community leaders at every level – right down to the district – is considered critical to the success of the campaign. It is only through the full participation of this leadership that all sectors of civil society are mobilized to ensure every child is reached.
More than 65,000 dedicated frontline workers are working tirelessly to eradicate polio from Afghanistan
Feroza and over 65,000 dedicated frontline workers are at the heart of efforts to eradicate polio from Afghanistan.
Feroza is one of the more than 65,000 dedicated frontline workers who are working tirelessly to eradicate polio from Afghanistan. For the past year, she has been working as a volunteer polio vaccinator, vaccinating children in her community during immunization campaigns.
“Polio is a very dangerous disease and people often underestimate how important and effective the vaccine is in preventing the irreversible consequences of the disease,” Feroza says. “I joined the polio programme because I want to raise awareness about the polio vaccine and its benefits to children in my community.”
Most of Afghanistan remains polio-free with the circulation of the virus confined to small areas in the southern, eastern and south-eastern parts of the country. In 2016, 12 wild poliovirus cases were reported, down from the 20 cases reported in 2015 and 28 in 2014. One case has been reported this year.
A number of new developments were implemented in 2016 to accelerate progress towards stopping polio transmission. This included the training of all polio field workers with a new curriculum to boost their skills and ensuring that frontline workers are kept motivated and committed.
Dedicated and brave vaccinators like Feroza are at the heart of the polio eradication effort. Female polio workers are particularly important in building trust in their communities and encouraging vaccination, ensuring more children are reached with life-saving vaccines.
“The best thing about my work is helping women and children and spreading awareness about the problems that are caused if children are not vaccinated. Sometimes mothers try to convince us to give them the vaccine as well since we are praising it so much – this is always amusing,” says Feroza smiling.
During vaccination campaigns, Feroza and her team visit houses to vaccinate all children under the age of 5 with the oral polio vaccine (OPV). “We work long and hectic days during the campaigns but I enjoy it.”
The work of volunteers like Feroza is crucial to reducing the number of children missed during immunization campaigns.
Afghanistan has a well-informed generation of parents who accept the polio vaccine every time it is offered to them. According to a study carried out in 2016, nearly 90% of Afghans recognize that vaccination is a way of preventing polio and there has been a reduction in the belief in preventing polio by using traditional medicine.
“We generally don’t face any problems during campaigns as most families are familiar with the vaccine and want to vaccinate their children. If families are hesitant, we try to encourage them by giving them information about the benefits of the vaccine. If they still reject the vaccine, we ask our supervisors to come and help convince them. I have never met a family who refused the vaccine in the end,” Feroza says.
A health worker prepares to administer a vaccine in northern Nigeria. WHO/L.Dore
A mass vaccination campaign to protect more than 4 million children from a measles outbreak in conflict-affected states in north-eastern Nigeria started on 13 January. The polio eradication infrastructure has been on hand to help with this feat of logistics. GPEI partners WHO, UNICEF and US Centres for Disease Control have been working with nongovernmental organizations to support the campaign in a range of areas including data management, training, social mobilization, monitoring and evaluation, supportive supervision and waste management.
“Nigeria’s well-established polio vaccination programme provides a strong underpinning for the campaign,” says Dr Wondimagegnehu Alemu, WHO Representative in Nigeria. “Population data from the polio programme has been essential to guide planning for the measles campaign. We are also able to make use of staff that have vast experience in providing health services in very difficult and risky areas.”
One third of more than 700 health facilities in Borno State, north-eastern Nigeria, have been completely destroyed, according to a report released in December by WHO. Of those facilities remaining, one third are not functioning at all. This is leaving the health of communities vulnerable.
WHO has a strong presence in the community in these areas thanks to a well-established polio programme which includes teams of health workers trained to work in areas of high insecurity and reach communities that no other partner can reach.
With levels of malnutrition as high as 20% in some populations in Borno State, children are particularly vulnerable to diseases like measles, malaria, respiratory infections and diarrhoea.
Planning for the future
This measles campaign in northern Nigeria is by no means the only example of polio funded functions and infrastructure contributing to other critical functions. On average, polio-funded staff spend more than 50% of their time on non-polio activities, such as routine immunization, measles campaigns, maternal and child health initiatives, humanitarian emergencies and disease outbreak, sanitation and hygiene programmes and strengthening health systems. In Nigeria in 2015, the Emergency Operations Centres set up to tackle polio were repurposed instantly in response to the spread of Ebola to the country, which enabled the outbreak to be ended almost as soon as it began.
Polio is closer to eradication than it has ever been; and while we keep all efforts on rooting out the virus in its final hiding places, the Global Polio Eradication Initiative is also beginning to plan for the future. The 16 priority countries, including Nigeria, where 95% of the programmes assets are based are planning now so that some polio funded functions and infrastructure can continue to contribute to other critical health and development goals, as polio funding gradually decreases
Read more about the measles vaccination campaign in Nigeria.
Children in a polio free India. Photo: GPEI
Six years ago today, Rukhsar Khatoon from West Bengal became the last Indian child to be paralyzed by polio. Since that day, India has not experienced a single case of wild polio, paving the way for the South East Asia Region of the World Health Organization to be certified polio-free in 2014.
Once considered the toughest context in the world to eradicate polio, India achieved this feat through a relentless focus on reaching and immunizing every last child: it has since maintained high immunity to polio and very high quality disease surveillance, made the switch from trivalent to bivalent oral polio vaccine in its routine immunization system, and is working to transition its extensive polio eradication knowledge and assets to serve broader public health goals.
Sensitive disease surveillance and high immunity against polio remain important priorities for all countries until the remaining endemic countries stop polio for good.
