©WHO Pakistan/A.Zaidi

Pakistan’s routine immunization programme Expanded Programme on Immunization will carry out a nationwide measles vaccination campaign targeting around 31.8 million children aged 9-59 months from 15 to 27 October to respond to an ongoing measles outbreak in Pakistan. Over 30 000 measles cases have been reported this year, compared with around 24 000 cases in 2017.

Pakistan typically encounters a measles outbreak every 8 to 10 years, and the Federal Ministry of Health works proactively to stop these outbreaks with regular vaccination campaigns. Although the Polio Eradication Initiative  and the Expanded Programme on Immunization are separate entities, they work together to improve immunization outcomes in Pakistan. Achieving strong essential immunization coverage is a critical step in bringing Pakistan closer to ending polio, and once this goal is reached, in maintaining polio-free status.

Many of the areas at highest risk for polio are also at high risk for measles. During the upcoming measles campaign, the polio programme will lend its human, physical and operational resources, knowledge and expertise to achieve the highest possible measles immunization coverage across the country.

Reaching more children through stronger collaboration

The collaboration between polio and routine immunization programmes has made a significant difference in vaccination efforts across dense urban environments as well as scattered rural settings. A key factor for success has been the polio programme’s highly-skilled workforce of community vaccinators, front-line health workers and social mobilizers.

During every round of country-wide polio vaccination campaigns, around 260 000 front-line health workers vaccinate more than 38 million children under the age of 5 across Pakistan. With vital on-the-ground experience in some of the most challenging settings, they are determined to ensure that the lessons learned in polio are transferred to other health interventions.

“Our front-line workers have built strong rapport in their respective communities,” said Dr. Rana Safdar, coordinator of the National Emergency Operation Centre (NEOC) for polio eradication and member of the National Measles Steering Committee.

“They understand the dynamics of the population, even as they relate to children, not only at the district level but also at the Union Council and village level. This indigenous knowledge coupled with community trust can definitely play an instrumental role for other health interventions.”

Unlike polio eradication activities, measles immunization is not carried out from door-to-door but at fixed centres at health facilities as well as through outreach sessions within communities. Children are mobilized to the vaccination sites where trained healthcare professionals administer the injectable measles vaccine. The deep local knowledge polio workers have developed and the trust they have built with their communities is vital in mobilizing caregivers to take their children for measles immunizations at nearby vaccination sites.

“The strong collaboration between the two programmes has helped us vaccinate more children. Our joint efforts are geared towards reaching every last child and they have shown significant progress so far. We hope that our synergized efforts during the upcoming measles campaign will lead us to reach every child in the target population with measles vaccine,” said Dr. Tahir Abbas Malik, from the Pakistan polio programme.

“For polio, these coordinated efforts have paved the way for increasing the coverage of persistently missed children, especially those who are on the move or reside in hard-to-reach areas. Similarly, integrated micro planning, monitoring and reporting of children who have not received essential immunization  have been instrumental for achieving gains for routine immunization through enhanced coverage,” said Dr. Tahir Abbas Malik.

Pakistan polio eradication programme has achieved significant progress in recent years, thanks to renewed government commitment and revitalized community ownership. However, in cities like Karachi, poliovirus continues to be detected.

Working to overcome the virus once and for all, the polio programme an emergency action plan in January 2018. Since then, the geographical scope of the virus has been noticeably reduced. Much of this progress is thanks to religious leaders like Imam Qari Mehboob, who has spent years building trust and demand for polio vaccination in some of the most difficult areas of the city.

In the Democratic Republic of the Congo, emergency response has been ongoing since 2017 to overcome outbreaks of circulating vaccine-derived poliovirus, caused by low rates of routine immunization. In the battle to close the outbreak, health workers, partners of the Global Polio Eradication Initiative, Governors of affected provinces, and the Ministry of Health are working together to vaccinate every child. In a context with weak health systems and other high-profile health and humanitarian emergencies, these united efforts are crucial to boost population health and keep all young children safe from paralysis.

The Mazar-e-Quaid is a prominent symbol of Pakistani independence. © WHO/Dawood Khan

 

Children clutch parents as the crowds gather. Overhead, clouds fill the sky, whilst below, noise rolls around the square where people stand. Shouts, music, and laughs all contribute to a growing sense of occasion.

The excitement lies at the heart of Karachi, Pakistan’s largest metropolis. Mazar-e-Quaid, the mausoleum of Pakistan’s founding father Muhammad Ali Jinnah, is a prominent symbol of Pakistani independence, and of the united people of Pakistan.

Each year, millions of people from across Pakistan and the world visit Mazar-e-Quaid. The number of visitors reaches its peak on 14 August, Pakistan’s Independence Day. As the sun rises, thousands arrive dressed in green, the national colour, carrying food and flags, ready to be first to enter once the site is opened up to the public.

A duty to the people of Pakistan

A child dressed in green, Pakistan’s national colour, is vaccinated against the poliovirus. © WHO/Dawood Khan

For the Pakistan polio eradication programme, Independence Day is an important opportunity. From morning to night, they will take part in a herculean effort to vaccinate all children visiting the mausoleum against the poliovirus. In doing so, they are setting world records for the number of children vaccinated in one location.

Permanent Transit Points (PTPs) are vaccination sites established at important transit points such as country and district borders, bus terminals and railway stations, to make sure that children on the move are vaccinated against polio. Currently, there are 390 PTPs across Pakistan.

On an ordinary day, eight vaccinators work at a PTP at Mazar-e-Quaid. After a quick brief, they are ready to protect all visiting children from the virus with just two drops of the safe, effective oral polio vaccine.

Independence Day requires a different kind of operation. The teams know that they have to take the opportunity to vaccine young children who otherwise might miss out.

Twenty vaccinators volunteer, enthusiastic to meet the influx of parents with young children entering the site.

As the crowds surge into the mausoleum, vaccinators immunize a new child every few seconds at fixed points at the entrance and exit, whilst others mingle with the crowds, searching for any young child without a purple stained finger – the sign used to indicate that they have been vaccinated.

This year, 11 409 children were vaccinated at Mazar-e-Quaid over the course of Independence Day. With such a small team, this is an impressive achievement.

The vaccinators

Mehwish Sheikh stands in front of the Mazar-e-Quaid, where she works as a polio vaccinator. © WHO/Dawood Khan

Mehwish Sheikh is a vaccination supervisor at Mazar-e-Quaid and is considered to be one of the most dynamic polio eradicators to have ever worked there.

Talking about her passion for polio eradication, and what drives her to protect Pakistan’s children, she says,

“Working against polio is in my blood. My mother started as polio worker in 1992 with the start of the polio eradication drive. Following her, I have worked for more than a decade now.”

“My mother vaccinated the current Chairman of Pakistan People’s Party Mr. Bilawal Bhutto Zardari, and she was featured on television and newspapers. My sister is also a vaccination worker so vaccination and work against polio is our passion.”

“Will you believe that I took only 3 days off on my wedding and then rejoined the team here?”, she laughs.

So what is it like vaccinating on Independence Day?

Mehwish isn’t afraid to acknowledge the challenges that the teams face on 14 August each year.

“This is really a tough day for all of us because the number of people is so overwhelming. Peoples’ connection with their leader is especially strong on Independence Day.”

With a wry smile, she continues, “Of course, our real independence will be our independence from polio virus.”

The parents

Whilst vaccination in this context might seem unexpected, parents visiting the Mausolem are enthusiastic. This is thanks to the efforts of the Pakistan polio programme and the government to educate the population about the vaccine.

One father notes, “As parents, it’s our duty to protect our children from going into harm’s way and administering all sorts of vaccines is one way of doing this.”

A nearby mother concurs, “The vaccinators are here to save the lives of our children and we must cooperate with them.”

The eradication of polio in Pakistan will be a success for thousands of people involved in the programme, and a source of national pride.

Speeding past to vaccinate more children, one vaccinator calls out, “We want to see our names among those who are fighting the final battle against polio in Pakistan”.

In April 2016, the polio programme embarked on a massive, coordinated effort to withdraw Sabin type-2 from routine use, through a synchronized switch from the trivalent formulation of the oral poliovirus vaccine (tOPV) to the bivalent form (bOPV). Over a two-week period, 155 countries and territories successfully made this change, marking the largest and fastest vaccine rollout in history.

Referred to as simply “the switch,” this global undertaking was a major programmatic achievement, but it was also a necessary step on the road to eradication. That’s because, in rare cases, the live, weakened virus contained in OPV can mutate and spread, resulting in cases of circulating vaccine-derived polioviruses (cVDPVs). The vast majority of these cases are caused by just one of the three components contained in tOPV (Sabin type-2 virus), so switching to a bivalent form that doesn’t contain this component was an attempt to significantly minimize the risk of further cVDPV2 cases – a decision that was endorsed by the global health community. Further, with Sabin type-2 responsible for 40% of vaccine-associated paralytic polio (VAPP) occurrences – a much rarer phenomenon at 2-4 cases per 1 million ‒ there was even stronger justification for the switch.

To assess whether the switch was successful, a group of researchers from Imperial College London, the World Health Organization and the Bill & Melinda Gates Foundation analysed stool and sewage samples from 112 countries collected in the first 15 months after the switch. The results, published in The New England Journal of Medicine, show that VDPVs and Sabin type-2 excreted into the environment after vaccination disappeared rapidly after the switch, shrinking to a much smaller geographic area.

These findings validate the GPEI decision to withdraw tOPV and demonstrate that the switch achieved its desired goal of reducing VDPVs and VAPP. This research also provides important evidence that the complete withdrawal of OPV after eradication of all wild polioviruses will eventually eliminate the risk of VDPVs, provided high immunity and effective surveillance are maintained. Eradication is simply not compatible with continued use of OPV.

The study also showed, however, that while some outbreaks of VDPV were expected post-switch, the number and magnitude of some of these outbreaks in different geographies has proven more difficult to control than expected. Type-2 VDPV outbreaks outside of Africa have been responded to with monovalent type-2 OPV (mOPV2) and controlled. However, outbreaks in the Horn of Africa, DR Congo and Nigeria have been very difficult to bring to a rapid close.

VDPV outbreaks emerge in areas with very low population immunity, due to low immunization coverage. Factors which enable them ‒ insecurity and resulting inaccessibility, weak health systems, and poor campaign performance – are the same that need to be addressed to stop their transmission. While the programme is aware of these risk factors and has proven experience and strategies to respond to them, the longer outbreaks persist, the harder they can be to stop.

The key to stopping these outbreaks will be to increase the focus on improving the quality of vaccination campaigns in accessible areas. In inaccessible areas, we need to use all available means to negotiate access and implement vaccination campaigns. Achieving high quality campaign activities will give us the best chance to stop all types of poliovirus for good and prevent any child from being paralysed by the virus ever again.

Thanks to the efforts of Hauwa, a UNICEF community mobilizer, Nasiru has taken responsibility for ensuring that all his children receive their polio and other routine vaccinations. © UNICEF/Nigeria
Thanks to the efforts of Hauwa, a UNICEF community mobilizer, Nasiru has taken responsibility for ensuring that all his children receive their polio and other routine vaccinations. © UNICEF/Nigeria

“Please wait, I’ll soon be with you,” says Nasiru, the father of six children, as he disappears into his house in Gagi Makurdi settlement in Nigeria’s northwestern State of Sokoto.

Within minutes, Nasiru reappears, proudly displaying immunization cards with the record of the vaccines given to his youngest three children. It is unusual for fathers in this conservative part of Nigeria to readily know the whereabouts of these documents. Tending to children and ensuring that they stay healthy is usually a mother’s job.

“Take a look at the cards. My children Fidausi and Fatima have completed all their required immunization, whilst my youngest, Nana Asmaiu, is well on course to complete his,” he says.

Nasiru is a champion for immunization, but he wasn’t always so enthusiastic.

20 000 community mobilizers

It was Hauwa Ibrahim, a 46-year-old UNICEF-trained Volunteer Community Mobilizer, who persuaded Nasiru that the vaccine was safe and effective. She is part of a 20 000-strong network of community mobilizers who work across twelve Nigerian states like Sokoto, where some communities have been resistant to polio vaccination.

Hauwa inspects a baby’s vaccination card. By building up trusting relationships with her community, her health advice gains credibility. © UNICEF/Nigeria
Hauwa inspects a baby’s vaccination card. By building up trusting relationships with her community, her health advice gains credibility. © UNICEF/Nigeria

As recently as 2012, Nigeria used to account for half the world’s polio cases. Today, with help from women like Hauwa, no wild poliovirus has been detected in the country since August 2016. There are still many immunity gaps in Nigeria – as underlined by an outbreak of vaccine-derived virus currently ongoing in the country – but in the villages where VCMs like her work, these gaps are beginning to close.

Using a simple register, Hauwa goes house to house in Gagi Makurdi to record all children below the age of five, as well as women who are pregnant. It is the same register that Hauwa used to track the pregnancies of Nasiru’s wife – Zara’u – and she now uses it to find out who manages the routine immunization schedules of the three youngest children in the household.

Strengthening routine immunization

This forms part of the polio programme’s work in Nigeria to strengthening routine immunization, building on the infrastructure developed to eradicate the virus.

Upon her first visit, Hauwa was determined to convince Nasiru that vaccination against polio and other diseases is important – and that he should take the children to the health facility.

“My culture does not allow a wife to go outside of the compound, so when Hauwa insisted that we take our children to the health facility for vaccines, I had no way but to go myself. Else, Hauwa would not give up,” Nasiru explains. Whilst he travels with his children, Zara’u takes care of their older siblings at home.

By recruiting locally influential women like Hauwa from communities where some parents are vaccine-hesitant, and training them to be advocates for child health, vaccination rates are improved throughout their neighbourhoods. In some areas, more than 99% of parents now accept the polio vaccine for their child.

“Hauwa resides in this settlement and I trust her; I trust that the advice she is giving is in the best interest of my children,” says Nasiru.

He also notes, however, that he is often the only man at the health facility.

Engaging all fathers

Hauwa hopes that by encouraging more fathers to take on the parental responsibility of completing their children’s routine immunization schedule, immunization coverage will increase across Sokoto. Greater vaccine acceptance and awareness means that children are more likely to receive a life-saving polio vaccine, and other vaccines, whether through routine immunization or through door-to-door vaccination.

Already, the trust that she has built amongst parents in Gagi Makurdi has helped surmount many of the barriers that deny children immunization and other health services. In Nasiru and Zara’u’s compound, nearly all children are now protected against polio and other vaccine-preventable diseases.

Only their baby, Nana Asmaiu, has yet to have all his vaccinations – and Hauwa will soon visit his household to support Nasiru and Zara’u, and ensure he gets them.

Reposted with permission from gavi.org.

Last month, Afia and her colleagues vaccinated 9.9 million children and educated millions of parents about vaccination across the country. © UNICEF Afghanistan
Last month, Afia and her colleagues vaccinated 9.9 million children and educated millions of parents about vaccination across the country. © UNICEF Afghanistan

This is southern Afghanistan. A place characterized by a rich, diverse, but often complex history. Enveloped by mountains, this part of the country has seen years of conflict which have left hospitals under-resourced and health services shattered. Children face many challenges – as well as conflict and poverty, southern Afghanistan has the highest number of polio cases in the world.

In this difficult environment, the virus can only be defeated if every child is vaccinated.

Afia holds a young child who has just received a polio vaccination. The polio eradication programme is one of the biggest female work forces in Afghanistan. © UNICEF Afghanistan
Afia holds a young child who has just received a polio vaccination. The polio eradication programme is one of the biggest female work forces in Afghanistan. © UNICEF Afghanistan

Afia (not her real name), who is nineteen years old, is one of over 70 000 committed polio workers in Afghanistan, supported by WHO and UNICEF. Last month, she and her colleagues vaccinated 9.9 million children and educated thousands of parents about vaccination across the country.

The polio eradication programme comprises one of the biggest female workforces in Afghanistan: a national team, all fighting polio. Some women work as vaccinators, whilst others, like Afia, are mostly engaged in education and social mobilisation efforts. The polio programme gives women culturally-appropriate opportunities to work outside the house and engage in their community, speaking to parents about the safe, effective polio vaccine, and answering their questions. Often, women vaccinators offer other kinds of health advice, including recommendations for good child and maternal health.

To be a good vaccinator and educator, women must be committed to better health for all, with strong communication skills. They must also be organized to ensure that every child is reached during the campaign.

Afia says that if she wasn’t eradicating polio, her parents would expect her to give up her education and get married. Her younger sisters look up to her, excited to work in the polio eradication programme when they are old enough.

Her job is very important to protect all children. Afghanistan is just one of three countries – the others are Nigeria and Pakistan - that have never interrupted poliovirus transmission.

Women can vaccinate children who might otherwise miss out. Culturally, male vaccinators are unable to enter households to administer vaccine, causing difficulties if young children are asleep or playing inside. Their freedom to enter homes and give the vaccine to every child is one reason female polio workers are so critical.

Afia started work at 7 am, and is now walking home ten hours later with a young boy she has just vaccinated. Her purple burka stands out against the sand as she goes home to tell her parents and siblings about her day.

Afia feels positive about the future of polio eradication in Afghanistan: “We have a duty to protect our children, and I won’t stop working until every child is protected.”
 

Women have a right to participate in all aspects of polio eradication. Removing barriers to women’s full participation at all levels is a key goal for the Global Polio Eradication Initiative (GPEI). To learn more, see the gender section of our website, and read the GPEI ‘Why Women’ Infographic.

Afghanistan is just one of three countries —the others are Nigeria and Pakistan — that have never interrupted poliovirus transmission. © UNICEF Afghanistan
Afghanistan is just one of three countries —the others are Nigeria and Pakistan — that have never interrupted poliovirus transmission. © UNICEF Afghanistan

 

Member of Provincial Scholars Task Force Molvi Hameedullah Hameedi vaccinating a child whose parents used to refuse vaccination. Killa Abdullah, Balochistan, July 2018. © D. Khan
Member of Provincial Scholars Task Force Molvi Hameedullah Hameedi vaccinating a child whose parents used to refuse vaccination. Killa Abdullah, Balochistan, July 2018. © D. Khan

Molvi Hameedullah Hameedi is a prominent religious scholar in a mountainous rural area of Killa Abdullah district, one of the poorest districts in Balochistan province, Pakistan. With a close connection to his community, who are mostly Pashtuns, he delivers the sermon each week during Friday prayers, and runs a religious seminary.

He is also a determined supporter of routine vaccination for all children, and an advocate for better health.

This might come as a surprise if you met Molvi Hameedullah just a year or two ago. For most of his life, he did not believe in the safety and effectiveness of the oral polio vaccine, the key tool of polio eradication.

“I was a religious scholar who was very sceptical of non-governmental organizations and the polio vaccine,” he reflects.

“After reading anti-vaccine books and papers, I began following the work of anti-vaccine campaigners. Soon, I came to consider it my religious duty to spread awareness against the polio vaccine.”

“But it all changed when I was invited to a two-day International Ulema conference in Islamabad where religious scholars from all over Pakistan and other Islamic countries were invited to debate polio vaccination.”

The conference Molvi Hameedullah attended was hosted by the Islamic Advisory Group for Polio Eradication (IAG). The IAG was launched in 2014 by leading Islamic institutions including Al-Azhar University, the International Islamic Fiqh Academy (IIFA), the Islamic Development Bank (IsDB) and the Organization of Islamic Cooperation (OIC).

For Molvi Hameedullah, attending the conference marked the beginning of a change in perspective. “At the conference, I was given an opportunity to discuss my apprehensions towards polio vaccine. The talks I had motivated me to further research the pro-polio vaccine stance, and I started meeting with religious scholars in Karachi to debate polio vaccination.”

“Through talking to these people, I was getting a completely different picture to what I had believed earlier.”

By educating religious leaders and scholars about the poliovirus, and explaining religious justifications for vaccine acceptance, the IAG and its national equivalent equip people like Molvi Hameedullah with the tools to act as health advocates. The same skills that help scholars engage with parents about the polio vaccine are applicable for wider health, including improving routine immunization, hygiene practices, and maternal and child health.

After the conference Molvi Hameedullah was offered support by other vaccine-promoting scholars.

“I received a book from a religious support person working for polio vaccination in my area. Included were dozens of fatwas from highly esteemed madrassahs and religious teachers. I was initially sceptical, so I telephoned the madrassahs who had written them. To my surprise, all the fatwas were genuinely issued by them, and they also urged me to support vaccination wherever I called.”

Today, Molvi Hameedullah teaches similar fatwas as a member of the Provincial Scholar Task Force under the National Islamic Advisory Group. Most Task Force members have an honorary position, and are not paid a salary. Instead, the local government facilitates their transport and communication needs during immunization campaigns. Of his new role Molvi Hameedullah says, “I was faced with a different problem. I had been working against polio vaccination for many years, and now felt that I had done a great damage to the children and parents of my community. I felt it was now my absolute religious duty to negate all that I had taught before. I decided to step forth, and started working in the community voluntarily to promote vaccination.”

Religious refusals in Molvi Hameedullah’s area have declined. He has begun supporting other ways of ensuring that every child receives a vaccine, including by recruiting women vaccinators.

He acknowledges that the work he does now is not easy. He and his fellow scholars sometimes face challenges from those accusing them of having a political agenda, and changing beliefs informed by years of cultural and religious tradition takes time and patience. But he vows to continue his new mission until eradication.

There have been no cases of polio in the area of the district that Molvi Hameedullah covers since he joined the Provincial Scholars Task Force. Looking ahead, he is determined not to stop until all of Pakistan is polio-free.

Since he joined the Provincial Scholars Task Force, there have been no polio cases in Molvi Hameedullah Hameedi’s district. © D. Khan
Since he joined the Provincial Scholars Task Force, there have been no polio cases in Molvi Hameedullah Hameedi’s district. © D. Khan
A child is vaccinated with fIPV during a campaign in Hyderabad, India. © WHO/Harish Verma
A child is vaccinated with fIPV during a campaign in Hyderabad, India. © WHO/Harish Verma

A new study published this month in the Journal of Infectious Diseases has shown that a single dose of fractional dose inactivated poliovirus vaccine (fIPV) boosts mucosal immunity to a similar degree as a full dose of IPV, in children previously immunized with oral polio vaccine (OPV). During the current IPV shortage, this vaccine is not recommended for outbreak response, however, if it is used, then this finding provides further evidence in support of fIPV rather than full dose IPV at a time of IPV global supply shortage.

The efficacy of fIPV in boosting humoral immunity (offering individual protection against paralytic disease) in comparison to full-dose IPV had already been established, and this dose-sparing approach for routine immunization programmes was subsequently recommended by the Strategic Advisory Group of Experts on immunization (SAGE). Thanks to an increasing number of countries adopting this approach, including Bangladesh, India, Nepal, Sri Lanka, Cuba and Ecuador, there have been significant improvements in the global supply of this vaccine.

These latest findings show that fIPV also has a significant role to play in outbreak response. Mucosal immunity is needed to interrupt person-to-person spread of the virus in a community, so is a critical factor in outbreak response. Used in conjunction with OPV, even a single dose of this formulation could now play a key role in such settings, by rapidly boosting mucosal immunity at a similar level to a full-dose IPV while using a fifth of the vaccine amount. This has clear benefits both on cost and supply.

“Globally, demand for IPV is high and the supply is constrained,” commented Dr Tahir Yousafzai from Aga Khan University in Karachi, Pakistan. “As polio eradication is gradually eliminating OPV, countries will eventually rely solely on IPV, further increasing demand. Fractional IPV can stretch the limited IPV supply and provide similar humoral and mucosal protection when compared to full-dose IPV in children vaccinated with OPV. In addition, it will play an important role in stopping poliovirus transmission, and hence help in the eradication of wild poliovirus and circulating vaccine-derived poliovirus.”

For the post-polio era, the Global Polio Eradication Initiative and its partners are continuing to explore new IPV approaches to ensure an affordable and sustainable supply following global polio eradication, including through the use of IPV vaccine manufactured from Sabin strains or non-infectious materials such as virus-like particles.

Additional information:

A child is protected from lifelong polio paralysis through OPV vaccination. © WHO
A child is protected from lifelong polio paralysis through OPV vaccination. © WHO

The first of four large-scale immunization campaigns is set to kick off in Papua New Guinea next week, following last month’s confirmation of a circulating vaccine-derived poliovirus type 1 (cVDPV1). More than 2900 health workers, vaccinators and volunteers have been mobilized to vaccinate almost 300 000 children under 5 years of age in Morobe, Madang and Eastern Highlands provinces. The campaign from 16-29 July is the first in a series of vital immunization campaigns planned every month for the next four months.

“Polio is back in Papua New Guinea and all un-immunized children are at risk,” said Pascoe Kase, Secretary of the National Department of Health (NDOH). “It is critical that every child under five years of age in Morobe, Madang and Eastern Highlands receives the polio vaccine during this and other immunization campaigns, until the country is polio-free again.”

As polio is a highly infectious disease which transmits rapidly, there is potential for the outbreak to spread to other children across the country, or even into neighbouring countries, unless swift action is taken. With no cure for polio, organisers of the immunization drive are calling for the full support of all sectors of society to ensure every child is protected. Parents living in the three provinces are encouraged to bring their children to local health centres or vaccination posts to receive the vaccine, free of charge, during the campaign.

“Everyone has a role to play in stopping this terrible disease,” commented Dr Luo Dapeng, WHO Representative in Papua New Guinea. “We call on parents to bring your children under five years of age for vaccination, irrespective of previous immunization status. Together, we can help ensure that this outbreak is rapidly stopped and that no further children are paralysed by polio.”

The Officer In Charge for UNICEF Representative, Ms. Judith Bruno, stressed, “As long as the polio virus persists anywhere, all un-immunized children remain at risk, and since polio carries enormous social costs, we must make it a key priority to stop its transmission so that children, families and communities are protected against this terrible disease.”

The immunization campaign is organized by the National Department of Health and the Provincial Health Authorities, with support from the World Health Organization (WHO), UNICEF, Rotary International and other partners.

Campaign dates are:
• First Round: 16-29 July 2018
• Second Round: 13-26 August 2018
• Third Round: 10-23 September 2018
• Fourth Round: 8-21 October 2018

Following confirmation of the cVDPV1, on 22 June the National Department of Health of Papua New Guinea immediately declared the outbreak a ‘national public health emergency’, requiring emergency measures to urgently stop it and prevent further children from lifelong polio paralysis. The measures implemented by the government intend to comply fully with the temporary recommendations issued under the International Health Regulations ‘Public Health Emergency of International Concern (PHEIC)’.

Papua New Guinea has not had a case of wild poliovirus since 1996, and the country was certified as polio-free in 2000 along with the rest of the WHO Western Pacific Region. In Morobe Province, polio vaccine coverage is suboptimal, with only 61% of children having received the recommended three doses of polio vaccine. Water, sanitation and hygiene are also challenges in the area, which could contribute to further spread of the virus.

Routine vaccination is one of the only health services available to internally displaced people living in Mélea camp for internally displaced persons. © WHO/D. Levison
Routine vaccination is one of the only health services available to internally displaced people living in Mélea camp for internally displaced persons. © WHO/D. Levison

The environment

Dar es Salam refugee camp, in Bagassola district, Chad, is home to thousands of refugees. 95% of the population is Nigerian, displaced by years of violent insurgency, drought and insecurity in the Lake Chad basin. Some have lived in the camp since 2014.

Here, temperatures soar to 45 degree Celsius nearly every day. Dust is inescapable, colouring everything a shade of yellow. Houses are constructed from tents, tarpaulins and reeds, pitched onto sand. There is no employment, few shops, and no green areas.

A health worker sets out to conduct house-to-house polio vaccination activities in Dar es Salam. © WHO/D. Levison
A health worker sets out to conduct house-to-house polio vaccination activities in Dar es Salam. © WHO/D. Levison

Kilometers from the lake, residents have no access to the water around which their livelihoods revolved, as fishing people, as traders at the markets located around the island network, or as cattle farmers. This renders them almost entirely reliant on aid. The edge of the camp is an enormous parking lot, filled with trucks loaded with donations. Signs interrupt the landscape, attributing the camp’s schools, football pitches, and water stations to different funding sources.

Polio immunization is a core health intervention offered by the health centre here, with monthly house to house vaccination protecting every child from the virus.

“We vaccinate to keep them healthy”

In return for their work, vaccinators receive a small payment, one of the few ways of earning money in the camp. In Dar es Salam, there are thirty positions, currently filled by 24 men and six women, and applications are very competitive. Those chosen for the role are talented vaccinators, who really know their community.

Laurence (centre) explains why vaccination is so important, whilst his colleague marks the finger of a child just vaccinated. © WHO/D. Levison
Laurence (centre) explains why vaccination is so important, whilst his colleague marks the finger of a child just vaccinated. © WHO/D. Levison

Laurence speaks multiple languages, adeptly communicating with virtually everyone in the camp. He is a fatherly figure, engaging parents in conversations about the importance of vaccination whilst his colleague gives vaccine drops to siblings. Their mother is a seamstress, constructing garments on a table under one of the few leafy trees. Laurence engages her in conversation, explaining why the polio vaccine is so important.

Describing his work, he says, “I tell parents that the vaccine protects children from disease, especially in this sun, and that we vaccinate every month to keep them healthy.”

A precious document in a plastic bag

Chadian nationals living in nearby internally displaced persons camps don’t have the same entitlements as international refugees. Several hours’ drive from Dar es Salam, children lack access to even a basic health centre.

A UNICEF health worker inspects the baby’s vaccination card. © WHO/D. Levison
A UNICEF health worker inspects the baby’s vaccination card. © WHO/D. Levison

At a camp in Mélea, vaccinators perform routine immunization against measles and other diseases under a shelter made from branches. Cross-legged on the ground, they fill in paperwork, carefully administer injections, sooth babies, and dispose safely of needles. Other vaccinators give the oral polio vaccine to every child under the age of ten. These children are mostly from the islands, displaced by insurgency. Their vaccination history is patchy at best, and it is critical that they are protected.

One father arrives accompanied by his small, bouncy son. As the baby looks curiously at the scene in front of him, his dad draws out a tied plastic bag. Within is his son’s vaccination card, carefully protected from the temperatures and difficult physical environment of the camp.

A UNICEF health worker reads it, and realizes that the child is due another dose of polio vaccine. Squealing with confusion, the baby is laid back in his sibling’s arms, and two drops administered. The shock over, he is quickly back to smiling, rocked up and down as his dad folds up the card, and ties it up in the bag once more.

A child living in Dar es Salam is vaccinated against the polio virus. © WHO/D. Levison
A child living in Dar es Salam is vaccinated against the polio virus. © WHO/D. Levison

“Our biggest challenge”

Back in Dar es Salam, DJórané Celestin, the responsible officer for the health centre explains the wider challenges of vaccination in this environment.

“We don’t just vaccinate within Dar es Salam in our campaigns. We are also responsible for 27 villages in the nearby surroundings. Reaching these places proves our biggest challenge.”

Away from the main route to Dar es Salam, there are no roads or signs, and many tracks are unpassable. To reach the 539 children known to live in the villages, vaccinators walk, or rent motorbikes, travelling for many hours.

This month, another round of vaccination in the Lake Chad island region concluded. Hundreds more refugee and internally displaced children are protected, in some of the most challenging and under-resourced places to grow up.

A mother and her child wait for routine immunization services in Mélea camp for internally displaced persons. © WHO/D. Levison
A mother and her child wait for routine immunization services in Mélea camp for internally displaced persons. © WHO/D. Levison
Salamatu Kabir (right), a HTR team lead, travels with other health workers to vaccinate children across two local government districts. © UNICEF Nigeria
Salamatu Kabir (right), a HTR team lead, travels with other health workers to vaccinate children across two local government districts. © UNICEF Nigeria

Three-year-old Ibrahim wouldn’t stop crying. Suffering from ringworm, a fungal infection, his leg had become badly infected. Left untreated, he risked developing fever and scarring wounds.

For Ali Musa, his father, it was hard to know where to turn for help. Where he lives, in the nomadic community of Daurawa Shazagi in the Nigerian state of Jigawa, there is little access to professional medical treatment.

From his home, it would take Ali a full day to trek to the nearest primary health centre. He does not recall the last time anyone in his community made this “practically unthinkable” journey.

Reaching all children with vaccines

“But when I heard in the market that a medical team was coming to us to treat sick people, especially women and children, I went with the hope to at least get him some relief from the pain,” Ali recalls.

There, Ali met members of the mobile health teams supported by the UNICEF Hard-to-Reach (HTR) project – funded by the Government of Canada’s Department of Foreign Affairs, Trade and Development. These teams are helping to ensure that children receive polio vaccinations, whilst also providing basic health services – including medications to fight infections like ringworm – in hard-to-reach areas of Nigeria.

A health worker wades across a shallow river to deliver polio vaccines and other health interventions. © UNICEF Nigeria
A health worker wades across a shallow river to deliver polio vaccines and other health interventions. © UNICEF Nigeria

The teams vaccinate against measles, meningitis and other diseases, and provide vitamin A supplements and deworming tablets for children. They also carry out health promotion activities, teaching communities about important practices such as exclusive breastfeeding. During each clinic, members of the HTR team give two drops of polio vaccine to every child, ensuring that all are protected from the virus.

At the end of their visit, the team pack up the clinic, and travel home, taking hours to cross difficult terrain by foot, boat and motorbike.

2390 children vaccinated

The HTR project aims to reduce the immunity gap among children living in Nigeria. Since 2016, when cases of wild poliovirus last were detected in the country, determination and commitment have helped to strengthen eradication efforts, but many states still face an uphill task to increase historically low routine immunization rates. This is especially the case in rural areas, where there are few services, and communities have to travel far to the nearest health clinic.

So far in 2018, the project has reached thousands of previously unvaccinated children with the life-saving polio vaccine, including 2390 children in Ibrahim’s state, Jigawa.

“Why should I let anything stop me?”

Salamatu Kabir, who leads a HTR team assigned to take immunization and basic health care services across Jigawa, says “I look at it this way. If people from outside can come all the way to bring the hard-to-reach project to my country, why should I let anything stop me from delivering it to my own people who are most in need?”

A retired health worker, she says that she doesn’t think twice about the many hurdles that she will have to overcome to reach children in communities like Ali and Ibrahim’s.

Far more of a concern is planning meals for her four children whilst she is away, and packing all the equipment she will need for the journey. Experience over the years has taught her what items to add to her bag besides vaccines. She always carries an umbrella, an extra pair of clothes, insect repellant and depending on the season, either an additional pair of sandals or, most often, rain boots.

Salamatu asserts that for the team members, “visiting the settlements to administer health care is something we have come to love and look forward to”.

When the team finally does arrive at their destination they are greeted by an expectant community. Salamatu is motivated by the direct impact her work has on the lives of others.

Little Ibrahim is one of those to benefit.  After treatment from the team, his condition improved quickly. His father Ali has since become a volunteer for the HTR project, and an avid advocate within his community for medical care.

“I will do my best to ensure every child in my village benefits from the help that is coming from far,” he says.

A child receives an IPV (inactivated poliovirus vaccine) vaccination during routine immunization activities in Bangladesh. © Gavi
A child receives an IPV (inactivated poliovirus vaccine) vaccination during routine immunization activities in Bangladesh. © Gavi

In the fight against the virus, two important tools are used to help prevent polio – two safe, effective vaccines. Only through full funding of these vaccines can worldwide immunity be achieved, and the virus eradicated.

Redoubling commitment towards this goal, last week, Gavi, The Vaccine Alliance, approve core funding for the inactivated poliovirus vaccine (IPV) for 2019 and 2020, to continue work to end polio, and protect every child.

Announcing this support, Gavi Board Chair Dr Ngozi Okonjo-Iweala said, “Polio will remain a threat until every child is protected against this crippling disease. That is why the vaccination of every child is the corner stone of the polio eradication effort. Introducing IPV to all countries to interrupt polio transmission and maintain zero cases represents an unprecedented push, and Gavi is proud to be part of it.”

Since 2013, the Gavi Board has supported IPV in all 70 Gavi-supported countries, through a dedicated funding stream financed by the Global Polio Eradication Initiative (GPEI) budget. Responding to continued wild poliovirus circulation in 2018, this most recent Gavi support represents an additional contribution, which will help ensure that the programme can continue its valuable work to protect every child worldwide.

The Gavi Board also approved an exceptional extension of support for Nigeria up to 2028, to help reach over 4.3 million under-immunized children in the country, who remain at risk of vaccine-preventable diseases including polio.

Michel Zaffran, Director of the Polio Eradication Programme at the World Health Organization, extended his thanks to the Gavi Board for their generous contribution, saying, “GPEI and Gavi are committing to work closer together than ever before, and take one more step towards the immunization of all children, to deliver and to sustain a polio-free world.”

© Simon Nazer/UNICEF Laos
© Simon Nazer/UNICEF Laos

For 15 years Daeng Xayaseng has been travelling through rugged, undulating countryside by motorbike and by foot to deliver vaccines to children in some of the most remote villages in Laos.

It’s hard work but she is determined: “We have a target of children to reach and we’ll achieve that no matter how long it takes,” she says. “We’ll keep working until we reach every child.”

Today her team visits Nampoung village, 4 hours north of the capital of Laos, to deliver polio vaccines.

“For 15 years I’ve been working on campaigns like this,” she says. “Today we’re here with our outreach team to vaccinate children against polio. We’ll also go house to house to make sure no child misses out on being vaccinated.”

“We don’t want there to be another outbreak of polio so we have to reach everyone,” says Daeng. “In order to do that, immunizing every child in remote communities like this is a priority to ensure everyone is protected.”

UNICEF and other partners of the Global Polio Eradication Initiative are supporting the Lao Government to reach nearly half a million children under five with potentially life-saving vaccines. More than 7,200 volunteers and 1,400 health workers like Daeng and her team have been mobilized to deliver the oral polio vaccine as well as other vaccinations such as measles-rubella.

“I’m very happy and proud to do this job,” says Daeng once the team has packed up. “I’m proud to do this job to serve the community and help in any way I can.”

© Simon Nazer/UNICEF Laos
© Simon Nazer/UNICEF Laos

Read more:

Unicef blog – Ending polio in Laos

© Sweden National Authority for Containment
© Sweden National Authority for Containment

A vaccine manufacturer in Stockholm has taken the first step towards becoming a certified Poliovirus Essential Facility (PEF), leading the charge in global efforts to safely and securely contain type-2 poliovirus. This facility has been awarded a Certificate of Participation co-signed by the National Authority for Containment (NAC) in Sweden and the Global Commission for the Certification of Poliomyelitis Eradication (GCC). The Certificate is the first of its kind to be issued, indicating formal engagement in the global containment certification process.

Wild poliovirus type-2 was declared eradicated by the GCC in September 2015, however, there is risk of the virus resurging. Following the removal of the type-2 component from oral polio vaccine (OPV) and the discontinuation of type-2 containing OPV from routine use in April 2016, countries around the world have been asked to safely and securely destroy their type-2 polio samples. As a further precaution, countries continue to immunize against type 2 polioviruses with inactivated polio vaccine. For facilities needing to retain the virus for vaccine production or for critical research, stringent containment measures need to be followed. The first step is getting a Certificate of Participation.

Handling of infectious virus. © Sweden National Authority for Containment
Handling of infectious virus. © Sweden National Authority for Containment

“We are pleased to see Sweden leading the way in demonstrating conforming with the processes to minimize the risk of releasing type-2 poliovirus into the environment. Participation in the Containment Certification Scheme shows that both the facility and the host country are serious about taking on and implementing the safeguard measures necessary to become a PEF,” said Prof. David Salisbury, Chair of the GCC and of the Commission’s European regional body.

“Handling and storing an eradicated pathogen is a risk and responsibility – a leak or breach could have devastating consequences,” said Michel Zaffran, Director of Polio Eradication at the World Health Organization. “We commend Sweden for its commitment towards ensuring safety standards are met and protocols are in place to help minimize risk, and for paving the road for the containment certification process,” he said.

“The issuance of a Certification of Participation formally engages a designated PEF in the containment process. Provided that the facility meets the requirements outlined in Global Action Plan III for the containment of polioviruses (GAPIII) within given time frames, it can then progress to achieving an Interim Certificate of Containment and finally, a full Certificate of Containment to become an accredited PEF,” said Prof. Salisbury. “Countries planning to retain type-2 poliovirus will need to establish their NACs as soon as possible, and by no later than the end of 2018. The GCC urges all countries that plan to have PEFs to get the ball rolling in this process,” he said.

Since April 2016, most facilities around the world have opted to destroy their type-2 poliovirus materials rather than contain them. Twenty-nine countries, however, plan to continue to handle and store their materials in 92 designated PEFs.

WHO will propose a resolution for consideration by the World Health Assembly in May to seek international consensus on accelerating containment efforts globally.

Throughout the course of the Commonwealth summit and related events, individual leaders voiced their continued support for eradication. © Malaria No More UK
Throughout the course of the Commonwealth summit and related events, individual leaders voiced their continued support for eradication. © Malaria No More UK

In London on 19-20 April, leaders of the 53 member states of the Commonwealth affirmed their commitment to end polio in the final Communique of the 2018 meeting. Leaders emphasized renewed support for international efforts to tackle polio and other diseases, and called for an increase in national health expenditure throughout the Commonwealth.

This outcome was largely thanks to the efforts of civil society, including outreach by members of Rotary clubs in Commonwealth countries, Global Citizen, and numerous other partners who urged Commonwealth leaders to uphold their commitment to polio eradication. This included the delivery of over 4000 messages to UK Prime Minister Theresa May appealing for her continued commitment to a polio free world.

Throughout the course of the summit and related events, individual leaders also voiced their continued support for eradication. Prince Charles, who will one day succeed Queen Elizabeth II as Head of the Commonwealth, held up the polio programme as an example of successful joint action against disease and noted that hundreds of millions of children have benefitted from polio vaccine because of the GPEI. The end of polio, he noted, will serve as an example of the Commonwealth’s proven track record in effecting change. Once eradication is achieved, polio infrastructure will be leveraged to address other health challenges, and may pave the way for malaria elimination. Incoming Chair of the Commonwealth Theresa May, in a direct letter to advocates, acknowledged that eradication “remains a top global priority,” and promised that the UK will “work closely with polio-endemic countries to ensure we eradicate this cruel disease, once and for all.” Malta’s Prime Minister Joseph Muscat, who has championed polio throughout his tenure as Commonwealth Chair, pledged during a speech to help end polio in Commonwealth countries Pakistan and Nigeria.

With a collective investment of more than US$ 4 billion and previous statements of commitment to polio eradication, Commonwealth governments have long-been leading champions to end polio. As Bill Gates noted during his summit remarks, “success [against polio] really goes back to the substantial commitments made in part at the Commonwealth meetings.” With a record low 22 cases registered last year, continued global support is vital to get the world over the finish line. The renewed support from the Commonwealth, which represents a wide range of countries, provides hope that governments remain firmly committed  to fulfilling the promise of a polio-free world.

Without the life changing impact of vaccines, our world would be a very different place indeed. © Anam Khan/WHO Pakistan
Without the life changing impact of vaccines, our world would be a very different place indeed. © Anam Khan/WHO Pakistan

Fear of paralysis, severe illness, or death from polio and smallpox was a very real and pervasive reality for people worldwide within living memory.

Ali Maow Maalin was the last person to develop smallpox, and later became an advocate for polio eradication. © WHO/John F. Wickett
Ali Maow Maalin was the last person to develop smallpox, and later became an advocate for polio eradication. © WHO/John F. Wickett

In 1977, the world was close to finally being smallpox free. The number of people infected had dwindled to only one man; a young hospital cook and health worker from Merca, Somalia named Ali Maaow Malin.

Before Ali, smallpox had affected the human population for three millennia, infecting the young, the old, the rich, the poor, the weak and the resilient.

Spread by a cough or sneeze, smallpox caused deadly rashes, lesions, high fevers and painful headaches – and  killed up to 30% of its victims, while leaving some of its survivors blind or disfigured.

An estimated 300 million people died from smallpox in the 20th century alone, and more than half a million died every year before the launch of the global eradication programme.

The power of a vaccine

Smallpox was declared eradicated in 1980, proof of the power of vaccines. © WHO
Smallpox was declared eradicated in 1980, proof of the power of vaccines. © WHO

Between 1967 and 1980, intensified global efforts to protect every child reduced cases of smallpox and increased global population immunity. Following Ali’s infection, the World Health Organization carefully monitored him and his contacts for two years, whilst maintaining high community vaccination rates to ensure that no more infection occurred.

Three years later, smallpox was officially declared the first disease to be eradicated. This was a breakthrough unlike any other – the first time humans had definitively beaten a disease.

But smallpox wasn’t the only deadly virus around

On March 26, 1953, Dr Jonas Salk announced that he had developed the first effective vaccine against polio. This news rippled quickly across the globe, leaving millions optimistic for an end to the debilitating virus.

Polio, like smallpox, was feared by communities worldwide. The virus attacks the nervous system and causes varying degrees of paralysis, and sometimes even death. Treatments were limited to painful physiotherapy or contraptions like the “iron lung,” which helped patients breathe if their lungs were affected.

Thanks to a safe, effective vaccine, children were finally able to gain protection from infection. In 1961, Albert Sabin pioneered the more easily administered oral polio vaccine, and in 1988, the Global Polio Eradication Initiative was launched, with the aim of reaching every child worldwide with polio vaccines. Today, more than 17 million people are walking, who would otherwise have been paralyzed. There remain only three countries – Afghanistan, Pakistan, and Nigeria – where the poliovirus continues to paralyze children. We are close to full eradication of the virus – in Pakistan cases have dropped from 35 000 each year to only eight in 2017.

Since there is no cure for polio, the infection can only be prevented through vaccinations. The polio vaccine, given multiple times, protects a child for life.

Better health for all

Thanks to vaccines, the broader global disease burden has dropped drastically, with an estimated 2.5 million lives saved every year from diphtheria, tetanus, pertussis (whooping cough), and measles. This has contributed to a reduction in child mortality by more than half since 1990. Thanks to an integrated approach to health, multiple childhood illnesses have also been prevented through the systematic administration of vitamin A drops during polio immunization activities.

Moreover, good health permeates into societies, communities, countries and beyond – some research suggesting that every dollar spent vaccinating yields an estimated US$ 44 in economic returns, by ensuring children grow up healthy and are able to reach their full potential.

Ali Maaow Malin, the last known man with smallpox, eventually made a full recovery. A lifelong advocate for vaccination, Ali went on to support polio eradication efforts – using vaccines to support better health for countless people.

Without the life changing impact of vaccines, our world would be a very different place indeed.

Vaccines ensure better health for all children. © Aman Khan/WHO Pakistan
Vaccines ensure better health for all children. © Aman Khan/WHO Pakistan