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
Binta marks a girl’s finger with indelible ink after vaccinating her in Kano State, Nigeria. © WHO Nigeria
Binta marks a girl’s finger with indelible ink after vaccinating her in Kano State, Nigeria. © WHO Nigeria

Binta Tijjani works to eradicate polio in her native Kano state of Nigeria. She is one of the over 360 000 frontline workers dedicated to ending polio in her country, the vast majority of whom are women. Nigeria is one of only three countries in the world yet to stop poliovirus circulation, together with Afghanistan and Pakistan.

Binta has worked in polio eradication for over 14 years. Starting as a house-to-house vaccination recorder, she was soon promoted to the role of polio campaign supervisor and now works as an independent polio campaign monitor.

“My biggest strength is my ability to work closely with our teams to ensure we reach every last child with vaccines, and advising teams so they can ask the right questions and raise important issues in each household they visit,” Binta says.

Working with the polio programme often opens up other opportunities for women to enter the workforce and utilize their skills to contribute to their communities, leading to positive investments beyond polio eradication.

“My work with the polio programme has enabled me to buy land and take care of my children’s school fees and our household needs. Currently I’ve enrolled in a course to get a certificate in catering. My dream is one day to open a restaurant,” Binta says.

Halima administers the oral polio vaccine to a child at a pharmacy where she works as a polio surveillance focal point. © WHO Nigeria
Halima administers the oral polio vaccine to a child at a pharmacy where she works as a polio surveillance focal point. © WHO Nigeria

Similar to Binta, Halima Waziri has been serving the polio eradication cause in different roles since 2005. Currently Halima works as a lot quality assurance sampling interpreter in Kano state, assessing the quality of vaccination coverage after immunization campaigns in her area.

“I am most proud of engaging in many productive dialogues about polio vaccination in remote and hard-to-reach areas and high-risk communities in Nigeria. This has helped me to improve my interpersonal communication skills and given me confidence in public speaking and influencing people,” Halima says.

With the money she has earned as a polio worker, Halima has opened a medicine store where she sells medicines and also acts as a community informant and focal point for disease surveillance.

Nigeria was on the brink of eradicating polio when a new wild poliovirus case was reported in 2016 after two years without any confirmed cases. Low overall routine immunization coverage is a key stumbling block to eradication, combined with ongoing violent conflict in the northeast where over 100 000 children remain inaccessible for vaccination teams.

Nigeria continues to implement an emergency response to vaccinate all children under the age of 5 to ensure they are immunized and protected, including implementing vaccination campaigns whenever security permits, vaccinating children at markets and cross-border points, and conducting active outreach to internally displaced people.

Without the critical participation of women as vaccinators, surveillance officers and social mobilizers, Nigeria would not be as close to eradicating polio as it is today. The latest nationwide immunization campaign, synchronized with countries in the Lake Chad basin, aimed to reach over 30 million children in Nigeria in April.

No wild poliovirus cases have been reported in 2017 or 2018. Binta and Halima, together with an army of frontline workers, are determined to keep it this way and secure a polio-free future for Nigeria.

A child is vaccinated in Raqqa. The recent polio vaccination activity was the first to go ahead in the city since it became accessible again. © WHO Syria
A child is vaccinated in Raqqa. The recent polio vaccination activity was the first to go ahead in the city since it became accessible again. © WHO Syria

From the front passenger seat of a small utility truck, Mahmoud Al-Sabr hangs out the window, looking for families and any child under five years old to be vaccinated against polio. As the car he travels in dodges rubble and remnants of buildings that once stood tall in Raqqa city, he flicks the ‘on’ switch for his megaphone.

“From today up to January 20, free and safe vaccine, all children must be vaccinated to be protected from the poliovirus that hit Syria for the second time,” he calls, beckoning families with young children who have recently returned to Raqqa city to come outside of their makeshift homes amongst destroyed buildings, to have their children vaccinated.

In 2017, amidst the protracted conflict and humanitarian crisis in Syria, an outbreak of circulating vaccine-derived poliovirus type 2 (cVDPV2) was detected, threatening an already vulnerable population.

Due to ongoing conflict, Raqqa city, which was once host to half of the governorates population, had been unreached by any vaccination activity or health service since April 2016. During the first phase of the outbreak response, more than 350,000 resident, refugee and displaced children were vaccinated against polio in Syria, but “Raqqa city remained inaccessible,” says Mahmoud.

In January 2018, polio vaccinators conducted the first vaccination activity in the city since it became accessible again, following the end of armed opposition group control.

There were no longer accurate maps or microplans that vaccinators could use to guide them in their work. Unrecognizable, the city was a picture of devastation with few dwellings untouched by the violence that once caused families to flee. The house-to-house vaccination campaign that usually helps the programme to reach every child under five wouldn’t work here. Teams knew they would have to innovate to seek out families wherever they were residing to vaccinate their children.

“All children must be vaccinated to protect against poliovirus,” Mahmoud echoes around shelled out buildings, and slowly mothers and fathers carrying their children start to appear in the street.

Mahmoud and Ahmed Al-Ibraim are one of 12 mobile teams that are going street by street, building by building, by car in search of children to vaccinate. Carrying megaphones to alert families of their presence and to tell them of the precious vaccines they carry that will protect their children from the paralysing but preventable poliovirus, they slowly cover areas of the city now unrecognizable.

“No one could enter Raqqa City now for two years,” says Abdul-Latif Al-Mousa, a lawyer from the city who joined the outbreak response as a Raqqa City supervisor for polio campaigns. “So children have not been vaccinated here since that time. Now that people have returned, we are learning where they have returned from and we vaccinate them regardless.”

“We must reach each child with the vaccine to protect them – polio is preventable, why should they suffer more?” Ahmed appeals.

Campaign brings vaccines and familiar faces

Vaccines were not the only thing to return to Raqqa City in January. It was the first time that WHO polio focal point Dr Almothanna could return to Raqqa City after being force to flee under the rule of the armed opposition group. Imprisoned for refusing the demands of the group, friends and neighbours of Dr Almothanna facilitated his escape from the city in 2016.

Dissatisfied but not deterred, Dr Almothanna continued to work with the polio programme, serving the whole governorate except his own city. Over the course of the January 2018 campaign, he worked tirelessly with vaccination teams to ensure more than 20 000 children under the age of five in Raqqa City received a dose of mOPV2 to protect them against polio. For many, it was the first vaccination they had received. In the additional campaigns that followed in March 2018, even more children were reached.

The microplans developed by vaccinator teams in the first vaccination round have become a critical road map for reaching children and families with health services, accounting for the locations of returned families and information about neighbouring families that teams had not yet located. In the second round, the microplans were updated to include new families who had returned.

Syria reported 74 circulating vaccine-derived poliovirus cases between March and September 2017. It has been more than six months since the last case was reported (21 September 2017). Efforts are continuing to boost immunity in vulnerable populations, maintain sensitive surveillance for polioviruses and strengthen routine immunization to enhance the population immunity.

Auta works as a Vaccine Security and Logistics facilitator in Borno State, Nigeria. © UNICEF Nigeria
Auta works as a Vaccine Security and Logistics facilitator in Borno State, Nigeria. © UNICEF Nigeria

Forty-year-old Auta A. Kawu says the only thing predictable about working in the conflict-affected northeastern Nigerian State of Borno is its unpredictability.

“No two days in my week are alike,” he says.

As a Vaccine Security and Logistics facilitator, Auta is one of 44 specialists working with the Government, UNICEF and partners in Nigeria, who strive to ensure sufficient vaccine stock, appropriate distribution and overall accountability for vaccines in the country. Through careful management, Auta works to give every accessible child in Borno protection from vaccine-preventable diseases, including polio.

Describing a typical week in his life, he explains that if on Monday he is arranging for the vaccination of eligible children among a group of Nigerians returning back from neighbouring countries where they had fled due to fear of violence, by Tuesday he could be speaking with government personnel to find a way to safely send vaccines to security compromised areas. On Wednesday, he may find himself rushing extra vaccines to an internally displaced persons (IDP) camp, where more people have arrived than initially expected, whilst on Thursday you may find him trying to locate a cold chain technician to fix a fridge where the heat-sensitive polio vaccine must be stored.

Evidencing the energy and commitment required to work on the frontline of vaccination, Auta notes that the work never lets up. Despite an exhausting week, on a typical Friday, you might find him on the road again, travelling to a remote location where health workers have just been given access. When he gets there, he will help out once more – trying to ensure that vaccines are distributed as effectively as possible to maximize the number of children reached.

He recounts a recent story of reaching the reception area of an IDP camp in Dalori, which is located in a highly volatile area of the state. Arriving with 300 doses of oral polio vaccine, and 200 doses of measles vaccine, he was told that new arrivals were expected later that day. Many of the people coming had been under siege by non-state armed groups since 2016, and had taken the opportunity of improved security and mobility to flee to the nearest town. Very few of the young children arriving had ever been reached with vaccines.

With the screening of children eligible for measles and polio vaccines starting around 9 am, and plenty more children yet to arrive, it was quickly clear that the available doses would not be enough.

Springing into action, Auta notified the head of the security team accompanying him of the need to go to nearest health facility to bring additional doses. Once clearance was given, he rushed to Jere Local Government, a district nearby, to collect more vaccines.

In the meantime, however, there were sudden changes in the security environment. The return journey to Dalori was not cleared until late noon.

Luckily, giving up isn’t in Auta’s nature.

By the end of the day, he had successfully delivered 580 doses of oral polio vaccine and 460 doses of measles vaccines for the children in the camp, providing some of them with their first ever interaction with a health system.

The crucial role of Vaccine Security and Logistics facilitators like Auta cannot be over-emphasized. In addition to his central work, Auta also conducts advocacy visits to traditional and religious leaders and supports the planning and implementation of vaccination campaigns in inaccessible areas.

Vaccine facilitation may be unpredictable work, but Auta is secure on one thing. Thanks to the work of him, and thousands of other determined health workers, community mobilizers and with support from donors and partners including the Bill & Melinda Gates Foundation, the Government of Canada, the Dangote Foundation, the European Union, Gavi – The Vaccine Alliance, the Government of Germany, the Government of Japan, the Japan International Cooperation Agency (JICA), Rotary International, the US Centers for Disease Control and Prevention, the World Bank and others, Nigeria is steadily on its way to being declared polio-free.

“No two days in my week are alike.” © UNICEF Nigeria
“No two days in my week are alike.” © UNICEF Nigeria
© UAE Pakistan Assistance Program
  • On top of the US$ 120 million committed in 2013, last year, HH Sheikh Mohamed bin Zayed pledged an additional US$ 30 million towards polio eradication, and the UAE is active on the ground in Pakistan through the UAE-Pakistan Assistance Program
  • UAE support also funded more than 5000 committed full-time vaccinators in highest-risk districts of Pakistan
  • Last year saw the lowest number of wild poliovirus cases in history (22 worldwide); Pakistan reported a 97 percent decline in cases between 2014 and 2017

GENEVA (16 April 2018) – The Global Polio Eradication Initiative (GPEI) announced today that the UAE has completed the US$ 120 million commitment made by His Highness Sheikh Mohamed bin Zayed Al Nahyan at the 2013 Global Vaccine Summit in Abu Dhabi.

“We thank the UAE for their long-term generous support and unwavering dedication to polio eradication, and particularly the personal commitment of His Highness Sheikh Mohamed bin Zayed Al Nahyan, Crown Prince of Abu Dhabi,” WHO Director General Dr Tedros Adhanom Ghebreyesus said. “This is the kind of support that will ensure we reach every last child to complete the job and to show the way to delivering health to all.”

Polio is a highly infectious disease that can cause lifelong paralysis, but it is entirely preventable with vaccines. Only three countries remain which have never stopped polio: Afghanistan, Pakistan and Nigeria. When the polio eradication effort was launched in 1988, 350 000 children were paralyzed by polio every year across 125 countries.

Polio eradication efforts have since made remarkable progress and there were only 22 cases in 2017 – the lowest ever recorded number. However, a number of key challenges remain. Reaching the most vulnerable children with the polio vaccine is hampered by a range of hurdles including difficult terrain, insecurity, and large-scale population movements.

Following the Global Vaccine Summit, the UAE expanded its role through the UAE Pakistan Assistance Program (UAE-PAP) to ensure that further gains would be made where it was needed the most. Through the “Emirates Polio Campaign” initiative, the UAE has helped drive on-the-ground eradication efforts within the most vulnerable communities in Pakistan.

Speaking about the UAE’s work, His Excellency Mohamed Mazrouei, Undersecretary of the Crown Prince Court of Abu Dhabi said: “The UAE’s pivotal role in eradicating polio completely is not limited to being a donor only, but extends to include its capacity to convene key groups and provide on-ground support to deliver vaccines in the highest risk areas of Pakistan.

“The UAE’s support – both as a leading donor and passionate advocate – has been critical for getting as close as we’ve ever been to making history by eradicating polio,” UNICEF Director of Polio Eradication Akhil Iyer said. “This is a gift not only to the children of Pakistan but to all future generations of children, everywhere, who are so close to the goal of being able to be born and be raised in a polio-free world.”

Dr. Chris Elias, President of the Global Development Program, Bill & Melinda Gates Foundation, said: “The UAE and His Highness Sheikh Mohamed bin Zayed Al Nahyan have shown an unwavering commitment to end polio, and we are delighted to partner with them in this effort. Without their involvement, achieving a record low number of polio cases in 2017 would not have been possible.”

The UAE is a longtime supporter of the polio eradication program. In addition to the US$ 120 million that His Highness Sheikh Mohamed bin Zayed Al Nahyan pledged in 2013, he pledged a further US$ 30 million to polio eradication, announced by Bill Gates at the Rotary International Convention in Atlanta, USA in June 2017. With additional commitments in 2011 and 2014, in total, the UAE has contributed US$ 167.8 million since 2011 to help end polio, with direct support to Pakistan, Afghanistan, Somalia, Ethiopia, Kenya, and Sudan.

About GPEI

The Global Polio Eradication Initiative (GPEI) is led by national governments and spearheaded by the World Health Organization (WHO), Rotary International, the US Centers for Disease Control and Prevention (CDC), and the United Nations Children’s Fund (UNICEF), with the support of the Bill & Melinda Gates Foundation. Since its launch at the World Health Assembly in 1988, the GPEI has reduced the global incidence of polio by more than 99%.

The GPEI receives financial support from governments of countries affected by polio, private sector foundations, donor governments, multilateral organizations, private individuals, humanitarian and non-governmental organizations and corporate partners. A full list of all contributors is available on the GPEI website, http://polioeradication.org/financing/donors/

© UAE Pakistan Assistance Program

We talk to Professor Rose Leke, Chair of the African Regional Certification Commission, to get her views on progress on the continent, and prospects for certifying the region polio-free in 2019.

Poliopolis is a 66-unit container village built by the University of Antwerp, Belgium, to house a polio vaccine clinical trial. © Ananda Bandyopadhyay / Bill and Melinda Gates Foundation
Poliopolis is a 66-unit container village built by the University of Antwerp, Belgium, to house a polio vaccine clinical trial. © Ananda Bandyopadhyay / Bill and Melinda Gates Foundation

Welcome to Poliopolis! You’ll spend the next 28 days in a container village to help us test a new polio vaccine. Poliopolis is equipped with all the amenities to make your stay comfortable: air-conditioned private rooms with workstations and sinks, a lounge area with a flat screen TV and foosball table, a fitness room with a variety of exercise equipment, and a bright, sunny dining area. Enjoy your stay!

Sounds like a scene from a science fiction story, right? But this is a real polio vaccine trial that took place in a parking lot at the University of Antwerp, Belgium in mid-2017. The study, funded by the Bill and Melinda Gates Foundation, evaluated two novel oral polio vaccine candidates. These vaccine candidates were developed by scientists from the US Centers for Disease Control and Prevention’s polio laboratory, the National Institute for Biological Standards and Control in the United Kingdom, and the University of California, in San Francisco, with support from the US Food and Drug Administration.

Once fully developed and tested, these new, more genetically-stable, live, attenuated vaccines will prove a critical resource to ensure global polio eradication.

Read more:

US Centers for Disease Control and Prevention – Welcome to Poliopolis

Ondrej Mach of the WHO polio research team discusses why new inactivated polio vaccine solutions are needed for the post-eradication era. Why are we developing entirely new vaccines for a disease which will no longer exist?

La Dre Adele vaccine des enfants dans son canoë, après avoir voyagé pendant des heures pour se rendre dans les îles les plus isolées du lac. © OMS / Tchad
La Dre Adele vaccine des enfants dans son canoë, après avoir voyagé pendant des heures pour se rendre dans les îles les plus isolées du lac. © OMS / Tchad

Le jour se lève dans le district sanitaire de Bol, au Tchad, et la Dre Adele commence sa journée. Elle monte dans son canoë et, après avoir jeté un coup d’œil à sa carte, commence un long voyage sur les eaux du lac Tchad. Dans quatre à six heures, se frayant un chemin parmi les roseaux, elle aura atteint une île isolée où les enfants n’ont encore jamais été vaccinés.

La Dre Adele Daleke Lisi Aluma vit dans l’une des régions du monde où la vaccination est la plus difficile. Dans le district de Bol, 45 pourcent des enfants vivent dans des îles isolées et difficiles d’accès où les obstacles géographiques, la violence, l’insécurité et la pauvreté empêchent le plus souvent de prodiguer à la population les services de santé et les autres services publics.

Son travail consiste à surmonter ces obstacles en cherchant chaque enfant non encore vacciné, tout en mettant à profit son expérience pour que le programme fasse le meilleur usage des ressources en vue d’atteindre à chaque fois le plus d’enfants possible.

Un itinéraire à planifier

La première étape de chaque campagne consiste à planifier l’itinéraire. En étudiant les cartes, en en comparant les informations, la Dre Adele et son équipe s’efforcent de trouver la façon la plus efficace  d’atteindre les nombreuses îles où les vaccinateurs doivent se rendre.

« L’équipe prévoit souvent ses campagnes lors du marché hebdomadaire, car on peut alors vacciner les enfants qui accompagnent leur mère pour l’achat et la vente des produits de base », explique-t-elle.

Afin que le vaccin soit mieux accepté, la Dre Adele et ses collègues téléphonent aux anciens et aux chefs de village quelques jours avant chaque campagne afin de leur expliquer pourquoi il est si important de se protéger contre la poliomyélite et les autres maladies évitables par la vaccination.

Cette approche permet d’accroître la portée du programme. Auparavant, les vaccinateurs parcouraient parfois de longues distances, pendant de nombreux jours, avant d’arriver sur des îles où se trouvaient en réalité très peu d’enfants. Cela entraînait des gaspillages, les vaccinateurs ne parvenant pas à maintenir, sur le trajet de retour, les vaccins à une température suffisamment froide pour qu’ils puissent profiter à d’autres enfants. Aujourd’hui, une meilleure planification et l’achat de réfrigérateurs solaires pour le stockage des vaccins contribuent à résoudre le problème.

« Pour tirer le maximum d’une session de vaccination, nous devons nous assurer que nos opérations sur le terrain soient efficientes et efficaces, en manquant le moins possible d’occasions », ajoute-t-elle.

Un voyage difficile

Pour la Dre Adele, éviter les piqûres d’insectes est l’une des plus grandes difficultés de son travail. © OMS / Tchad
Pour la Dre Adele, éviter les piqûres d’insectes est l’une des plus grandes difficultés de son travail. © OMS / Tchad

Le lac Tchad n’est pas un plan d’eau dégagé : les voies navigables y sont entravées par des roseaux et des arbres et par la vie animale. Pour atteindre les îles, la Dre Adele utilise un canoë, naviguant adroitement dans ces eaux difficiles pendant plusieurs heures. Les équipes doivent faire preuve de la plus grande vigilance. Il leur faut avancer, maintenir les vaccins au froid et éviter les piqûres d’insectes, voire les rencontres avec les hippopotames.

Malgré ces difficultés, elle trouve son travail extrêmement gratifiant.

« À chaque fois que j’atteins un village isolé, je me sens plus motivée que jamais à poursuivre mon action. »

Opérationnelle dès son arrivée

Dès qu’elle est arrivée sur l’île, la Dre Adele commence à vacciner. La majorité des enfants qui vivent dans des villages insulaires isolés ont reçu moins de trois doses de vaccin antipoliomyélitique oral, et sont donc vulnérables face au virus. La Dre Adele s’efforce de protéger chacun d’eux.

Un membre de la famille proche de la Dre Adele a été touché par la poliomyélite et cette expérience est pour elle un véritable moteur. Auparavant, elle a participé à des campagnes de vaccination et à la surveillance épidémiologique de cette maladie en République démocratique du Congo et en Haïti,  dans le cadre d’une carrière qui l’a menée partout dans le monde.

Des résultats tangibles

À chaque campagne, la Dre Adele vaccine des centaines d’enfants, mais recherche également des signes du virus.

Lors d’un récent déplacement dans les îles, elle et son équipe ont découvert un enfant atteint de paralysie flasque aiguë, un signe potentiel de poliomyélite, qui n’avait pas été signalé au réseau de surveillance de la maladie. Il s’est finalement avéré que l’enfant n’avait pas la poliomyélite, mais cet exemple montre que le programme doit absolument continuer d’intervenir dans ces zones difficiles d’accès, de vacciner les enfants et d’inciter les communautés à signaler tout cas présumé.

La Dre Adele contribue d’ores et déjà à renforcer la surveillance en formant les habitants de chaque village à reconnaître les signes d’un cas de poliomyélite potentiel.

Elle prévoit également de futurs déplacements : « Nous pensons revenir bientôt encadrer et accompagner les équipes de vaccination dans les zones insulaires. »

Ces efforts sont indispensables pour atteindre les communautés les plus isolées du lac Tchad.

La Dre Adele Daleke Lisi Aluma et ses collègues se frayent un chemin à travers les marécages du lac Tchad pour vacciner les enfants jusque dans les zones les plus difficiles d’accès. © OMS / Tchad
La Dre Adele Daleke Lisi Aluma et ses collègues se frayent un chemin à travers les marécages du lac Tchad pour vacciner les enfants jusque dans les zones les plus difficiles d’accès. © OMS / Tchad

Pour plus d’informations sur les femmes en première ligne de l’éradication de la poliomyélite (en anglais)

In March, the Afghanistan polio eradication initiative conducted its first nation-wide immunization campaign for polio eradication in 2018. In just under a week, around 70 000 workers knocked on doors and stopped families in health centres, city streets and at border crossings to vaccinate almost ten million children. What an incredible achievement.

But what does a huge campaign like this take?

We had a look behind the scenes and followed the week in Herat, western Afghanistan. See what the campaign looked like from beginning to end through this photo essay.

Zulaihatu Abdullahi, a volunteer community mobilizer in Kaduna State, goes door-to-door to ensure that every child is vaccinated against polio. © UNICEF Nigeria / Jasmine Pittenger
Zulaihatu Abdullahi, a volunteer community mobilizer in Kaduna State, goes door-to-door to ensure that every child is vaccinated against polio. © UNICEF Nigeria / Jasmine Pittenger

Zulaihatu Abdullahi is well known in her community, particularly to the mothers. As a volunteer community mobilizer in Kaduna state, northern Nigeria, her mission is to ensure that no child contracts polio, or any other preventable childhood disease.

This is difficult, as immunization programmes are sometimes treated with suspicion in her part of Nigeria. As a ‘change agent’, Zulaihatu’s job is to go door to door, counselling parents about the importance of the polio vaccine.

This particular lunchtime, she is visiting an 18 year-old mother living in a compound in a densely-populated, urban district of Kaduna State.

The young mother puts down the pole she is using to pound millet and welcomes Zulaihatu, recognising her royal-blue UNICEF hijab. She sits, and pulls on a hijab for cover as she settles down to breastfeed her baby. She has three other small children at home, a fifth on the way and she is new to the area.

“Before I came here I was rejecting all vaccines,” she says, “but because of this woman, Zulaihatu, I decided to accept. She told me the usefulness and I was convinced to do it.”

Thanks to Zulaihatu’s patience, and her work to build trust with the younger woman through regular visits, four more children are now protected against polio who might otherwise still be at risk. The mother has also been encouraged to seek anti-natal care, and the youngest child has just received his routine immunization shots.

“Sister Zulaihatu was one of the first women I met when we moved here,” the mother recalls. “She came here every day. She told me how she takes care of her own children. What she feeds them. How they all take vaccines. Little by little I started to change my thinking.”

Zulaihatu is trained to make her community aware of important household and parenting practices to keep their children thriving. The list is extensive and includes tips to treat diarrhoea, the importance of basic hygiene and sanitation, how to protect the family from malaria, the benefits of neonatal care and breastfeeding for infants, and the importance of registering their births.

She is one of nearly 20 000 UNICEF-trained community mobilizers, influencers and communication experts spread across 14 northern ‘high risk’ Nigerian states. With the support of donor and partners including the Bill and Melinda Gates Foundation, CDC, Dangote Foundation, European Union, Rotary, GAVI, JICA, the World Bank and the Governments of Canada, Germany, Japan, and others, the mobilizers are a key part of UNICEF’s ongoing support to the Government of Nigeria’s immunization programme.

Despite their achievements, Zulaihatu and other mobilizers know that there is much is still left to be done in their communities. Tomorrow, Zulaihatu will continue her work, going from household to household to keep every child safe.

Zulaihatu is one of nearly 20 000 UNICEF-trained community mobilizers, influencers and communication experts in Nigeria, who offer advice and support to parents to keep their children healthy. © UNICEF Nigeria / Jasmine Pittenger
Zulaihatu is one of nearly 20 000 UNICEF-trained community mobilizers, influencers and communication experts in Nigeria, who offer advice and support to parents to keep their children healthy. © UNICEF Nigeria / Jasmine Pittenger

More stories about women on the frontlines of polio eradication

Bella smiles as she vaccinates a small baby against polio – one of hundreds of children she will protect over the course of a campaign. © WHO Somalia
Bella smiles as she vaccinates a small baby against polio – one of hundreds of children she will protect over the course of a campaign. © WHO Somalia

Somalia, which stopped indigenous wild polio in 2002, is currently at risk of circulating vaccine-derived poliovirus type 2, after three viruses were confirmed in the sewage of Banadir province in January 2018. Although no children have been paralysed, WHO and other partners are supporting the local authorities to conduct investigations and risk assessments and to continue outbreak response and disease surveillance.

Underpinning these determined efforts to ensure that every child is vaccinated are local vaccinators and community leaders – nearly all of whom are women.

Bella Yusuf and Mama Ayesha are different personalities, in different stages of their lives, united by one goal – to keep every child in Somalia free from polio. Bella is 29, a mother of four, and a polio vaccinator for the last nine years, fitting her work around childcare and the usual hustle and bustle of family life. Mama Ayesha, whose real name is Asha Abdi Din, is a District Polio Officer. She is named Mama Ayesha for her maternal instincts, which have helped her to persevere and succeed in her pioneering work to improve maternal and child health, campaign for social and cultural change, and provide care for all.

Protecting all young children

Working as part of the December vaccination campaign, which aimed to protect over 700 000 children under five years of age, Bella explains her motivation to be a vaccinator. Taking a well-deserved break whilst supervisors from the Ministry of Health and the World Health Organization check the records of the children so far vaccinated, she looks around at the families waiting in line for drops of polio vaccine.

“I enjoy serving my people. And as a mother, it is my duty to help all children”, she says.

For Mama Ayesha too, the desire to protect Somalia’s young people is a driving force in her work. A real leader, she began her career helping to vaccinate children against smallpox, the last case of which was found in Somalia. Since then, she has personally taken up the fight against female genital mutilation, working to protect every girl-child.

She joined the polio programme in 1998, working to establish Somalia as wild poliovirus free, and ever since to oversee campaigns, and protect against virus re-introduction. In her words, “My office doesn’t close.”

Working in the midst of conflict

The work that Bella and Mama Ayesha carry out is especially critical because Somalia is at a high risk of polio infection. The country suffers from weak health infrastructure, as well as regular population displacement and conflict.

For Bella, that makes keeping children safe through vaccination even more meaningful.

“Through my job I can impact the well-being of my children,” she says. “For every child I vaccinate, I protect a lot more”.

Mama Ayesha echoes those words when she contemplates the difficulties of working in conflict. For most of her life, the historic district where she works, Hamar Weyne, has been affected by recurrent cycles of violence and shelling. With her grown children living abroad, she could easily move to a more peaceful life. But she chooses to stay.

“This is my home, and this is where I am needed. I am here for my team, and all the children.”

“I am the mother of all Somali children. I am just doing my job”. © WHO Somalia
“I am the mother of all Somali children. I am just doing my job”. © WHO Somalia

Ongoing determination

Looking up at a picture of her husband, who died many years ago, Mama Ayesha considers the determination and courage that drives her, Bella, and thousands of their fellow health workers to protect every since one of Somalia’s children. Behind her thick wooden desk, she is no less committed than when she began her career. “If I had to do it again it would be my pleasure.”

Bella has a similar professional attitude, combined with the care and technical skill that make her a talented vaccinator. Returning to her stand below a shady tree, she greets the mothers lined up with their children. As she carefully stains the finger of the first small child purple, showing that they have been vaccinated, she grins.

“I am the mother of all Somali children. I am just doing my job”.

Mama Ayesha, a leader of eradication efforts in her district, considers what drives her work. © WHO Somalia
Mama Ayesha, a leader of eradication efforts in her district, considers what drives her work. © WHO Somalia

For more stories about women on the frontlines of polio eradication

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

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

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

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

Planning the route

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

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

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

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

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

The journey

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

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

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

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


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

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

The results

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

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

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

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

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

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

For more stories about women on the frontlines of polio eradication

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

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

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

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

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

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

Nomads at risk

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

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

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

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

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

Becoming advocates

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

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

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

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

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

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

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

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

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

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

Vaccinating adults

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

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

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


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

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

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


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

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

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


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

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

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

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

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

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

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

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

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

Last push to eradicate polio in Afghanistan

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

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

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

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

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

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

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

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

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

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

The team marks this household vaccinated for today.

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

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

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

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

Humanitarian crisis

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

Benefits beyond polio eradication

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

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

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

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

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.”

Vaccinators attended celebrations to help mark the three years polio-free in Somalia. The event took place at the General Kahiye Police Academy in Mogadishu on August 13, 2017. UN Photo / Omar Abdisalan

This week marks a milestone occasion for Somalia – three years since the detection of the last case of poliovirus in the country. With significant commitment and hard work, Somalia has effectively raised population immunity to the virus, and improved disease surveillance to help pick up any trace of the disease.

Speaking at a celebratory event in Mogadishu, WHO Regional Director for the Eastern Mediterranean, Dr Mahmoud Fikri, has praised Somalia’s efforts to rid the country of the virus, but emphasised the importance of continued attention and focus to keep the country polio free.

“The absence of cases of polio in Somalia today is testament to the leadership, commitment and hard work of the Government and people of Somalia, and the effective support and collaboration of many partners,” Fikri said. “We need to remember however, that Somalia is at risk of reinfection and we must stay vigilant,” he said.

Gaps in vaccination and disease surveillance create an environment where polio can hide and thrive, particularly in countries where health systems are under strain.   While the virus exists anywhere, children everywhere are at risk. Countries must remain committed to improving vaccination and disease surveillance activities to achieve eradication and keep the world polio free.

Just like responding to a polio outbreak, ENDING an outbreak requires in depth data, partnerships and attention to detail. @ WHO

The detection of even a single case of polio anywhere in the world is considered an outbreak. As soon as the polio surveillance system sounds the alert that a virus has been found, an outbreak response springs into action.

But when a virus has so many possible hiding places, how can we be sure it is gone? What enables an outbreak response to be called to an end?

Ending an outbreak: on paper

According to official guidelines, an outbreak is considered to be stopped following a period of 12 months without the detection of any new polioviruses detected from any source, assuming disease surveillance meets certification standards. Once experts are confident that there are no immunity or surveillance gaps that could allow the virus to hide, the World Health Organization (WHO) removes the country from its list of re-infected or endemic countries.

Finding the needle in the haystack

These guidelines set important standards, yet carrying them out in the real world can be complicated. In Nigeria in August 2016, four wild poliovirus type 1 cases were detected. They were caused by a strain that had not been detected since 2012, due to insecurity making disease surveillance difficult in the surrounding area, enabling the virus to move unchecked.

This reminds us that guidelines – while essential – cannot do the job alone. Thorough epidemiological, operational and virological analysis is needed before interruption of poliovirus can truly be verified; and each new outbreak coming to an end must be assessed individually.

Outbreak response assessments

Gathering immunization and surveillance data is crucial to inform outbreak response assessments so that an outbreak can be closed. @ WHO

Every three months in outbreak countries, Outbreak Response Assessments are held by independent experts. They directly observe the implementation of all activities, analyse and verify the data and track how the outbreak is evolving – and whether the response is having an impact. They make recommendations to strengthen the continued outbreak response.

Outbreak Response Assessments provide crucial evidence for programmatic performance, risk management and evolving epidemiology. Without such assessments, we could not verify the continued presence or absence of poliovirus circulation.

Once 12 months have passed with no cases and immunization and surveillance data has been carefully scrutinised through these assessments, the outbreak response assessment committee finally draws its conclusions that the outbreak is over.

International Health Regulations

Information and conclusions from Outbreak Response Assessments are taken into consideration by the Emergency Committee of the International Health Regulations (IHR). Through the IHR, countries work together for global health security, limiting the risk that outbreaks spread across borders. In 2014, polio was declared a public health emergency of international concern under the IHR, leading to temporary recommendations which were put in place for all countries with or at risk of polio to reduce the risk of international spread.

The Emergency Committee on the Spread of Poliovirus meets every three months to review global epidemiology. They draw their own conclusions and classify countries into categories of risk. This helps to stop new outbreaks from taking place and adds an extra pair of eyes to assess when an outbreak has come to an end.

Becoming officially polio-free

Teams of independent experts assess the outbreak response. Only when no case has been found for 12 months can an outbreak be called to a close. @ WHO

The final stamp of approval that a region is polio-free only comes with regional certification. An independent Regional Certification Commission reviews data from all countries in a given region, ensuring that surveillance indicators and vaccination coverage from every single area are of the highest possible levels.

This process takes at least three years. Only when no virus has been detected anywhere in the region for a significant length of time and no doubt is left that the virus is completely gone does a region become certified as polio-free.

Only when no case of polio has been detected anywhere in the world for more than three years will the Global Certification Commission for the Eradication of Poliomyelitis meet to take a decision on whether the virus is truly gone from the world.

No room for complacency

Time, attention to detail and double checking what we know – this is what it takes to end an outbreak.

In the end, the decision to end an outbreak is only as good as the data from each remote village, each sample tested in a laboratory and each vaccination round. This makes knowledge the most powerful tool we have in the fight against polio.

Even once an outbreak has been stopped there is no room for complacency. As long as poliovirus continues to circulate anywhere in the world, countries everywhere remain at risk.  As polio moves with people, any population movement to an area of low immunity can lead to a new outbreak.

Until the world has been certified polio-free by the Global Certification Commission, all countries must vaccinate every last child, find every last virus and be prepared for any outbreak.

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A child is given two drops of the oral polio vaccine to protect them against polio in Lao PDR. @ WHO/ R. Tangermann

As of May 2017, Lao People’s Democratic Republic (PDR) is officially no longer infected with circulating-vaccine derived polio virus (cVDPV), according to the International Health Regulations (IHR) Emergency Committee on the international spread of poliovirus.

After an outbreak of circulating vaccine derived poliovirus type 1 (cVDPV1) in 2015 and 2016, the country has now been without cases for over 12 months, with the last case reported in January 2016.

Since the outbreak, WHO, UNICEF and other partners have supported Lao PDR in their outbreak response efforts. This included support for multiple rounds of supplementary immunization activities, expanded social mobilization to raise community awareness and desire to vaccinate, and enhanced acute flaccid paralysis (AFP) surveillance activities to find the virus.

Ending the outbreak

In general, an outbreak is considered over following a period of 12 months without the detection of any new polioviruses from an AFP case, a healthy individual or an environmental sample, and with confirmed certification-standard disease surveillance.

An outbreak response assessment (OBRA) team visited the country in March to confirm the virus had, in fact, been stopped. The team, made up of representatives from WHO, UNICEF, and the US Centres for Disease Control and Prevention, concluded that all evidence suggested the outbreak had been successfully stopped, with all immunity and surveillance indicators meeting rigorous international standards.

At the OBRA meeting, development partners commended the Ministry of Health on its leadership in response to the outbreak. Tremendous progress was made in micro-planning, cold chain and vaccine storage at all levels, as well as nationwide social mobilization and strengthening of AFP surveillance.

Deputy Health Minister of Lao PDR, Dr. Phouthone Muangpak, noted that the Ministry of Health and local authorities need to take ownership to further improve surveillance sensitivity in the country.

Lessons from the outbreak response

Both adults and children were vaccinated through the response to make up for low levels of vaccination over an extended period of time. @ WHO /R. Tangermann

A challenging landscape and diverse ethnic communities added to the challenge of running vaccination schedules in Lao PDR. As the outbreak occurred in an area where vaccination levels had been very low for an extended period of time, campaigns were extended to reach all children under 15, and in some cases even adults. The nuanced cultural, lingual, religious and social needs of the Hmong community called for a response tailored to local needs, especially building an awareness of the importance of vaccines. Impromptu cinemas were set up against bamboo walls to pull in interested families and share information about vaccination campaigns after dark.

Find out more about the response in Lao in this photostory.

Meeting International Health Regulations standards

Information and conclusions from OBRAs are taken into consideration by the IHR Emergency Committee on the Spread of Poliovirus, resulting in this instance in the IHR classification as a state no longer infected with cVDPV1.

Despite being classified as polio-free, the IHR Emergency Committee still categorizes Lao PDR as vulnerable to reinfection. The country must continue to strengthen routine immunization to ensure all children are protected from any polio outbreak that may happen in the future and to maintain the improvements in disease surveillance, to ensure the virus is detected and stopped wherever it may emerge.