GPEI-Africa’s drive to end polio under the microscope

Participants of the Africa Regional Commission for the Certification of poliomyelitis eradication (ARCC) in Nairobi, Kenya, from 12-16 November 2018. WHO AFRO/2018

Efforts to end polio across the WHO African Region came under the microscope at a meeting of the Africa Regional Commission for the Certification of poliomyelitis eradication (ARCC) held in Nairobi, Kenya, from 12 – 16 November 2018.

Seven countries (Cameroon, Nigeria, Guinea-Bissau, the Central African Republic, South Sudan Equatorial Guinea and South Africa) made presentations to the ARCC on their efforts to eradicate polio, presenting evidence on their level of confidence that there is no wild polio in their borders, the strength of their surveillance systems, vaccination coverage, containment measures and outbreak preparedness. Kenya, the host country, alongside the Democratic Republic of the Congo and Namibia, presented updated reports on their efforts to maintain their wild poliovirus- free status.

Professor Rose Leke, Chair of the ARCC, speaking to the participants. WHO AFRO/2018

A total of 109 participants including partners of the Global Polio Eradication Initiative, non-governmental organisations and Health Ministries were in attendance to hear the reports.

The ARCC is an independent body appointed in 1998 by the WHO Regional Director for Africa to oversee the certification and containment processes in the region. It is the only body with the power to certify the Africa region free from wild polio. The African Regional Office and the Eastern Mediterranean Regional Office are the two WHO regions globally that remain to be certified free from wild poliovirus.

Professor Rose Leke, Chair of the ARCC, reflected on the importance of this meeting: “The rich, open and in-depth discussions held this week with each of the ten countries will allow these countries to strengthen ongoing efforts to further improve the quality of surveillance and routine immunization including in security compromised and hard to reach areas as well as in special populations such as nomads, refugees and internally displaced persons.”

Recommendations made

The ARCC, made up of 16 health experts, made recommendations to the ten countries. They noted with concern that outbreaks of circulating vaccine-derived poliovirus in the Democratic Republic of Congo, Kenya, Niger, Nigeria and Somalia were symptoms of low population immunity and varied quality vaccination campaigns. These countries were encouraged to conduct a high-quality outbreak response. Neighbouring countries were advised that they should assess the risk of spread or outbreaks within their borders. Low population immunity was identified as a significant concern, given the risk further emergences of vaccine-derived poliovirus strains.

Inaccessibility and insecurity were also flagged as a significant concern, with limits to the number of children who were being reached with polio vaccines and the coverage of surveillance efforts in affected areas. Countries were advised to scale up strategies that have proved in the past to be effective in the face of these challenges and to build relationships with civil society and humanitarian organisations who could provide immunization services.

Recommendations were made across the board to address chronic surveillance gaps, especially related to factors affecting the quality and transportation of stool samples reaching the laboratory for testing. The introduction of innovative technologies was commended, and a call was made for countries to expand their use, especially in inaccessible and hard-to-reach areas. Countries were also encouraged to accelerate their progress towards poliovirus containment.

In addition, all of the presenting countries received specific recommendations to support their efforts towards improving surveillance, immunization and containment in order to achieve a level that would give the ARCC the confidence needed to declare the region to have eradicated polio.

Dr Rudi Eggers, WHO Kenya Country Representative, said: “I commend all the countries on the efforts that have gone into achieving the results presented in their reports. It gives us hope that eradication is achievable in the midst of the unique challenges faced by all countries. We appeal to all the countries to fully implement all ARCC recommendations.”

Polio eradication efforts in Kenya

Dr Jackson Kioko, Director of Medical Services, the Kenyan Ministry of Health, said: “Kenya has worked hard to rid the country of wild poliovirus, and we will continue to do so until Africa and the world are certified polio-free.”

While Nigeria remains the only country in Africa to be endemic for wild poliovirus, responses are underway to stop outbreaks of circulating vaccine-derived poliovirus in the Democratic Republic of the Congo, Kenya, Niger and Somalia.

The circulating vaccine-derived poliovirus in Kenya was found in a sewage sample in Eastleigh, Nairobi, in March 2018, closely related to viruses found in Somalia. The Ministry Health, with the support of WHO, UNICEF and partners, has done several polio vaccination campaigns since then to ensure that every child’s immunity is fully built and no virus can infect them.

Related Resources

A frontline worker is vaccinating a child against polio. WHO Afghanistan/R Akbar

In November, polio vaccination teams across Afghanistan targeted 5.3 million children under the age of five in high-risk provinces. The vaccination campaign came on the heels of several newly reported cases. Afghanistan has 19 documented cases of wild poliovirus in 2018, as of November. Confirmation of even one polio case anywhere signals remaining vaccination coverage gaps which must be filled to achieve eradication.

The targeted vaccination campaign took place from 5-9 November, and with support across the board from healthcare workers, communities, religious clerics, and the government. “The Ministry of Public Health and health partners are committed to ending this disease,” said Dr. Ferozuddin Feroz, Minister of Public Health.

Afghanistan is one of the three remaining endemic countries in the world along with Pakistan and Nigeria. The endemic countries are intensifying their efforts by making sure they fully implement the strategies in their national polio emergency action plans.

Read more about the details of Afghanistan’s vaccination campaign here.

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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.

A team of house to house vaccination workers during a polio campaign in northern Nigeria. © WHO / Nigeria

In a rural village in Nigeria, a group of women knock on the door of new mother Hauwa Abubakar. She emerges from within, exhausted from the routine of feeding, sleeping, and caring for a little one. But she has extra reason than most to be tired.

A few months ago, she became mother to triplets, two baby girls and one baby boy.

The women visiting her are from her local community, but today they have come in their roles as polio vaccinators.

Realizing that they are there with vaccines, Hauwa picks up her young son, and carries him to another room. She closes the door, and returns to her daughters, ready to present them for their polio vaccinations.

The health workers ask Hauwa why she hid her son – he is just as vulnerable as his sisters, and the vaccine is the only way to keep him safe from polio paralysis.

“He is my only son,” she explains. “He will grow up and continue my family lineage. As for my girls, I’ll give them away to another family when they turn 18.”

“Boys or girls, your children all need polio immunization. Please don’t discriminate when it comes to matters of health,” says the lead health worker, as she puts two drops of polio vaccine into each of the girls’ mouths.

“You never know who your daughters will become one day, and you never know what disease you are protecting your son from.”

After a little more discussion, Hauwa is reassured. She fetches her son, and soon he too is protected from the virus.

Gender and polio eradication

Hauwa’s perspective is not unusual in communities where there is hesitation about the need to vaccinate. In communities where boys are more valued, and there is uncertainty about the need for vaccination, they may not be given the polio vaccine alongside their sisters. Sadly, this leaves them vulnerable to polio paralysis, whilst girls grow up protected from the virus.

Understanding that the world can only become polio-free if all children are vaccinated, the polio programme is developing a gender strategy which recognizes the way that gender impacts access to immunization, and also considers the valuable role of women health workers.

Dr Usman Adamu, the Incident Manager at the Nigerian National Emergency Operations Centre for Polio Eradication, explains how these things are related.

“All team members performing house-to-house for the polio campaign must be women. This is because we want to reach all eligible children with polio vaccines irrespective of whether children are inside or outside the house. Having a female team member makes it easy to reach these children in the household [where male vaccinators cannot enter]. ”

Polio workers are locally recruited, and women vaccinators often have a preexisting relationship with the mothers they visit with vaccines. This means that they are uniquely placed to answer questions and reassure them of the safety of the vaccine for boys and girls. With extra training, many women vaccinators also provide mothers with important information about other health interventions, including maternity health.

Keeping boys and girls safe

The GPEI gender strategy will help guide endemic countries like Nigeria to respond to gender related barriers to immunization. A first step has been the developing of several gender-sensitive indicators which country programmes use to track gender as a determinant of health.

The team lead of the WHO Immunization Cluster, Dr Fiona Braka, explains, “These gender-sensitive indicators measure the equal reach of girls and boys in vaccination campaigns, the doses of polio vaccine received by girls and boys, the timeliness of disease surveillance for girls and boys and women’s participation as front-line workers in polio-endemic countries.”

By recognizing the impact of gender on immunization, the polio programme can better deliver a vaccine to every baby.

For Hauwa’s triplets, the most important thing is that all three are well on their way to being protected from the virus.

After 25 years with the polio programme, it’s easier to list the things the World Health Organization’s Chris Maher hasn’t seen than the things he has. © Courtesy of The Australian/Photo: Jake Nowakowski

After more than 25 years on the hunt for polio, it’s easier to list the things the World Health Organization’s Chris Maher hasn’t seen than the things he has. He began his career with WHO five years after the global health community vowed to eradicate polio, which was then found in over a hundred countries. Since then, Maher has progressed to spearhead on-the-ground operations for the global polio eradication initiative, a partnership that has seen the disease beaten back by 99%. In a ceremony in May 2018, the Australian Government awarded him the Order of Australia, recognizing his immense contributions to the fight against a disease that has gone from paralyzing more than 350 000 children every year in 1988, to fewer than 22 cases worldwide today.

In 1993, Maher had several years of experience in public health, but none in polio-endemic countries. “I don’t think I’d ever seen an active polio case,” he recalled. Upon joining the WHO immunization team in a region that spanned from Mongolia to the Pacific Islands, polio was suddenly at the top of his agenda.

Maher and his colleagues worked as disease detectives, stalking the wild poliovirus through hard-to-reach communities in south-east Asia. From immunizing small communities on the Pacific Islands to taking on massive campaigns targeting millions of children in China, the complexity made his head spin.

The Philippines was the first country to go polio-free on Maher’s watch, seeing its last case that year.

Tracking unimmunized children through a population maze

Chris in his early days of fighting polio. © WHO

It was here that Maher came face to face with polio’s full force of devastation, after a Khmer nurse at a district health clinic invited him home to meet her son. Maher and a colleague followed the woman to a house on stilts in a flooded field, where a quadriplegic teenager lay on a rattan bed.

“I realized very early on, he had polio. It was typical of the kind of polio that had no rehabilitation whatsoever”, Maher said.

Maher recalls being struck by the young man’s intelligence and his interest in the world, despite his isolation. As polio destroyed his body, his mother bestowed constant care.

“While she was working every day, somehow she had managed to look after him, to provide for him. As an example of motherly love I had never seen anything like that in my life.”

By the 2000s, it seemed that the most challenging country to eradicate polio was India. With its vast population and sprawling slums, in Maher’s words, “If technically we couldn’t do it, India would be the place we’d fail.”

Maher recalls Bihar, India as “the most extraordinary place that I ever worked on polio.” Eighty million people live in the state. Widespread illiteracy, a lack of infrastructure and high levels of population movement compounded the complexity of polio eradication there.

Despite the daunting challenges, Maher and his colleagues developed systematic plans to administer vaccine to all children across the country, taking a critical step in a journey to eradication. By the end of 2011, India was polio-free.

The risk of doing something different

At the start of the global push to eradicate polio, those involved in the operation would sometimes encounter skepticism from those who thought it simply couldn’t be done. The scale of the project, the size of activities and the time, energy, effort and cost involved had never been seen before.

Today, wild polio is endemic in three countries: Afghanistan, Pakistan and Nigeria. Immense efforts to battle the virus into extinction in these places are ongoing. Outbreaks of vaccine-derived polio virus (VDPV) add complexity to the end goal. Conflict, low routine immunization and population movement in the most at-risk areas complicate things further. Some of the approaches Maher and his eradication colleagues take to navigate these and myriad other challenges are astonishing – feats of logistics, diplomacy and detection that would not be out of place in a textbook.

“We’ve learned a lot about reaching every community, the most difficult access places, we’ve learned a lot about the importance about communicating what we are trying to achieve, to bring communities along with us in what we were doing. We’ve learned that there are certain things that are too big to do yourself. You need to build coalitions, you need partnerships to be able to make something happen, and the broader that partnership is, the greater the likelihood that you are going to be able to achieve something significant,” he said.

For Maher, the real risk is not that polio won’t be defeated, but that the world might one day forget how it was done. He sees the lessons learned during eradication as critical to the global health community.

“It would be a terrible pity if we lost that, if after eradication we kind of collectively heaved a sigh of relief and said, ‘well thank goodness that’s over, let’s do something else now’.”

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”.

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

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.

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 (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

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

Dr Adele Daleke Lisi Aluma speaks to Robert about the symptoms of measles, polio, and other vaccine-preventable diseases. His answers are recorded using a smartphone app, and transmitted to a central database. © WHO/ Darcy Levison

Nine hours away from the nearest large town, Dr Adele Daleke Lisi Aluma speaks to Robert, who manages a small health clinic on an island in the Lake Chad Basin. With paperwork spread around them, she listens carefully he responds to each question: Can you tell me how to recognise the symptoms of a potential polio case? Can you show me the records of any measles cases since I last visited?

In the past, she would be writing down details of the disease surveillance system in this village in a notebook, spending time later typing up her notes, and emailing them to a central database. Today, thanks to the introduction of an electronic surveillance approach for active surveillance and monitoring of disease outbreaks, she inputs Robert’s answers directly into an app, allowing for quick, accurate, and up-to-date data collection.

Hundreds of kilometres away in Nigeria, on the other side of the basin, surveillance officer Dr Namadi Lawal also feels the difference that innovative application-based technology has made to operations. For years, his employer, the National Primary Health Care Development Agency, depended on paper-based recording methods.

When the World Health Organization introduced the electronic surveillance (e-Surve) approach, Dr Namadi discovered he was receiving far more accurate information in real time, making his work to defeat the poliovirus more efficient.

“e-Surve is such a wonderful innovation. I can only imagine how much more accurate data I would have collected in a fast and effective manner if I had adopted this approach long time ago,” he says.

Using application-based technology, conversations with health workers in the field are guided by a simple questionnaire, which improves the quality and consistency of data collection. © WHO/ Darcy Levison

The e-Surve approach involves the use of a smartphone application to ensure that health workers know what symptoms they should be looking for and how to report suspected cases of vaccine-preventable disease.

After using the application to guide their conversations with health workers, disease surveillance and notification officers send the results of the questionnaire to a central database, where the data can be analysed and sorted by health district.

This is one way to keep track of an outbreak response that covers areas of five different countries, all with their own unique health challenges.

“This is remarkable progress as it shows where we can actually reach for surveillance”, said Dr Isaac Adewole, Nigeria’s Minister of Health, as he was presented with a dashboard of e-Surve during the recent opening ceremony of the African Regional Certification Commission in Nigeria.

New technology helps to reduce outbreak risk

This innovation is particularly important as when cases of disease are not properly reported, an outbreak can be in full swing before a country even realises that there is a problem.

Active disease surveillance, where officers physically go out to communities to speak to health staff and parents, is proven to increase case detection rates. There are hundreds of these frontline workers spread out across the Lake Chad Basin, each conducting multiple visits every month. Before mobile technology, the outcomes of these visits were cumbersome to track, time consuming to catalogue, and difficult to analyse for a prompt response.

Real-time reporting stems the spread of diseases

With e-Surve, governments and partners in the polio programme and other health programmes can easily see trends, track data, and take action. This encourages a preventive approach to disease outbreaks rather than a reactive one.

Dr Isaac Adewole, Nigeria’s Minister of Health, views a dashboard of e-Surve during the recent opening ceremony of the African Regional Certification Commission in Nigeria. With government commitment, the polio eradication programme is getting closer to closing the outbreak. © WHO/ AFRO

In Nigeria, as of May 2018, about 18 840 active surveillance visits to health facilities had been made using e-Surve technology: as a result, over 3000 suspected cases of vaccine-preventable diseases – previously unreported from health facilities – were identified and investigated.

Strong support from government

Behind the new technology stands commitment from governments, communities, and partners to close the polio outbreak response. Dr. Sume Gerald at the WHO Nigeria office, states that “e-Surveillance in Nigeria is government-led and driven, supported by WHO.”

Through innovation, determination, and commitment at all levels, those working to end polio are getting ever closer to their goal.

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

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.