GPEI-Serosurveys map child immunity in Afghanistan

Shokria, aged 4, displays her ink-stained finger to show that she has been vaccinated against polio. ©WHOEMRO 2016

In Afghanistan this year, staff from the non-governmental organization Care of Afghan Families collected 420 blood samples from children under 4 at the Mirwais Regional Hospital in Kandahar province. The aim? To find out whether polio vaccination campaigns have been reaching enough children, and whether the vaccines have been generating full protection against this paralysing disease. These ‘serosurveys’ showed that immunity in Afghanistan is high – and also identified where vaccination campaigns need to reach out further.

Whenever a polio vaccination campaign takes place, a purple dot of ink is painted onto the little finger nail of every immunised child to show that they have received the lifesaving vaccine. This data is collected and allows people to monitor the campaign and know exactly where children have been reached.

Now, with more children being vaccinated than ever before, the polio eradication programme needs to know more than how many children are being reached: we need specific data on where children are being missed.

Serosurveys testing for immunity

Serosurveys are simple tests of the serum in a child’s blood, which measures their immunity (or seroprevalence) to different diseases. The polio eradication programme uses this test to see what level of protection a child has against wild poliovirus types 1, 2 and 3, allowing them to assess whether the vaccination campaigns are reaching enough children, enough times, to give them immunity.

At the Mirwais Regional Hospital, the children tested were from a diverse range of provinces. Their results were sent to Aga Khan University for initial testing, and then sent for further analysis to one of the Global Polio Eradication Initiative partners, the US Centers for Disease Control and Prevention in Atlanta. Through mapping both where they live and their immunity results, scientists at both institutions helped polio eradicators to discover the areas where a child is at most risk of being missed by vaccination campaigns.

Serosurvey results can be crucial for planning campaign strategies – making sure that every last child is reached, no matter where they live.

Serosurveys help to map where at-risk children are living. ©WHOEMRO 2016

For Ondrej Mach, team lead for clinical trials and research in the WHO’s Polio Eradication Department, serosurveys “… are increasingly important for eradication efforts, allowing us to form an accurate picture of our progress so far, and the locations where we are being most effective.”

High immunity in Afghanistan

The Mirwais serosurvey proved that Afghanistan is closer than ever to eradicating polio, with more than 95% of children surveyed immune to wild poliovirus type 1, the virus type still circulating in some areas of Afghanistan, Pakistan and Nigeria, and more than 90% immune to type 3, which hasn’t been found anywhere in the world since November 2012. The tests also pointed to where gaps in immunity are, so that missed children can be found and protected.

These results are a strong reflection of the devoted work of polio vaccinators and community workers throughout the country, using their expertise to reach into every family, and spread awareness of the importance of polio vaccination.

Volunteer vaccinator Haji Mohammad inspects children from all over Kandahar, ensuring that no child is missed. ©WHOEMRO 2016

Using serosurveys in at-risk countries

As in Afghanistan, serosurveys are increasingly used in other countries where polio remains or poses a threat, to help identify the last remaining pockets of under-immunized children in high risk areas. This is especially important because with polio in fewer places than ever before, it is these unreached children that will take us over the finishing line.

By getting an increasingly accurate picture of where vaccination campaigns are operating successfully, as well as where the programme needs to renew efforts, we can move further towards the goal of reaching every child.

This helps us reach our ultimate goal – ensuring that every last child, everywhere, can be polio free.

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

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

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

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

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

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

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

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

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

Innovative approaches are improving the reverse cold chain in Sudan, the process by which stool samples from potential polio cases are transported carefully to a laboratory. © WHO

It starts with a sick child, whose arms or legs have suddenly become weak and floppy. A trip to the local health centre, which could be many miles away, confirms that the child is showing classic signs of acute flaccid paralysis. This is one of the key indicators for poliovirus and kick starts the polio surveillance system into action. In Sudan, an innovative approach to transporting stool samples from potential polio cases to the laboratory for testing is making it even more likely that if polio returns, it will be found.

Strong surveillance to identify every case of acute flaccid paralysis is the golden standard of the polio eradication programme. In countries like Sudan, where the last case of wild poliovirus was seen in March 2009, it remains critical. Even though Sudan is now polio-free, it remains at risk of reimporting the virus, so a high level of vigilance is needed while polio continues to circulate anywhere in the world.

The importance of strong surveillance in Sudan

Amid outbreaks of acute watery diarrhoea, severe malnutrition in children under 5, large scale internal population displacement and an influx of more than 1 million refugees from South Sudan due to conflict, Sudan has managed to maintain a strong surveillance system for polio. Despite these challenges, global surveillance standards – which tell a country whether their system is sensitive enough to catch polio circulating in communities – continue to be met.

But polio remains a threat to every child, everywhere, until it is stopped for good. Today, only three countries remain to be polio endemic – Pakistan, Afghanistan and Nigeria. Countries like Sudan that are close by, with low routine immunization rates, weak health infrastructure or facing conflict and population displacement, remain at a higher risk of polio finding its way back.

The role of the reverse cold chain for surveillance

When any case of acute flaccid paralysis is found anywhere in the world, stool samples from the affected child must be transported carefully to the laboratory so that they can be tested to identify whether the poliovirus was the cause.

Mr Jaouad Tilout, from WHO Eastern Mediterranean Office Polio Eradication Programme, explains that this journey undertaken by each sample is known as the ‘reverse cold chain’. “If a cold chain is what you call the transport chain that goes from a laboratory to the field – where vaccines must be kept at a certain temperature from the moment they are produced, until they are administered in order for them to work – a reverse cold chain is the process of stool samples that need to be tested getting back to the lab from the field at a certain temperatures so that the virus that might be in the sample will still be identifiable.”

Innovations in the reverse cold chain

With support from Global Polio Eradication partners, Sudan is part of a pilot study of a new device that aims to ensure stool samples collected from acute flaccid paralysis cases reach Sudan’s National Poliovirus Laboratory in the right condition for effective testing.

Mr Jaouad Tilout says that the pilot study aims to assess whether specimens being transported are meeting global guidelines and introduce continual temperature recording probes known as ‘LogTags’ to track specimens during their journey to the lab.

Dr Christopher Hsu, from the Centers for Disease Control (CDC), and Mr Tilout co-led a two-day workshop in Khartoum to train public health staff on the use of the new tool.

“This is a really important innovation that could be implemented in other EMRO countries, such as Yemen and Somalia, to assess their reverse cold-chain too. It’s a critical process in the end game for polio because we are looking to keep any potential poliovirus alive in the stool specimen so it can be properly notified by the lab,” Mr Tilout says.

The LogTag training has been delivered to 20 health staff from Sudan’s National and State health offices, the National Polio Laboratory, and the WHO Sudan Country Office. The study will be conducted over the next six to 12 months with the goal of collecting approximately 250-300 LogTag measurements. Findings from this assessment will be used to give feedback to state polio surveillance officers on any deviation from reverse cold-chain parameters.

Some of these girls have been practising for six years to master the skills they have. Being part of the circus enables them to also attend school. Children in the audience take great please watching other children perform with amazing skill. © UNICEF Afghanistan/Ashley Graham

“I am the king of this village! Every child belongs to me and I will spread my poison to a new person every day,” screams the snake, bursting onto the stage.

In the audience, children gasp and jump backwards, their eyes wide.

Hamid, clutching his precious box of vaccines, attacks the snake, managing to defeat him. The crowd cheers.

“Vaccinating your children will destroy this disease!” cries Hamid. “Make sure your whole village takes these droplets and you will see how strong you and your children can be.”

Clutching the precious box of vaccinations, the vaccinator (played by Hamid himself) finally manages to defeat the deadly polio threat. The crowd watches intently, you can see in their face that they are listening to the story about the danger of polio. © UNICEF Afghanistan/Ashley Graham

This poisonous snake – mor zaharia as it’s called in Dari – represents the dangerous threat of polio, a disease that Afghanistan is fighting hard to eradicate.

Hamid leads a touring youth circus group made up of children and teenagers from all across the capital, Kabul, who performs juggling, acrobatics and theatre routines for local audiences around the city and beyond.

Today the circus is in Qargha, Kabul, Afghanistan. It was started 14 years ago by Mobile Mini Circus for Children and is supported by UNICEF.

The circus enables the children who join – often from internally displaced communities around Kabul – to go to school every day and then practise circus skills at their centre after school and on weekends.

Part of their impressive performance includes passing on vital messages about healthcare and social issues to the audience, who may otherwise not have access to this information.

“Our circus is entertainment and it is so much fun for the performers and for the audience,” says Hamid.

The objective is to pass on a message about the importance of vaccinations against polio. “We pass on these important messages in a fun way which people listen to and they understand. Giving a message without fun means people will not take that message away,” says Hamid, who leads the circus. © UNICEF Afghanistan/Ashley Graham

“We pass on these important messages in a fun way which people listen to and they understand. Giving a message without fun means people will not take that message away.”

This is especially true of the children, who flock to the circus the moment they see youngsters their own ages pull out their juggling sticks and begin clowning around on the makeshift stage.

“We often perform in the internally displaced persons camps,” says Hamid. “These areas are not peaceful and the people have no proper shelters, no electricity and no running water.”

These conditions provide the perfect environment for communicable diseases like polio to spread; yet a simple oral vaccination, just two drops in the mouth, can bring a child closer to a life without polio. Children in Afghanistan will be vaccinated against polio multiple times, until the disease is stopped for good.

During the August and September 2017 National Immunization Days 9.9 million children under five across Afghanistan were targeted with repeat doses of the oral polio vaccine.

NPR’s Global Health and Development Correspondent Jason Beaubien moderates the Harvard Forum panel discussion in Boston

Harvard University and National Public Radio (NPR) in the United States this month hosted a high-level panel discussion to review how the systematic collection of social data has helped to understand communities and inform and shape strategies to reach every child in the world’s highest-risk polio areas.

The event, titled Eradicating Polio: Reaching the Last Child, featured the Pakistan Prime Minister’s Focal Point for Polio Eradication, Senator Ayesha Raza Farooq, Rotary’s International PolioPlus Committee Chairman Mike McGovern, UNICEF’s polio unit deputy director Jalaa Abdelwahab, and Harvard’s Senior Research Scientist Gillian Steelfisher, in a moderated panel discussion with Jason Beaubien of NPR, which broadcast the forum live.

Since 2013, the Harvard Opinion Research Polling centre has partnered with UNICEF on a collaborative polling effort to support 11 high-quality, strategic knowledge, attitudes and practices (KAPs) polls in seven polio-priority countries, including multiple waves in the remaining polio-endemic countries of Afghanistan, Pakistan and Nigeria.

Hosted in Harvard’s Boston studio before a live university audience, with the video live-streamed on the Harvard Forum website, the Forum speakers described how polling data had underlined the importance of a human-centered approach that placed the frontline worker at the centre of the program, with polling data emphasizing how local, well-trained and motivated frontline workers were the cornerstone for engendering trust in vaccination.

Ms Steelfisher explained that Harvard’s partnership with polio was about generating “data for action – we have to understand the views of the caregivers, what do they think of the vaccine, of the vaccinator. We think this polling puts the ‘public’ in public health.”

Senator Ayesha highlighted Pakistan’s critical innovations of establishing the polio Emergency Operations Centres, the weight given to oversight, monitoring and supervision systems, the need to remain vigilant despite the dramatic reduction to just 5 cases nationwide to date this year, and the importance of strong, evidence-based scientific data to inform the program’s thinking.

“The data informed us to build trust around our vaccinators … to build community ownership. The fact now that polio is considered a locally owned campaign is critical. This last point of eradication is the most difficult to cover and fundamentally it boils down to a question of political will. My Prime Minister has made a commitment to a polio-free world for all future generations and we have no intention of letting them and the rest of the world down.”

Mr Abdelwahab said it was critical to sustain momentum until eradication, not just in the endemic countries but globally. “The ultimate goal is not only eradication but the proof of concept that it is possible to reach every single child. We need to sustain the appetite of communities all the way to certification (of a polio-free world) via the human-centred approach and community-based vaccination.”

To watch The Forum, go to: https://theforum.sph.harvard.edu/events/eradicating-polio/

Afghanistan is closer than ever to eradicating polio. Through this photo essay, discover 10 innovative approaches that are bringing Afghanistan closer to ending polio, for good.

Young mothers waiting to vaccinate their children receive information on exclusive breastfeeding from a polio-funded Volunteer Community Mobilizer. @ UNICEF/R. Curtis

“Are you watching me?” “Yes, ma’am.”

“Are you seeing me?” “Yes ma’am.”

Along two rows of benches under the awning of the Chikun Primary Health Centre in northern Nigeria’s Kaduna State, about 50 young mothers sit still, their babies swaying on their laps. All eyes are fixed on Lidia, the assured polio social mobilizer who is not delivering polio vaccine, but showing the women how to correctly breastfeed.

Lidia is a grandmother, a one-time community midwife now employed with Nigeria’s polio eradication programme as a UNICEF-supported Volunteer Community Mobilizer (VCM). During the monthly polio vaccination campaigns, she goes house to house with the vaccination team, opening doors through her trusted relationship with the mothers, tackling refusals where they occur and tracking any children missed in the campaigns through her field book containing the names and ages of all children in her area. But it is between campaigns where Lidia’s full worth is realized.

Trust

Helen Jatau, a supervisor in this Local Government Area, supervises 50 VCMs and five first-level supervisors. She is convinced the health care polio frontline workers provide between campaigns provides benefits beyond the surface value – it establishes trust. “When we bring different things to the mothers, it helps the community live better and even accept us more, because we are giving more than just polio vaccines.”

Between polio vaccination campaigns, mobilizers like Lidia track pregnant women and ensure the mothers undertake four Ante-Natal Care visits, including immunization against tetanus. They advise mothers-to-be to give birth at the government health facility, provide them with the first dose of oral polio vaccine, facilitate birth registration and connect them to the routine immunization system. In houses and at monthly community meetings, the mobilizers also provide information on exclusive breastfeeding, hand washing, the benefits of Insecticide Treated Bed Nets, Routine Immunization and the polio vaccination campaign.

Ante-Natal Care

VCM Charity Ogwuche stands before the mothers at the health centre and peels over the pages of a colourful flip book. “Breastmilk builds the soldiers inside your child,” she shouts. “It will save you money. You don’t need to find food for your child to eat. You don’t need to find water: 80% of breastmilk is water. It will protect your child.”

Adiza, a young mother holding her first child, Musa, carries a routine immunization card including messaging on breast feeding and birth registration. “Aminatu talked to me about antenatal care. She asked me to get the tetanus shot, and today she has brought me here to receive routine immunization for my baby. I am really grateful. If she wasn’t here I wouldn’t be here. I wouldn’t know about it. She is the only one who tells me about this.”

Charity is proud of her work. “The women are so familiar with me, it makes me happy. They call me Aunty. I provide most of the health information for them. Really there is no other in our community. They are very young mothers and they need me.”

Birth registration

Every Tuesday is birth registration day. Once, hardly a soul turned up to register their newborns, but today, a long line of VCMs are standing clutching handfuls of registration forms, waiting to register the newborns within their catchment area.

Aminatu Zubairu, wrapped in the trademark blue hijab of the VCM, explains how all social mobilizers must come from their own community, and how that familiarity breeds the trust that has enabled her to register hundreds of children in her area. “I go to their houses and ask if they had the birth registration. If they say no I take all the information. Now I will register them and get the certificate of birth and carry it to their house to give back to them. In a month I can do 50 of these. This year there are plenty of newborns.”

Danboyi Juma, the district’s Birth Registration Officer, believes birth registrations have increased by 95% since VCMs assumed responsibility for the service. “They are helping us so much because they go house to house,” he says. “They have increased the number of birth registrations in this area by so much – oh, that’s sure.”

Routine Immunization

Jamila and her baby Arjera, who was vaccinated for the first time, following the persistent efforts of her VCM Rashida Murtala. @ UNICEF/R.Curtis

Despite stifling heat, on this Tuesday, there are more than 50 mothers and several fathers sitting on benches, waiting for their turn to have their babies vaccinated. More than 80% of them carry the cardboard cards given to them by VCMs to remind them their baby is scheduled for routine immunization.

Jamila, a young mother wrapped in a white shawl around her orange head-dress, is bringing her six-month-old baby Arjera to be vaccinated for the first time. Her VCM, Rashida Murtala, badgered her for months before Jamila finally accepted.

“Oh, she refused and refused,” Rashida says. “She’s fed up with me visiting. I went to see her today and finally she followed me. I’m happy to see her here.”

Jamila smiles. “She has been disturbing me every day that I have to take this child to the health centre. I know she’s right, so today I followed her.”

Priscilla Francis, the Routine Immunization provider who vaccinates young Arjera, believes VCMs are key to strong vaccination coverage in Chikun district. “There is much improvement in attendance since the VCMs started. They are well trained. They do a good job of informing mothers to come. If we lost them we would lose our clients – no doubt. When they come we tell them to come back, but no one else is going to their house to bring them.”

Hassana Ibrahim, a Volunteer Ward Supervisor, knows her mobilizers are important. “I have 10 VCMs, five in this ward. Non-compliance used to be a big problem but not now. Now with the routine immunization, the community sees they are providing a package of health care and now people comply with the polio vaccination.”

Naming ceremonies

New mother Naima with newly named Jibrin and her friends and family was happy to welcome her VCM to immunize children at her son’s naming ceremony: “She is my friend.” @ UNICEF/R.Curtis

Following the routine immunization session, the VCMs fan out to attend the naming ceremonies of newborns in their catchment area. Naming ceremonies provide an important opportunity to vaccinate lots of children, as family gathers around to celebrate. On average, they attend 10 naming ceremonies a month. Today we visit Naima, the young mother of a 7-day-old boy, who as per tradition has just been named Jibrin by his grandfather. Naima is surrounded by her sisters, family and village friends, who cook and eat with them, and their 68 children under five. Within minutes, the VCM has walked among them all, vaccinating them as they sit waiting with their mouths open to the sky like little birds.

Naima is happy to see her trusted VCM, and encourages her to vaccinate the children. “I know her well,” she says. “She taught me to go for ante-natal care, to deliver at the hospital and to go for immunization. She is the only health care worker who comes. We are from the same community. She is my friend.”

Related News:

Research underpins the implementation of the Polio Eradication & Endgame Strategic Plan. It evaluates the effectiveness of existing strategies, strengthens tactical and operational implementation and pioneers new tools and approaches. The aim is to protect children from poliovirus in the best and quickest way possible.

The Global Polio Eradication Initiative, guided by its independent body of experts the Polio Research Committee, is issuing an urgent call for research proposals to help secure a lasting polio-free world.

For more information, please visit Grants and Collaborations

WS20170207_Afghanistan — © WHO Afghanistan/ S. Ramo

Afghanistan’s long struggle to eradicate polio is showing strong signs that the country is closer than it has ever been to finally stopping the disease, once and for all.

The year 2016 ended with only 13 cases, down from 20 in 2015 and 28 in 2014. Notably, 99% of all districts ended the year polio-free, with transmission cornered in small geographical areas in the south, east and south-east of the country.

While Afghanistan this week will announce its first case of wild poliovirus for 2017 – an 11-month-old girl in Kandahar District of Kandahar Province – the country has made substantial gains that make eradication in the short term a realistic goal. Monthly campaigns will be held through the end of May during the traditional ‘low season’ for polio transmission, which provides the best opportunity to stop transmission country-wide.

Every last child vaccinated

There is reason to be cautiously confident about 2017. Last year saw notable improvements in the quality of immunization campaigns across the country – particularly in high-risk areas – with significantly more children being reached and protected than ever before. The proportion of areas achieving required coverage standards in post-campaign Lot Quality Assessment Surveys has increased over the 12 months to December 2016 from 68% to 93%. Concurrently, the quality of campaign monitoring has improved with new approaches including remote monitoring through mobile phone technology and independent third-party monitoring.

Strategic district-specific plans for 2016-2017 are focused on 47 high-risk districts responsible for 84% of polio cases in the past 7 years. An intensified community engagement communication network has been established in these districts to ensure parents and caregivers are aware of the benefits of the polio vaccine and vaccinate their children during campaigns.

A National Islamic Advisory Group for Polio Eradication has been established in 2016 and Afghan religious scholars, the Ulama, issued a Declaration calling on all Afghans to vaccinate their children. Religious leaders are now strongly involved in supporting polio eradication efforts.

A strategy to revisit homes where children were missed was introduced in 2016. By the end of the year, in areas where the Immunization Communication Network was present, teams of mobilizers were successful in vaccinating 75% of missed children in very high-risk districts.

A single block

Afghanistan and Pakistan form one epidemiological block – reaching children on the move is another priority. Coordination and joint planning between the two countries is strong. Currently, 294 Permanent Transit Teams vaccinate children who travel in and out of security-compromised areas, special campaigns target nomadic populations and 49 cross-border teams at 18 cross-border vaccination points vaccinate children when they cross into or from Pakistan and Iran. In 2016, these border teams vaccinated over 122,000 returnee children with oral polio vaccine and over 32,000 with the injectable inactivated polio vaccine.

Surveillance is king

Underpinning all eradication efforts is a surveillance system which is able to pinpoint any virus. An external surveillance review concluded in 2016 that Afghanistan’s disease surveillance surpassed global standards and circulation of the virus is unlikely to be missed. In the past 12 months, an additional 458 disease surveillance reporting sites have been introduced and the number of reporting volunteers has increased by 18% to 21,000. Three additional environmental sewage surveillance sites have been added, in Kandahar, Nangarhar and Khost, and sampling frequency has been doubled in the south.

The road ahead: neutrality

Significant challenges remain: routine immunization coverage remains weak in many areas and insecurity and active fighting has hampered vaccination teams’ access. In this complex and challenging environment, the programme continues to maintain its neutrality. Maintaining dialogue with communities remains essential.

Now more than ever, Afghanistan has all the systems in place and tools it needs to achieve eradication: high-quality immunization campaigns, strong monitoring and supervision of vaccinators, vigorous communications platforms, a strong community engagement strategy creating an enabling environment for vaccination campaigns, national and regional Emergency Operations Centres to oversee and manage the programme, a supportive civil society, religious leadership and media and – most importantly – a committed network of local health workers who are trusted and supported by their communities.

In the coming months, Afghanistan has a unique opportunity to take the world over the finishing line for polio eradication. If all elements of the polio programme are accountable for reaching and immunizing every child in high-quality monthly polio vaccination campaigns, eradication is possible.