GPEI-Three African countries halt polio outbreaks

Polio workers hold up a banner during a 5-day campaign to vaccinate 2.6 million children in Kenya. ©WHO/Kenya — Polio workers hold up a banner during a 5-day campaign to vaccinate 2.6 million children in Kenya in July 2019. ©WHO/Kenya

Brazzaville, 19 December 2019 – Kenya, Mozambique and Niger have curbed polio outbreaks that erupted in different episodes over the past 24 months, World Health Organization (WHO) announced.

Transmission of vaccine-derived poliovirus was detected in the three countries in 2018, affecting 12 children. No other cases have since been detected.

“Ending outbreaks in the three countries is proof that the implementation of response activities and ensuring that three rounds of high-quality immunization campaigns are conducted can stop the remaining outbreaks in the region,” said Dr Modjirom Ndoutabe, Coordinator of the WHO-led polio outbreaks Rapid Response Team for the African Region.

“We are strongly encouraged by this achievement and determined in our efforts to see polio eradicated from the continent. It is a demonstration of the commitment by Governments, WHO and our partners to ensure that future generations live free of this debilitating virus,” added Dr Ndoutabe.

Vaccine-derived polioviruses are rare, but these viruses affect unimmunized and under-immunized populations living in areas with inadequate sanitation and low levels of polio immunization. When children are immunized with the oral polio vaccine, the attenuated vaccine virus replicates in their intestines for a short time to build up the needed immunity and is then excreted in the faeces into the environment where it can mutate. If polio immunization coverage remains low in a community and sanitation remains inadequate, the mutated viruses will be transmitted to susceptible populations, leading to emergence of vaccine-derived polioviruses.

No wild poliovirus has been detected anywhere in Africa since 2016. This stands in stark contrast to 1996, a year when wild poliovirus paralysed more than 75,000 children across every country on the continent. The WHO African Region however, is currently facing outbreaks of a rare poliovirus strain known as circulating vaccine derived poliovirus.

The work of the Rapid Response team starts once the lab confirms that a sample collected from either the environment or a paralysed child is caused by a poliovirus. Every minute that passes from then means that the virus is circulating and risks infecting more children that is why the Rapid Response Team deploys with 72 hours. The team supports local health authorities in the affected country in preparing the risk assessment and outbreak response plan. Then assist with launching the emergency response vaccination campaign, called round zero, within 14 days. A second team then takes over after the first eight weeks and continues the outbreak response activities including ensuring that three more rounds of high-quality vaccination campaigns are conducted.

To end outbreak activities in an affected country national and regional disease surveillance and laboratory teams need to confirm that no polio transmission is detected in samples collected from paralysed children, children in contact, and the environment have been negative for at least nine months. Response to the polio outbreak requires a strong multisector collaboration. In these efforts, WHO with other Global Polio Eradication Initiative spearheading partners: UNICEF, Rotary International, the US Centers for Diseases Control (CDC), the Bill and Melinda Gates Foundation (BMGF) and other stakeholders have been supporting the Government of Angola in implementing measures to end the transmission of the poliovirus.

Countries still experiencing outbreaks of vaccine-derived poliovirus in Africa are: Angola, Benin, Cameroon, Central African Republic, Chad, Côte d’Ivoire, Democratic Republic of the Congo, Ethiopia, Ghana, Nigeria, Togo and Zambia. The risk factors for these outbreaks include weak routine vaccination coverage, vaccine refusal, difficult access to some locations and low-quality vaccination campaigns, which have made immunization of all children difficult.

Countries of the region experiencing outbreaks are continuing to implement outbreak response, following internationally-agreed guidelines and strengthening surveillance activities to rapidly detect any further cases. To successfully implement the outbreak response required, the engagement of government authorities at all levels, civil society and the general population, is crucial to ensure that all children under the age of five are vaccinated against polio.

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Thanks to the unbending resolve and resilience of women health professionals as they go door-to-door across villages and mountains administering vaccine in some of the most marginalized or remote communities, women are truly the backbone of the polio programme at the ground-level. We asked a few of these women about their most daunting and heartening moments in polio, and how they worked through them.

Julia Kimutai—Community Strategy Coordinator Nairobi, Kenya

A day in the life of Julia Kimutai as a Sub-County Community Strategy Coordinator in Nairobi, Kenya. ©WHO EMRO

For Julia Kimutai, a 38-year-old community strategy coordinator in Kenya, educating the public about the importance of vaccines is a constant project. As a specialist in dense urban areas with high rise buildings, Julia knocks on a lot of doors and is often greeted with refusals.

“To convince some mothers is not easy,” she says. “It has never been a smooth ride.”

But where some might just see a campaign-time encounter with skeptical parents as a one-off, Julia sees a long-term project.

“Where we have difficulties is where we double down our efforts to build relationships. We even go back when there is no polio campaign to try to talk with parents, emphasize why vaccination is important and try to do a lot of health education,” she says.

As a woman and as a mother, Julia believes she is uniquely qualified as she can relate, understand and convey the importance of polio vaccines to the numerous apprehensive mothers she meets daily.

“I am a good listener, a good communicator and patient. These tools help me daily as Polio Eradicator and a mother.”

Asha Abdi Dini—District Polio Officer, Banadir, Somalia

A district polio officer with over two decades of experience in Banadir, Somalia, for Asha Abdi Dini, refusals are always heartbreaking. “My worst moment was seeing a family who had three girls and a son. They vaccinated their daughters but refused to allow the boy to take the vaccine. The boy got the polio and the girls survived.”

But Asha takes pride in the challenges she has been able to overcome since joining the polio programme.

“My best moment is seeing the same children I once vaccinated all grown up and bring their own children for vaccinations. It gives me immense hope and happiness,” she says.

Women are on the front lines of polio eradication. ©UNICEF Somalia

Bibi Sharifa—Health Communication Support Officer, Islamabad, Pakistan

A continent away, for 39-year-old Islamabad district health communication support officer, Bibi Sharifa, a big part of the job is demonstrating how women can do difficult work and stand firm in the face of adversity.

“People often think that women are incapable, but they really couldn’t be more wrong. The women on our programme are extraordinary – they are strong, gentle, dedicated, humble, passionate, disciplined and fierce at the same time,” she says. “They are driven by the love of their children and their community, and despite the challenges they face, people should realize that women are like grass, not like trees: where trees can be uprooted by floods, grass can face the brunt of flood easily.”

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©CDC
Steve Oberste has been chief of US CDC’s picornavirus laboratory since 2012. He also worked as a research microbiologist at CDC, from 1996 – 2011.

Could you please provide some background on your labs and the polio-related work carried out there?

SO: CDC’s polio and picornavirus lab is a global specialized laboratory in the WHO Global Polio Laboratory Network. It was set up in the mid-1950s and is US-government funded, with CDC being an agency under the Department of Health and Human Services. Our polio lab is one of the largest out there with approximately 55 staff dedicated to polio. We largely deal with the more complex side of polio diagnostics – sequencing, which is the molecular testing of poliovirus-positive samples to determine genetic connections to other known polioviruses.

We also act as a ‘lab of last resort’ when countries, for whatever reason, are unable to carry out preliminary diagnostic tests on their samples. We’re involved in the development of a new and even safer form of oral polio vaccine, and have a team which looks at population immunity through examining blood samples from communities (serosurveys). Importantly, we also develop and distribute reagent kits for testing samples for polio, to labs across the Network.

PB: The polio laboratory at KEMRI is combined with the measles and rubella laboratory and has been in operation since the 1980s under the general virology programme. The lab became formally accredited as one of the WHO Global Polio Laboratory Network labs in 2000. Our primary role in relation to polio is supporting surveillance through detection, i.e. isolation of poliovirus from samples we receive. We also conduct intratypic differentiation to identify strains of polioviruses isolated. KEMRI has 12 staff working on polio. WHO funds our routine diagnostic work and supplies and the Kenyan government funds our infrastructure, staff and recurrent costs such as electricity.

What’s the geographic scope of the support you provide?

SO: CDC’s polio lab provides sequencing support to countries around the world. Some examples of countries we are currently assisting include Nigeria, Yemen and those in the Horn of Africa. In terms of serosurveys, we’ve recently done work for Nigeria, DR Congo, Sri Lanka, Ukraine, Pakistan and Lebanon to name a few. We also assisted with testing of samples from Syria during recent polio outbreaks.

PB: We test samples collected from Kenya, Somalia, Djibouti, Eritrea and occasionally from Yemen, for poliovirus. In a year, we would process roughly 4,000 samples and we’ve tested about 200 from Yemen this year. In fact, around 800 samples from Yemen arrived just yesterday. We are in the process of shipping these on to CDC in Atlanta as currently we do not have the capacity to test this quantity. We assist when we can but need to be careful of our capacity so we don’t compromise our support to the other countries.

Type 2 poliovirus (PV2) has been eradicated and WHO has called for countries to destroy unneeded PV2 stocks. However, some will continue to keep PV2 to perform critical functions. Facilities keeping the virus will need to follow GAPIII guidance and pass through a rigorous certification process to prove they can safely and securely handle and store the virus. Their governments are also responsible for putting in place safeguards to minimize risk of containment failure. CDC has decided that it will continue to work with poliovirus but KEMRI has decided to destroy its infectious materials. How were these decisions made?

©WHO/Leilia Dore
Dr Peter Borus has been at KEMRI since 1994. Before moving to polio, he worked in yellow fever serology and virus isolation.

SO: To do the diagnostics and research work we do, it’s a basic requirement to have a large bank of samples of known identity – PV2 or otherwise. We also need samples to produce our kits, which we distribute to around 120/146 of the Network labs worldwide. CDC has been involved in containment for about 15 years and so understands the GAPIII requirements very well. Most of our facilities meet specifications although a few modifications are needed.

The bulk of the work ahead is related to work practices and documentation ‒ essentially making sure all our i’s are dotted and t’s are crossed. We’re bringing on a containment and safety manager to help with this and with monitoring and training. CDC is also looking closely at its risk assessment models and revising protocols for use in the event of a spill.

PB: Initially, we oriented ourselves to what it means to go through this process and become a poliovirus-essential facility (PEF). We looked at costs; actually the major determinant behind the decision was cost.

The costs of maintaining the infrastructure necessary to remain a poliovirus-essential facility are not tenable as the resource demands are above the government’s capacity. The decision was not from a lab safety aspect. We operate on biosafety level 2 and are a low-risk facility from our own assessments. However, the demands of GAPIII include certain other safeguards.

The primary safeguards that we have here we could easily manage, but the secondary and tertiary safeguards including immunization of the surrounding community and high levels of immunity, the requirement for an effluent system going out of our lab… these are things that made it [becoming a PEF] untenable for us as a country to maintain. In view of the implications of resources versus the benefits, the Kenyan government decided it was not worth KEMRI becoming a PEF.

What were the arguments, if any, for keeping samples at KEMRI?

PB: As any researcher would know, the material is valuable. That was the main argument for retaining. We refer to our stool sample collection as ‘golden stool’ ‒ golden because samples really generate information. When you have isolates, these are useful to share with other facilities on request for vaccine production.

For the unprocessed samples which contain poliovirus, as a research institution, this material is very useful to us for diagnosis of other agents. But when you look at it from the perspective of committing a whole country to putting a lot of resources in [to become a PEF], you say ‘OK, fine’. You let go.

What process did KEMRI follow to destroy its infectious material? And what happens to the new positive samples that come in?

PB: We had a local containment committee in-country who oversaw the destruction activities. We had an inventory and they set a date for us. We removed all our archived wild virus materials from storage and put them in an autoclave. So it was heat deactivation; we incinerated all the materials. KEMRI management and government officials witnessed the process. Because of the large amount of archived materials, it took one full week to prepare and actual destruction took three days. We didn’t want to come back and repeat the process for types 1 and 3 materials and so destroyed all types 1, 2 and 3 wild virus materials at the same time.

©CDC/James Gathany
CDC scientist Chelsea Harrington placing samples into a real-time thermocycler, to identify the various types of poliovirus contained therein.

For new samples, we archive those positive for types 1 and 3. For type 2, all isolates are sent to CDC for sequencing and original stools are destroyed within 72 hours of the final genomic sequence result.

Having experience with containment, does CDC’s polio lab help others reduce risk of breaches?

SO: We help answer technical questions coming from other facilities in the US looking to contain the virus. Part of preparing to become a PEF is to have emergency plans in place in case there is a spill. We assist facilities in putting together their plans, and can help out with response if there is a spill.

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.

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“We’re all immunized against polio!” UNICEF Africa

Six months after polio found its way back to the Horn of Africa, the pace of transmission appears to be slowing.

After several rounds of immunization campaigns, the number of cases being reported at the outbreak’s epicentre in Mogadishu, Somalia, has dropped off. At the same time, Kenya has not seen a case in more than four months and Ethiopia has contained the outbreak to the Somali region alone.

That may be little consolation, however, for the more than 200 children across the Horn of Africa whose lives have been changed forever by this devastating disease – and the outbreak is not completely finished yet. There’s no room for complacency with the high risk that polio will continue to spread.

“While we are pleased with the results achieved thus far, we must remain vigilant as there is still a risk that the virus could spread further, not only within the affected countries, but also cross borders into neighbouring countries,” said Steven Allen, UNICEF Regional Director for Eastern and Southern Africa. “Children in this region and elsewhere will not be safe from polio until we reach every unimmunized child.”

Across the Horn of Africa, close to one million children, most of them in Somalia, have never been immunized or have not received the required number of doses. Low immunization coverage was a key factor behind the outbreak, which was also fuelled by frequent population movement and areas of insecurity.

“WHO and UNICEF have supported countries in their response, working closely with health authorities as well as civil society groups to ensure children everywhere can be vaccinated,” said Hamid Jafari, Director, Polio Operations and Research, WHO.

With the outbreak slowing down, the affected countries are now moving into a new phase of polio outbreak response. The priority is to stop the residual transmission in South Central Somalia and in the Somali region of Ethiopia, reduce vulnerability by boosting immunity of populations and increasing immunization coverage, especially in hard-to-reach and inaccessible parts of the region.

In Somalia, in addition to immunization campaigns, strategies have been put in place to reach the most vulnerable children. Around areas affected by insecurity, 284 permanent vaccination posts have been set up at transit points, and vaccines are readily available in health facilities, so that children moving in or out will not miss out on the opportunity of immunization. In Ethiopia, 28 permanent vaccination points have also been set up in border-crossing and large transit points.

UNICEF and WHO require at least $88 million to support governments’ polio eradication efforts in 2014 and maintain the momentum built over the last six months.

In a polio outbreak in 2006, Namibia carried out several rapid vaccination campaigns for its entire population. UNICEF Namibia/Tony Figueira

Polio is a cunning virus. Just when a nation becomes a little too comfortable with their polio-free status, or when insecurity or some other disruption gets in the way of strong population immunity, that’s when polio pops up and attacks vulnerable communities.

As such, outbreaks will continue to occur until polio is completely eradicated. The Global Polio Eradication Initiative (GPEI) is hard at work making that happen; and the new Polio Eradication and Endgame Strategic Plan 2013-2018 has been designed to wipe out this virus within the next six years. But, in the meantime, the GPEI and the global community will have to be prepared to gain quick control over new outbreaks.

The World Health Assembly’s 2006 resolution on polio eradication – WHA59.1 – is considered the holy book of polio outbreak response. It contains a series of recommendations outlining the ideal response both from the affected country and the international organizations that support them.

Thanks to the resolution and the lessons learned since it was passed, the GPEI is getting better and better at putting an end to new outbreaks. Since 2011, only one outbreak has lasted longer than six months. In 2008, it took an average of 20 weeks to put a stop to a new outbreak; but by 2011, that was whittled down to 12 weeks.

So what exactly does the ideal outbreak response look like? Here is a breakdown:

On the ground

The response in the affected country begins immediately. Within 72 hours of the first polio case being confirmed, the country will conduct an initial investigation, activate the local response and make a request for an international risk assessment (if needed), so that they it can put together an emergency action plan. At least one mass polio immunization round will be conducted within the first 28 days, reaching at least two million children in the immediate area depending on the country’s population, with at least two vaccination campaigns to follow. Surveillance should also be sensitized enhanced, and routine immunization should be boosted to reach at least 80% of children across the country.

Internationally

Internationally, it’s all about providing support to the affected country. Immediate priorities are to ensure they have enough funds, vaccines, finger markers and technical assistance to plan and execute their emergency plans. Outbreak managers are appointed at the regional and global level to coordinate with their counterparts on the ground, and within seven days the emergency action plan will be shared across the spearheading partner agencies.

Ongoing efforts

However, putting a stop to new outbreaks is about so much more than simply being reactive. First of all there is the continuing research into improving the tools and tactics used to tackle polio. So part of the reason why outbreaks are now being stopped more quickly than ever before is due to things like improved surveillance and lab methods (meaning it now takes less time to confirm the presence of polio; hence less time to conduct the first response campaign) and the fact that the GPEI now has more personnel at its disposal (including STOP teams), ready to be deployed to newly affected countries.

Better than outbreak control is outbreak prevention, and the ultimate prevention will be the eradication of polio and stronger immunization systems.

Learning lessons the hard way
Horn of Africa polio outbreak
Success against polio by end-2014 a realistic prospect: IMB

West and Central Africa Polio Campaign Enters Decisive Phase

20120322_WestAfrica — Every last child must be reached WHO/C. Lamoureux

Brazzaville/Dakar, 21 March 2012 — Health Ministries, UN agencies and communities are uniting with tens of thousands of volunteer immunizers over four days to go door-to-door and hut to hut for a vaccination campaign against polio in 20 African countries starting on 23 March.

The vaccination campaigns are critical to protect children before the ‘high season’ for polio, which starts in the northern hemisphere summer. Due to insufficient funding, the polio eradication initiative is scaling back campaigns planned from March to July in over 20 countries. Many of these countries remain therefore vulnerable to polio outbreaks. The reduction in vaccination activities leaves the eradication effort with a funding shortfall of US$405 million for 2012.

Across West and Central Africa, over 111.1 million children below the age of five are expected to be vaccinated through this campaign. Nigeria, the only polio endemic country in Africa, aims to get two drops of the oral vaccine into the mouths of 57.7 million children. Nineteen other countries, which are at risk of re-infection, are stepping up efforts to reach nearly 53.3 million children.

This gigantic exercise represents a dramatic effort of will by governments and partners, and relies on hundreds of thousands of health workers and volunteers who will be administering the drops to all children under the age of five, irrespective of their previous immunization status.

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Vaccination campaigns rapidly boost immunity of refugees vulnerable to outbreaks of communicable diseases.

Newly arrived refugees at the Dadaab refugee camp, northern Kenya. Riccardo Gangale/UNICEF — Newly arrived refugees at the Dadaab refugee camp, northern Kenya.
Riccardo Gangale/UNICEF

8 August 2011 – The Horn of Africa is facing its worst drought in over 50 years; child malnutrition rates are more than double or triple the 15% emergency threshold and are expected to rise.

Malnourished children are more prone to sicknesses and diseases, such as measles. An outbreak in the Kobe refugee camp in Ethiopia, for example, has already resulted in 47 confirmed cases of measles, including three deaths.

From 25–29 July, the Kenyan Ministry of Health, WHO Kenya and Somalia and UNICEF Kenya and Somalia launched a cross-border vaccination campaign for children living around Dadaab, a large settlement for Somali refugees in north-eastern Kenya. After registration, newly arrived Somali refugees in the Dadaab camps are medically screened and vaccinated. To protect the host population in the area, a vaccination campaign, lead by WHO, targeted about 215 000 children under five, with measles and polio vaccines, together with vitamin A and deworming tablets.

This photo story and video illustrate in more detail the nature of the vaccination campaign.

Country: Kenya

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Recommendations made

Polio eradication efforts in Kenya

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Related:

On the ground

Internationally

Ongoing efforts

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West and Central Africa Polio Campaign Enters Decisive Phase

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Vaccination campaigns rapidly boost immunity of refugees vulnerable to outbreaks of communicable diseases.