GPEI-Rallying to vaccinate every child in Somalia against polio

Fahima Ahmed Hassan is a 25-year-old community mobilizer who goes the extra mile to ensure parents of children under the age of five are informed of Somalia’s polio vaccination campaigns and are ready for their children to be vaccinated.

Fahima and the other mobilisers are from the local community and they lay the groundwork for vaccinators ahead of campaigns. They work tirelessly to reach every house, speaking to families to help them understand, trust, and accept the vaccine.

On a mid-October morning, children and their families are waiting anxiously. They have been informed, by Fahima and through loudspeaker announcements, that a team of vaccinators will be visiting their community.

Amid the COVID-19 pandemic, some people are concerned and worried about taking their children for vaccinations. They fear they might contract the virus or expose their children to it. Together with her team, Fahima takes every precaution to keep herself and the community she serves protected.

She explains that it is critical to show the community that vaccination can go ahead while maintaining physical distancing, wearing protective masks and using hand sanitizer.

Somalia’s vaccine advocates

Some people do not need to be convinced about the benefits of immunization. Asha Osman Yarow is one of them. She is patiently waiting for her son to be vaccinated.

“I decided to vaccinate my children because their health is important to me,” Asha says, holding her young son. “Vaccines protect children against diseases, like polio, measles and others.”

“Praise be to Allah that these services come to us,” chimes in Sahro Mohamed Haile. “I encourage all mothers to take care of their children, vaccinate them and keep records of their vaccination status. Me, I’m here today with my grandson,” she adds with a smile.

Others in the community are more reluctant to accept vaccines. “At first, I refused to vaccinate my children. I heard people say that the vaccines were no good and that they were made by non-Muslims. I was scared,” explains 30-year-old Wardo. “After speaking to the community mobilizers, I realized that the vaccines are good for my children’s health – and I changed my mind.”

“I understand where they are coming from, and I do my best to give them information and convince them that vaccinations are beneficial,” says Fahima. “Illiteracy, lack of education and myths make people reject the vaccines.”

Together with the other community mobilizers, Fahima engages elders, religious leaders and community influencers as well as urging parents until the very last minute to come forward.

“I’ve vaccinated all of my children and I was one of the first people in my community to support vaccines,” says Isha Hassan Saney, a fellow community mobilizer. She believes showing a good example helps to convince others in the community to vaccinate their children.

“I am motivated to serve the community, especially the mothers and children, because they need to be taken care of,” Fahima says. “There is no better reward than seeing them healthy.”

COVID-19 shows why vaccines are so important

Despite COVID-19, and the enhanced risk of infecting her husband and her extended family members when she comes home, Fahima continues to show up for work and doesn’t let fear take over.

The COVID-19 pandemic has revealed what is at stake when communities do not have the protective shield of immunization against an infectious disease. When vaccines are available, they are the most effective tool to prevent dangerous disease outbreaks.

Staying informed about their benefits and understanding the risks of not getting vaccinated has never been so important. Fahima and the other community mobilizers play an instrumental role in this.

During the recent polio immunization campaign, 8 951 vaccinators went door to door and 3 390 community mobilizers, including Fahima and her team, sensitized communities. The two-part campaign, organized by the Federal Ministry of Health, UNICEF and WHO, reached more than a million children under the age of five in south and central regions of Somalia.

Read this story on the UNICEF Somalia site.

Community surveillance teams for COVID-19 and acute flaccid paralysis speak to households about any individuals with symptoms in their area. The Somali polio team is currently steering the COVID-19 response and fighting ongoing polio outbreaks amidst challenging conditions. ©WHO/Somalia

For Somalis, COVID-19 is the most immediate crisis in a seemingly unending cycle of floods, food insecurity, conflict and outbreaks of vaccine-preventable diseases like measles, cholera and polio. Against this backdrop, the World Health Organization’s polio programme is working to steer the COVID response and, more broadly, maintain vaccine immunity levels and improve access to healthcare. It’s no easy feat.

Dr Mohamed Ali Kamil, the outgoing World Health Organization Polio Team Lead and COVID-19 incident manager for Somalia, is in awe of the commitment shown by health staff. He recently phoned a Polio Logistician diagnosed with COVID-19 who was experiencing symptoms, to insist he stop working remotely from his sickbed. Dr Kamil recalls, “He said, “No Sir, I will continue.”

Since the first COVID-19 case was diagnosed in Somalia on 16 March 2020, the polio programme has fought the pandemic from the ground up. Dr Kamil explains, “No other health programme has comparable expertise to serve the Somali population during COVID-19. During their time in the programme, members of the polio team have responded to many different disease outbreaks. This means they were well placed and well trained to respond to COVID-19.”

“The polio programme has spent years building staff capacity and systems to implement vaccination campaigns and detect the poliovirus in the community. In some ways, the team are the first and last line of defense.”

The response includes education, case identification, contact tracing, case management and data support. As of June, polio staff working as part of rapid response teams (RRTs) had reached 2.6 million people with messages about COVID-19 prevention. District Polio Officers within the RRTs have led the investigation of over 4500 people with suspected COVID-19 across the country. The country has set up three COVID-19 testing facilities and the polio structure established for the collection and shipment of stool samples from AFP cases has been used for the transportation of COVID-19 samples.

Dr Mohamed Ali Kamil, the outgoing World Health Organization Polio Team Lead and COVID-19 incident manager for Somalia, speaks to a polio vaccinator before the onset of the pandemic. ©WHO/Somalia

Throughout, polio personnel have continued their full-time work to end the circulating vaccine-derived poliovirus (cVDPV) outbreaks that have thus far paralyzed sixteen children since 2017.

The team are driven by a humanitarian commitment to the Somali population, who have suffered over 30 years of protracted conflict and insecurity. At least 5.2 million people are in need of humanitarian assistance, and secondary and tertiary healthcare is virtually non-existent outside of a few large cities. Health literacy is low, and populations are highly vulnerable to diseases like polio, measles, cholera and now COVID-19. In November 2019, widespread flooding brought further turmoil and danger to Somali families.

The team’s work is made more difficult by the emotional toll wrought by the pandemic. To date at least 143 health workers have been identified with COVID-19 infection. In April, Ibrahim Elmi Mohamed, a District Polio Officer who spent 19 years striving for a polio-free Somalia, died of a COVID-19-related illness. His death, one of many frontline staff around the world due to COVID-19, remind us of the risks they face every time they go to work.

Challenges lie ahead to defeat polio

Dr Kamil is clear that the polio programme will require ongoing funding and the support of authorities, partners and communities in order to maintain polio activities amidst the pandemic.

“To sustain the immunity gains we must implement a number of polio vaccination campaigns each year until the routine immunization programme can reach every Somali child with all polio vaccines. Somalia is extremely fragile and at high risk of becoming endemic for poliovirus if we do not maintain and support the polio infrastructure,” he says.

Since the cVDPV outbreaks were first detected in 2017, the programme has streamlined disease surveillance for cases of acute flaccid paralysis and other preventable diseases, including by introducing mobile technology to record details of suspected cases. For the first time, environmental disease surveillance was introduced. Over three years, frontline health workers have implemented more than 15 polio campaigns, including integrated campaigns with the measles programme.

A volunteer vaccinator gives two drops of the polio vaccine to a Somali child in August 2019. Despite efforts, many inaccessible areas remain where the programme cannot deliver vaccines. ©WHO/Ilyas Ahmed

Dr Kamil explains, “We still don’t know where the virus is coming from exactly. There are many inaccessible areas, where we cannot deliver vaccines or respond with immunization campaigns. We suspect that the virus is circulating among vulnerable children and communities living in these areas.”

Dr Kamil feels strongly that the polio programme has a duty to support other health interventions. He says, “COVID-19 shows what the frontline polio staff can achieve and the strength of surveillance and response systems.’’

Despite the challenges, Dr Kamil retains his belief that with ongoing funding and support, the cVDPV outbreaks in Somalia can be brought to a close. He reflects, “COVID-19 is a huge emergency in Somalia. Our staff are working flat out, and we expect to see many more cases, but at the same time we must continue to fight polio. The Somali community and the world deserve to be free of this disease.”

“We must reschedule our March polio vaccination campaign which was delayed because of the COVID 19 outbreak. We must do everything possible to keep health workers safe from COVID-19. It’s a hard situation, but we must not stop until we overcome both viruses.”

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Polio programme staff are conducting disease surveillance for COVID-19 as well as educating communities on the symptoms of the virus, how to prevent transmission, and how to report suspected cases. ©WHO/Somalia

“The road to the mountain village was rough. It’s only 50 kilometres, but it took more than 3 hours,” says Dr Fatima Ismail, a disease surveillance officer working in Somaliland. “We were bouncing in the car.”

In early 2020, Dr Fatima’s team headed to a remote village near Djibouti to check on a small boy. The boy’s right arm and leg showed a kind of paralysis that sometimes indicates polio. “The village polio volunteer in this mountainous area, geographically inaccessible, found an acute flaccid paralysis (AFP) case,” Dr Fatima remembers.

When children show signs of this paralysis, it is critical to get stool samples to a laboratory to determine whether they have polio. Polio teams ride camels in the desert or donkeys in the mountains when they have to. They brave conflict to get samples to laboratories. In brutally hot climates, they plug mini-freezers into car dashboards to keep samples cool.

All over the world, polio surveillance systems that have been built up over decades track infection sources, evaluate symptoms and transport samples to the laboratory — despite distance, natural disasters, and sometimes war. Now, disease surveillance network — reaching into the most far-flung corners of the globe — is being tapped to address the COVID-19 pandemic.

“In Somalia, the polio programme pivoted its workforce of thousands of frontline staff to support the effort as the cases of COVID-19 spread. Rapid response teams — made up of disease surveillance officers, community health care workers and volunteers — were trained to educate people about the virus and to test suspected cases. By April 2020, the teams were deployed in the field,” said Dr Mamunur Malik, WHO Representative in Somalia.

“In Somalia’s remote villages, they know us as their polio teams, and once they see us, what comes to their minds is that we’re giving them information about polio,” says Mohamed*, a surveillance officer. “So we also give them information about COVID-19. Social mobilisers tell them about COVID-19 symptoms, how to prevent getting infected, physical distancing, cleaning their hands very well with running water and soap.”

The careful procedures that the teams learned for polio surveillance have been adapted for COVID-19, where the required sample is a naso-pharyngeal swab. “We’ve trained our surveillance people on the case definition and how to collect the samples correctly, from people that meet the definition of a suspected case of COVID-19,” says Dr Fatima. “It’s the same infrastructure. After, when we collect the samples from the patient, we send it to the laboratory in Hargeisa.” WHO has given the laboratory equipment and supplies to test samples for COVID-19.

“As with polio samples, the samples of COVID-19 have to be refrigerated, the ice packs should be VERY cold,” says Mohamed. Teams are used to monitoring the packs’ temperature, even in Somalia’s hot weather.

“The logistical challenges we face with AFP/polio surveillance are still the same. This is the rainy season and the roads tend to be terrible,” says Mohamed. “You can’t get to certain places you normally get to, because of the situation on the road. Most of our vehicles can’t make it through the mud.” In those situations, teams work with other United Nations agencies to arrange special humanitarian flights to ship samples.

Frontline staff put their own lives on the line. In April 2020, the polio team lost a colleague due to COVID-19-related infection. Ibrahim Elmi Mohamed, who joined WHO in 2001, was working as a district polio officer in Lower Shabelle. His tragic death, one of many frontline staff around the world due to COVID-19, reminds us of the risks they face every day they go to work.

“Despite overwhelming challenges, teams are committed to continuing their polio work in tandem with the COVID-19 response. It is critical that polio surveillance continues during the pandemic, as Somalia is also fighting outbreaks of vaccine-derived polio type 2 and 3. With polio vaccination campaigns temporarily paused, the teams must be able to track any resulting spread of poliovirus and get ready to respond as soon as it is safe to do so,” says Dr Malik.

“All of us are still doing polio surveillance at the same time as we do surveillance for COVID-19,” says Dr Fatima. “I used to hear from my colleagues that the polio surveillance system is the strongest disease surveillance system. Any polio surveillance team can work in the detection of COVID-19 cases because of the system’s structure, the capacity and experience of the teams.”

Mohamed agrees. “My surveillance coordinator said don’t leave the AFP surveillance behind, follow that normal routine, don’t forget it and leave it aside.’”

As Somalia grapples with the COVID-19 pandemic, its trained teams are working quickly to prevent the spread of both COVID-19 and polioviruses. “What gives me hope in the COVID-19 response is when I look behind and I see what we have done with the polio teams, the impact we’ve had on so many lives,” says Mohamed. “We face everything and we overcome it.”

*Family name withheld for security reasons

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A female vaccinator stains the finger of a child who has just received a polio vaccine. This photo is illustrative and does not feature the women interviewed for this story. ©WHO

Noora Awakar Mohammad

Noora Awakar Mohammad was only sixteen years old when she started working as a volunteer for the Polio Programme in Somalia. Since then, she has lived through civil war and armed conflict in her country, which have left the health infrastructure in tatters. Recalling the days of war, Noora’s face tenses. “During the civil war years, on many occasions the polio campaign was stopped because of intense fighting. As soon as the fighting would stop, we would run to communities to vaccinate children,” she recalls.

During those days, it was mostly elderly women and mothers who trained as vaccinators. The adolescent Noora had to work hard to build community trust. “Often, I stayed with the community and vaccinated the children amidst war. The community trusted me even though I was a young health worker,” she remembers.

Noora still faces challenges in her fight against polio. Many areas in Somalia are unreachable because of the presence of non-state groups. These groups, who oppose vaccination, have been responsible for creating fear among parents by spreading misinformation. Noora has also encountered vaccine-hesitancy among parents because of inadequate health awareness. “I have seen fathers refusing to vaccinate their children on one hand, while mothers request us to vaccinate them on the other. Under such trying circumstances, we have to seek the help of religious leaders to convince the refusing fathers,” Noora explains.

Alongside polio vaccination, Noora works as a midwife. As part of her role, she educates pregnant women and young mothers about the benefits of vaccination. She also builds awareness of Acute Flaccid Paralysis (AFP) in the community, a key symptom of polio. “I share information about AFP with mothers and now I see more and more mothers bringing their children to health centers even with the slightest symptom of AFP,” Noora says.

Noora emphasizes that closing the current polio outbreak in her country remains tough given the climate of insecurity and inaccessibility, but she remains determined to carry on with her work.

A female health worker monitors the polio vaccination campaign coverage. This photo is illustrative and does not feature the women interviewed for this story. ©WHO

Zainab Abdi Usman

Zainab Abdi Usman is a midwife in Madina district in Banadir state in central Somalia. For the last twenty years, she has volunteered for the polio eradication programme. A source of frustration for Zainab is the children missing out on vaccination in inaccessible areas. The barriers health workers face to access populations in desperate need of basic healthcare and community services are sometimes insurmountable.

“During the civil war, I used to carry the vaccine in a thermos kettle to keep it cold and I would hide it under my Abaya. If fighters got suspicious, they would not allow me to go into the communities to vaccinate the children. Today, many areas remain inaccessible,” Zainab says.

Whenever the access situation changes, the polio programme is amongst the first health initiatives to reach children. Zainab explains, “In a conflict situation, there is an immediate need to treat victims of the conflict. However, at the same time, it is important that we save our children from paralysis resulting from polio. Therefore, reaching out to children in insecure areas is very crucial in our fight against the disease.”

Women check their vaccine supplies during a polio vaccination campaign. This photo is illustrative and does not feature the women interviewed for this story. ©WHO

Feriha Abdur Rehman Yusuf

Feriha Abdur Rehman Yusuf is the young mother of a one-year old boy. She sees the fight against polio as personal and has been part of over 30 immunization campaigns in Somalia.

An incident from Feriha’s past stays with her years later. “One day, during a door-to-door campaign, I knocked at the door of a house. A man carrying a gun opened it. He yelled at me and started shooting in the air. I was shaken for days,” she remembers. Thankfully, the situation has changed in Feriha’s district since then.

Thanks to efforts to educate parents, the public is more aware of the long-term benefits of vaccination. However, Feriha still faces a few families who reject the polio vaccine during campaigns. She tries to convince parents using the examples of her own son, and her nephews and nieces. If families continue to be worried, she seeks help from religious leaders and community members.

Working during campaigns is not easy for Feriha now she has her son. Feriha says that her mother is the biggest supporter of her work and source of encouragement. “When I am in the field during the polio campaigns, my mother practically moves into my house and takes care of my child,” she says.

Feriha believes that despite the climate of insecurity and inaccessibility, things are improving in Somalia. “Health services are getting better than before. More and more children are getting vaccinated, so they have a better shot at life,” she says.

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Abdullahi Mahamed Noor, hailing from Mogadishu in Somalia, wears multiple hats. By day, he is an experienced and dedicated polio programme zonal coordinator. By night, you can find him racing down the court as president of the Somali Basketball Federation.

Abdullahi Mahamed Noor is president of the Somali Basketball Federation, and a dedicated polio programme zonal officer. ©WHO/Somalia

Mahamed’s journey to end polio started in 1999, as a vaccinator in Adale District of Middle Shabelle in Southern Somalia. Since then, he has worked to combat multiple polio outbreaks in his country, including the current cVDPV outbreak.

Mahamed strongly believes that eradicating polio isn’t just about delivering the vaccine. To maintain high immunity levels, the programme must deliver a clear message about the safety and importance of the vaccine and help communities become better informed. To achieve this goal, Mahamed uses his sporting connections to combine basketball with innovative polio immunization messages, with the objective of increasing awareness throughout his community.

Last year, Mahamed took advantage of a Vaccination Week to deliver messages on polio eradication at several basketball games held in Mogadishu. “When people come to the stadium, they see messages on polio awareness and how important it is to vaccinate children to build their immunity against polio virus. They pass those messages to family and community members,” he explains.

From 1999 to 2010, a period during which Somalia suffered several polio outbreaks, the inaugural ceremonies of most of the major sports activities in Somalia would begin with statements encouraging people to vaccinate their children against polio.

Through basketball, Mahamed engages the community in his work to end polio. ©WHO/Somalia

Currently, Mahamed supports polio officers to develop comprehensive microplanning for immunization campaigns in Somalia. He emphasizes fostering trust between frontline workers and communities, since the polio workers in Somalia travel door to door to deliver vaccine. The basketball games that he organizes in his spare time help to increase acceptance of polio workers in the community.

“Part of my job is to convince the families who refuse to vaccinate their children. I quite often use my experience of being involved in basketball to educate them on benefits of polio vaccination and preventing disability related to poliovirus.”

Sportspeople are active in the fight to end polio the world over. Ade Adepitan, a British Paralympian, wheelchair basketball player and broadcaster, who is himself a polio survivor, is a strong advocate for polio eradication. In Pakistan, cricketers often promote polio eradication campaigns during the highly watched and well-attended matches.

In many parts of Somalia, poverty, conflict, internal displacement and weak health infrastructure often mean that vaccination levels remain relatively low. Amidst these trying circumstances, dedicated workers like Mahamed are playing a critical and innovative role in educating communities about polio and the absolute importance of vaccination to defeat the disease.

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Environmental surveillance teams in Mogadishu access the underground closed drainage system to collect sewage waste water samples, which they package and send to the laboratory for testing. If poliovirus is identified in a sample, epidemiologists know that the disease is likely to be circulating amongst the community whose sewage drains into that part of the system. This process is called environmental surveillance and is one of the most important tools for the polio programme to help detect poliovirus.

Vaccinating every child and conducting disease surveillance to know where the poliovirus is circulating are key strategies to end the outbreak. Low immunization coverage has led to an outbreak of vaccine-derived poliovirus in Somalia. This can occur in places where not enough children have received their full vaccine doses.

The teams must follow best practice to collect samples, to ensure that any poliovirus present can be detected.

Click through this photo gallery to learn more about the sample collection process.

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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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Women are the true driving force of the polio programme in Somalia. © WHO Somalia

If you ask the women who work in Somalia’s polio programme why they do what they do, most will tell you they do this to help Somali children, to build a stronger future for Somalia, and to support their own families. Somalia is a complex country with many cultural and institutional challenges for women who work outside the home. Perhaps, as a result, there is a sense of solidarity among the women to pull each other up and work together in the fight against polio.

From the senior member of the polio programme to the district-level polio officer (who chooses to remain anonymous for her own security), and for so many women in between, being part of the polio programme is not just a job, but a way to work together and support each other.

Dr Rehab Kambo—International Focal Point and Head of the Polio Programme, The World Health Organization, Garowe, Somalia

Dr Rehab Kambo wears two hats at The World Health Organization (WHO): International Focal Point and Head of the Polio Programme in the satellite office at Garowe, Puntland state of Somalia. After joining the polio programme, Dr Rehab set out to understand the context she was working in and one of the things she learned was about the strength of Somali women.

Dr Rehab Kambo vaccinating a young child in Somalia. © WHO Somalia

“It is easy not to notice that Somali women are stronger than men in their society, until you spend time with them,” she said.

For Dr Rehab, this realization was driven home on an early assignment. She and a colleague were conducting a surveillance review in a region known as Mudug. Dr Rehab had traveled to Galkacyo by road for eight hours during an active clan conflict, which was no easy feat. Movement was challenging, and the women had to travel with armed escorts. But they were determined, Dr Rehab explains, and they were on a mission.

The two visited transit points at the airport and health facilities to meet with Village Polio Volunteers, who serve the polio eradication initiative at the district level. Upon completing the mission, she and her colleague were elated. Dr Rehab looks back on this as one of the most satisfying – albeit stressful – experiences of her life as a polio eradicator.

Since then, Dr Rehab has taken on the challenge of two roles in one of the most operationally demanding regions in the world. For Dr Rehab inspiration comes easily from the women around her.

“In many instances, they are powerful, independent, and are decision-makers in their families,” said Dr Rehab of the Somali women. Even as a relatively privileged, educated woman, Dr Rehab admits there is a lesson in here for her, and for other women like her.

“Women are so strong, honestly. They can adapt to any role for the good of others,” she said.

Mira A—District Polio Officer, Somalia

Life in Somalia has been extraordinarily difficult since war broke out in 1991, and there is no doubt that it has been harder for women than for men. With an average fertility rate of 6.6 per woman, and high death rates in mothers – one out of every 12 women dies due to pregnancy complications – women are in need of timely and quality health services. A lack of education compounds the problem.

“Despite the challenges, women in Somalia have resiliently stood up to the task and engaged in small-scale businesses over the years to earn a living for their families,” said Mira A, a District Polio Officer in Somalia (we are not using her real name for security reasons).

For Mira A and women like her, taking work outside the home is a way to support not just their families, but themselves – and each other.

“Many women have no time to continue their education or look for other jobs, as they are so busy trying to earn money with their existing means,” she said.

When Mira A looks at the women around her, she sees that education is only part of the answer.

“There is a small sector of women who have managed to earn formal education, but even they do not earn money in most cases. They stay at home and look after their homes and children. Even they need to be empowered, even if it is just to help other women.”

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Polio eradication efforts are as much rooted in the social realities as they are in the technological tools. The success of the Global Polio Eradication Initiative comes down to one simple action: the knock on the door, when the child’s caregiver greets the health worker.

Why do caregivers let vaccinators enter their homes? The caregiver’s decision to vaccinate is influenced by many moving parts: social, cultural, economic, and religious. Women health workers and leaders are able to transcend many of these boundaries as they are not only health workers; they are members of that community – someone’s neighbour, friend, aunt, cousin or grandmother.

Polio-endemic, at-risk, and outbreak countries regularly engage women as health officials in immunization activities, constituting about 68% of the frontline workforce. In Nigeria, 99% of frontline workers are women, followed by 56% in Pakistan and 34% in Afghanistan. But their strength in numbers is not the only reason why women are crucial to polio eradication efforts, they are, in fact, behavioural change agents.

Here’s a look at some of the resilient and inspiring women working to eradicate polio in their communities – in their own words:

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A nomad child is vaccinated against polio in Lower Juba, Somalia. © WHO/EMRO

Since polio was confirmed in Somalia in late 2017, health authorities have led a complex response to twin outbreaks of circulating vaccine-derived poliovirus type 2 and type 3 (cVDPV2 and cVDPV3), paying special attention to high-risk populations: nomads, internally displaced people (IDPs), and people living in peri-urban slums and rural areas.

So far, five of Somalia’s 12 infected children are from nomadic communities, and another four are from internally displaced families living in urban areas. To boost immunization among eligible children in these populations, vaccination activities have placed a special focus on reaching these communities.

Somalia has a rich culture of people leading pastoral lifestyles, raising livestock and moving with them as the seasons and the weather change. Nomadism has a long history in Somalia and nomads have a special place in Somali society: almost a third of Somalia’s people are nomads. However, they do not observe formal international borders – just like the poliovirus. For health workers, this context poses a significant challenge: How can you be sure you have vaccinated every last child when so many children are on the move?

For health workers, this means searching for polio symptoms in more than 900 health facilities across the country, as well as nutritional centres, camps for IDPs, and key sites along Somalia’s borders. At transit points, along borders and at water collection points, polio teams work to vaccinate children moving in and out of areas experiencing conflict or with limited access to health services. In high-risk areas, the Somali Government, WHO and UNICEF hire local vaccinators – people known and trusted by their communities – and when additional security is necessary, polio partners provide it.

Gaining high-level political goodwill

Even in an emergency, cross-border collaboration is not always easy to come by. In the Horn of Africa outbreak, regional collaboration moved into high gear in September, when health ministers from across the region and representatives from the Intergovernmental Authority on Development (IGAD) countries came together in the Kenyan town of Garissa to reiterate their commitment to ending polio.

One of the event’s key messages was around the risks posed by the easy and frequent mobility of communities across borders. Kenya’s national polio immunization ambassador, former UN Person of the Year and polio survivor, Harold Kipchumba, spoke directly to the pastoral communities in the region.

Kipchumba highlighted their focus on vaccinating animals, and urged parents in these communities to use the same vigour to vaccinate their children against polio, so they are able to serve as future herders for their families.

A regional response to support high-risk populations

The Technical Advisory Group, an independent body of experts that monitors outbreaks and offers guidance, recommended that countries in the region strengthen their coordination. In response, the Horn of Africa Coordination Unit coordinates joint responses among HoA countries – work that includes monitoring current outbreaks, and collaboratively planning, mapping, conducting immunization campaigns and communicating with various audiences. This ensures that countries work together in partnership rather than in silos, viewing the outbreak as one epidemiological block.

At regional and district levels, teams have spent the last few months building records of every settlement in their area, by lifestyle (nomad, IDP, peri-urban slums, rural). The highest priority: locating special populations – internally displaced persons, refugees, nomadic families, people living in informal settlements in urban areas and communities living in access-compromised areas – in order to reach them with vital polio vaccine.

Vaccinators at work in a camp for internally displaced people (IDPs). © UNICEF/Somalia

Using technology to reach more children

A vital step in reaching more children, particularly those on the move, has been to move away from paper records and use electronic tools to collect data on children reached and missed during campaigns. This gives data specialists and decision-makers timely, accurate information, allowing them to analyze data in real time and flag areas with where high numbers of children are missed, so teams can revisit these households the following day.

Getting vaccines to the doorstep is not the only challenge for polio eradication teams in Somalia. Parents and caregivers also need information to ensure their children are vaccinated – something Kipchumba spoke to. On rare occasions, vaccinators meet families unconvinced of the need for vaccinations, particularly when the family has a newborn child or a sick child. In the lead up to every campaign, teams of social mobilizers, sometimes joined by influential Islamic leaders or scholars, visit communities to alert them of dates of polio immunization campaigns and the benefits of vaccination. Here, too, special attention is paid to nomadic communities, as polio teams liaise with elders from these communities in order to learn more about these communities and their needs, and to inform community members in appropriate ways about immunization dates and benefits of vaccination.

Related Resources

Left: Shire gives child two drops of the oral polio vaccine to protect them against lifelong paralysis Right: Shire works with vaccination teams to prepare cold boxes to carry polio vaccines

I have spent nearly my whole career working on eradication programmes – first smallpox, then polio. Eradication has been a rewarding career for me because I am so curious to know what is happening in the world. Every time I see a disease that we have worked so long to stop returning, I become so unhappy and know I need to work to stop it.

I worked for the smallpox eradication programme back in the 1970s. I was an epidemiologist – this means that my job was to track the disease and plan how we could stop it.

We used to hold vaccination campaigns at night because then we knew everyone would be at home, and we wouldn’t risk missing a single person. As our cars pulled up out of the dark, people would peer out of their houses to see what was happening. Somalis are very curious! As we brought them the vaccine, occasionally someone would make trouble, but mostly people were pleased to see us.

Somalia was the last country where smallpox was found in the whole world. When I knew we had really ended it in 1977, I was so happy. My name was printed there on the certification document – it was something to be proud of. We had freed the world from smallpox!

I remember one of my friends calling me in 1997 to tell me we were going to eradicate another disease, and that we had to look out for something called ‘AFP’. I thought to myself, what is this ‘AFP’? I hadn’t heard of it. They explained to me that it means acute flaccid paralysis – and that it was the symptom of a disease called polio.

Then one day in 1999, I received a call asking if I would come and work for the second eradication programme in my single lifetime. They said, “If you are ready, we will make you a coordinator. We don’t know if there is polio in Somalia or not, but we want you to come and see.” I jumped at the chance.

We started to search, looking for AFP cases, to collect stool samples and then to send them to the laboratory for testing. And soon, we had confirmation that polio was in Somalia. As soon as we found cases, lots of people came from inside and outside Somalia to help.

By 2002, we found the last case of indigenous polio, and thought the game was won. I even joked to my friends saying, what will we do now that polio is eradicated? They said to me, no – we still have polio in Nigeria, Egypt, Pakistan, many other countries – another case will come. We have to be prepared to stop it if it comes.

And true enough, we had an outbreak in 2005, and again in 2013. Each time we stopped it. Last year, we found circulating vaccine-derived poliovirus type 2. Vaccine-derived polio causes paralysis just like wild polio, and we must eradicate it too.

We started to organize ourselves and held two vaccination campaigns. But then we found another virus – circulating vaccine-derived poliovirus type 3. So now, we are responding to two outbreaks that need different vaccines at the same time. If we miss cases and miss getting vaccines to all children, we can’t stop polio. It is hard, but we will end these outbreaks just as we ended wild polio before.

Eradicating polio has been very difficult – more difficult than it was to end smallpox. I suffered – me and my wife were even kidnapped once. But I am always motivated to keep going. My motivation was never my salary – to stay alive, I need to work. I must know what is going on in my country, if my people are safe. From morning until night, my job is to make sure activities can go on peacefully. My family are my true reason for committing my life to eradication. I have seven children, and 30 grandchildren; I never once missed getting any of them vaccinated. Never.

I am sure that we will finish this job. When we eradicate polio, I will be so happy – I will have been involved in the certification of the second human disease ever to be eradicated. I feel so lucky to have spent my life working for these two eradication programmes; I am proud to tell stories to my grandchildren of my life’s work.

Eradicating polio won’t take a miracle. It is a job. It needs a lot of hard work to end an outbreak. There is no other way – the only way is to work hard, to find cases, and to respond. We hope that in the coming months we will make it. I do believe we will make it. Inshallah.

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“Ali was a humble, simple person. He had talent – real talent – in communicating the importance of vaccines to people in his community and around Somalia. He was seen by many as a hero.”

This is how Mahamud Shire, a long-time collaborator of the World Health Organization in Somalia, remembers the late Ali Maow Maalin.

Ali was the last person in the world to be infected with naturally occurring smallpox. After contracting the virus, he decided to devote his life to improving health through vaccination. He did so until his sudden passing in his home district of Merka on 22 July 2013. At the time, he was still serving with WHO as a district polio officer as part of the global polio eradication programme. He was 59 years old.

2018 marks five years since Ali’s passing. This article is being published to commemorate his life and achievements.

Smallpox

Ali Maow Maalin was born in 1954 and worked as a hospital cook. Aged 23, he contracted the smallpox virus.

Although he had previously worked as a vaccinator in the smallpox eradication programme, he himself had not been vaccinated. Fearing the needle, he had avoided the shot by holding his arm when vaccinators came to visit, pretending he had already been inoculated.

“I was scared of being vaccinated then. It looked like the shot hurt,” Ali would later recall when asked why he wasn’t immune on the day the smallpox virus caught up with him.

A man carrying two smallpox-infected children from a nomad encampment had been driving all day, looking for the local isolation camp. Taking wrong turn after another, he finally decided to stop and ask for directions. He did so at the hospital where Ali worked.

“Ali didn’t think about it twice – he jumped in the van and immediately offered to accompany the driver,”
Mahamud tells us. The driver then asked Ali if he had been vaccinated, but Ali simply said: “Don’t worry about that. Let’s go.”

It only took 15 minutes for Ali to contract the virus. Luckily, the form he caught was the less virulent one – variola minor – although still potentially lethal.

Nine days later, Ali started feeling sick.

Making history

Ali’s infection did not lead to a new outbreak. This was primarily because once the hospital where he worked found out he was sick, he was told to stay home. In the meantime, the hospital stopped accepting patients while everyone inside was being vaccinated and quarantined.

A 2011 WHO publication reports how a special team set out to vaccinate everyone in the 50 houses around Maalin’s home. Over the course of two weeks, a total of 54 777 people were vaccinated.

Effectively isolated, the virus didn’t spread. Smallpox was officially declared eradicated in 1979.

This was the first time in history that a major disease had been completely destroyed by human endeavour.

Document declaring the eradication of smallpox. Geneva, 9 December 1979. © WHO Archives

After sickness – a lifelong commitment to polio eradication

After recovering, Ali decided to commit his life to the eradication of another major disease: polio.

Beginning his new role as a vaccinator, he was determined that his own encounter with smallpox would serve as a powerful reminder of why immunization is so important.

“When I meet parents who refuse to give their children the polio vaccine, I tell them my story,” said Ali in 2006. “I tell them how important these [polio] vaccines are. I tell them not to do something foolish like me.”

When we spoke with Mahamud Shire, Ali’s friend and collaborator, we got the unequivocal impression that everyone who crossed paths with Ali, in one way or another, simply liked him.

“He was this really happy person – happy that he was the last case of smallpox still alive, happy that he now had the chance to do his part for his community,” Mahamud says.

Mahamud, who first met Ali in 1977, says Ali’s methods were very successful.

“The way he communicated the importance of vaccination to people – his entire approach – was very effective,” Mahamud says. “He would tell people, ‘I’m vaccinated, and I’ll never get sick’.”

Getting the job done

His work, together with that of his WHO colleagues and peers, helped crush Somalia’s polio outbreak in 2005, protecting children from the paralyzing virus.

When Ali suddenly passed away in July 2013, he was still working with WHO through the Global Polio Eradication Initiative, trying to fulfill his quest.

We have never been so close to the final eradication of polio as we are today. When smallpox was eradicated, there were a total of about 52 000 cases each year of wild polio virus. In 2017, only 22 cases of wild poliovirus were reported worldwide.

Now, as with smallpox, the final steps are the most challenging. To eradicate the virus, we must reach every last child with vaccines. We must maintain political and civil society commitment, continue filling immunization gaps, and strengthen disease surveillance in difficult settings.

Ali’s work in communities across Somalia is a reflection of WHO and partner’s long-standing commitment to increasing access to vaccines – everywhere.

One of Ali’s most famous quotes, the one most often used to capture his energy, enthusiasm and firm commitment, is one that puts smallpox and polio one next to the other.

“Somalia was the last country with smallpox. I wanted to help ensure that we would not be the last place with polio too.”

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

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

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

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

Protecting all young children

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

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

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

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

Working in the midst of conflict

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

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

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

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

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

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

Ongoing determination

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

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

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

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

For more stories about women on the frontlines of polio eradication

Status: affected by circulating vaccine-derived poliovirus type 2 (cVDPV2)

Polio this week in Somalia

No case of circulating vaccine-derived poliovirus type 2 (cVDPV2) was reported this week. There are 14 cVDPV2 cases reported in 2020 and 3 cases were reported in 2019.

International Health Regulations

Somalia is classified by the International Health Regulations (IHR) as a state infected with cVDPV2 with potential risk of international spread. It is therefore subject to temporary recommendations as of August 2021.

Travel advice

WHO’s International Travel and Health recommends that all travellers to polio-affected areas be fully vaccinated against polio. Residents (and visitors for more than 4 weeks) from infected areas should receive an additional dose of OPV or inactivated polio vaccine (IPV) within 4 weeks to 12 months of travel.

More on vaccine-derived polioviruses

In Somalia, a Member State of the Organization of Islamic Cooperation, Minister of Health Dr Fawziya Abikar Nor (right), and Dr Ghulam Popal, WHO Representative for Somalia, vaccinate a child against polio. ©WHO / A.Wolasmal

The Organization of Islamic Cooperation has celebrated the efforts of its Member States to eradicate polio and is working to ensure that eradication remains at the top of national health agendas. In a resolution passed at the sixth session of the Islamic Conference of Health Ministers, held in Jeddah in early December, the Organization of Islamic Cooperation recognized the importance of ensuring that all children are consistently reached and vaccinated with the polio vaccine. It also highlighted the critical roles of Government leaders and the Islamic Advisory Group in the effort to put an end to the crippling disease.

The Jeddah Declaration

In the Jeddah Declaration, signed by representatives from all Member States, the Organization of Islamic Cooperation reiterated health as one of the basic rights of every human being and reaffirmed their belief that “… the right to health must be at the core of the global agenda.” They reiterated their support to polio eradication and to the full implementation of the Polio Eradication and Endgame Strategic Plan, and recognised the efforts of their Member States to stop transmission. In particular, members were called upon to support the work of the remaining polio endemic countries – Afghanistan, Nigeria and Pakistan – and for the Islamic Advisory Group to continue their work to support the Global Polio Eradication Initiative. The resolution issued at the end of the conference also called upon Member States and other donor entities to provide the necessary financial support that would allow the Islamic Advisory Group to continue its work.

High level support in action in Somalia

Just days after the commitment of member states was reemphasised, the Minister of Health of Somalia Dr Fawziya Abikar Nor showed her commitment to eradication by attending a polio vaccination campaign, alongside Dr Ghulam Popal, WHO Representative for Somalia. High level government commitment has been one of the most important components of eradication in some of the most challenging countries around the world.

Crowds gather as Minister of Health Dr Fawziya Abikar Nor, and Dr Ghulam Popal, WHO Representative for Somalia attend a polio vaccination campaign following the declaration. ©WHO / A. Wolasmal

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

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

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

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

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

The polio eradication programme is using technology in innovative ways to map the activities of polio workers on the ground, and ensure that expertise and support is getting to the areas where it is most needed.

More than 300 international consultants are deployed by the partners of the GPEI in some of the countries most vulnerable to polio. By strengthening surveillance, tracking the virus, identifying immunity gaps and supporting vaccination campaigns to fill them, these consultants provide an important boost to capacity in polio-affected or vulnerable countries. By using new technologies, the programme is mapping the activities of all consultants to capture the range of locations they travel to and the activities they carry out. These innovations ensure that countries receive the best support from these consultants, and that they are working where the need is greatest.

Survey 123

The introduction of this new technology means that each week, no matter where they are in the world, international consultants report on their activities using a smartphone application called Survey123. The report only takes a minute to complete, works offline and captures their location at the time of reporting. By answering questions on what activities and diseases they have been working on that week, this tool enables the GPEI to capture data in real-time and ensure international consultants are being efficiently deployed in high risk polio areas and being used to their greatest advantage.

In the below snapshot from the first week of October, reports from the consultants can be seen in Guinea, the Lake Chad region, Madagascar, Somalia, Afghanistan and Pakistan – the areas that are most vulnerable to the virus.

Getting people where they are most needed

Survey123 is also enabling the GPEI to identify changes in deployment over time. The recent notification of wild poliovirus in the Lake Chad region demonstrated the use of this clarity, by showing the movement of consultants into and around the Lake Chad region, despite insecurity and inaccessibility.

In depth analysis such as this provides greater clarity on what additional human resources are needed to respond to outbreaks or newly recognised risk areas, and indicates how rapidly GPEI resources can be used to fill important needs.

Following cases of polio being found in Nigeria in July 2016, Survey 123 was able to show the movement of international consultants into the affected areas to strengthen the response effort.

The broader benefits of polio eradication

Due to the scale of polio eradication activities even in the most remote and vulnerable areas to reach every last child, international consultants are sometimes present where other health infrastructure is weak. The capacity of the polio programme in these vulnerable areas is sometimes used to support other health initiatives, including improving routine immunisation, measles activities, communication for development and emergency response.

Analysing the collected reports from Survey 123 is giving us greater insight into the extent to which consultants are supporting other health programmes. The support provided to other health programmes shown in the map below highlights the continued benefits of the polio eradication infrastructure to other public health initiatives, giving the donors to the GPEI more bang for their buck when investing in polio eradication. The information gathered from this new technology is helping to inform transition planning efforts, providing information needed to country governments and GPEI partners as they look ahead to what should happen to the polio eradication infrastructure once the goal of a polio-free world has been achieved.

International consultants working on polio are also helping to support other health programmes. This map shows the amount of time in the different WHO Regions being spent on both polio and non-polio activities.

The Global Polio Eradication Initiative (GPEI) is highlighting the innovations that are helping to bring us closer to a polio-free world. Find out about other new approaches driving the polio eradication efforts by reading more in the Innovation Series.

The Puntland Health Ministry/UN agency convoy on the road to Jeriban District to investigate the polio outbreak. @UNICEF Somalia/2014

24 July 2014 – PUNTLAND, Somalia: UN agencies in Somalia combined forces once again to help a joint UNICEF and WHO team visit a remote district of Puntland in north east Somalia where four people have contracted polio this year.

The victims – a young father who died and three children who were paralysed – all came from Jariban district, a long drive on a dusty track from the nearest main town Galkayo in an area known for pirates and armed gangs. As these were the only four polio cases in Somalia so far this year, it was essential to visit the area to discover how the virus got there and how to stop it spreading further. However the terrain, distance, logistics and above all security concerns made it an extremely challenging proposition.

After coordination and cooperation involving at least four UN agencies, the convoy set off on at dawn on 22 July and drove seven hours from Galkayo to Jariban town, where the team met a group of elders to discuss the outbreak and raise awareness. The town has only one Mother and Child Health clinic run by the Red Crescent Society but no hospital or other facilities. The following day they drove another three hours to Towfiq village where they visited the family of the 29 year old man who had died after contracting polio.

‘This was a very sad visit – the man’s wife said she and their five children had been vaccinated but he had not. He was the only breadwinner in the family,’ said Dr. Abraham Mulugeta, WHO Somalia’s Polio Team Leader.

The three children who were paralysed by polio this year live in villages close to Towfiq that are only accessible on foot, so the team could not visit them. However experts had already met one of the children, two year old Asha, who had earlier been brought by her mother who was desperate for help to Galkayo.

While in Towfiq, the team watched the door to door vaccination campaign for children – the third round of vaccinations since the outbreak was discovered in the area in May this year. There will be another campaign in August in the whole of Mudug region and surrounding areas, for adults as well. There is no health facility in Towfiq so these campaigns are crucial to stop the virus spreading.

Vaccinators have been selected from the local community, and clan leaders and elders are being informed about the need for vaccination. More volunteers have been recruited to search actively for any cases of paralysis so that any polio can be swiftly found and the community adequately protected.

Polio vaccinators in Somalia WHO/H. Shukla — Polio vaccinators in Somalia
WHO/H. Shukla

Q: You work closely with vaccinators: who are they and what does their day look like?

Vaccinators are carefully selected by the Community District Field Assistants (DFA). Many of these vaccinators are females from local communities who have been trained on polio vaccination. They play a key role as they walk from door to door, talking to families, giving vaccine – all to protect children against polio.

Vaccinators work long hours, starting at dusk and continuing through the evening only to break briefly for lunch. They vaccinate around 100 children each day and often walk many kilometers to reach pastoralist, nomadic and migrant populations. Vaccinators’ days can be unpredictable: if a security analysis identifies a window of accessibility in a previously inaccessible area, locally recruited volunteers will quickly go in to deliver additional doses of oral vaccines.

Q: What are the biggest challenges to vaccination?

In Somalia, there are a number of challenges, starting with insecurity. In the South and Central zones, more than 35 districts are still partially or completely inaccessible due to insecurity.

Even in secure regions, implementing successful campaigns is difficult because more than half of the population lives in remote areas, and many communities are nomadic, traveling across Somalia and into Kenya and Ethiopia. We have set up 300 transit vaccination points across the country to vaccinate these people, but it remains difficult.

Another challenge is maintaining a cold chain system: with a lack of infrastructure in many parts of the country, vaccinators must use frozen ice packs to keep vaccines cold, which can be difficult when traveling across vast rural areas.

Q: How do the local populations react to vaccinators?

In general, people want vaccine. The Ministry of Health uses radio broadcasting to educate the community on vaccines and to announce polio campaigns, which is very effective because Somalia relies on the radio to obtain information. What’s more, vaccinators tend to come from the community they are working in, which helps build trust and vaccine acceptance.

Q: You work closely with vaccinators: who are they and what does their day look like?

Q: What are the biggest challenges to vaccination?

In Somalia, there are a number of challenges, starting with insecurity. In the South and Central zones, more than 35 districts are still partially or completely inaccessible due to insecurity.

Q: How do the local populations react to vaccinators?

“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

A health worker marks the finger of the President of Somalia to indicate that he has been vaccinated against polio. Courtesy Office of the President

Mogadishu, Somalia – President Hassan Sheikh Mohamoud was first in line to receive a polio vaccine as Somalia’s senior government officials gathered today at the Presidential Villa to launch Somalia’s first-ever polio campaign to vaccinate adults as well as children. This round of the campaign runs from 12 – 19 June, targeting different areas.

In Banadir Region – which includes the capital Mogadishu, where the first case was identified – adults as well as children are being given polio vaccination in an effort to stop the outbreak before it spreads into other regions and possibly into neighbouring countries. While polio mainly affects young children, adults can also catch the virus.
Somalia reported its first case of wild polio for more than six years on 9 May. Already 12 children have been paralyzed , including a 13-year old boy, all in southern Somalia. A further five cases have also been confirmed across the border in Kenya.

As part of the effort to stop one of the world’s only polio outbreaks in a previously polio-free country, the Prime Minister Abdi Farah Shirdon, Speaker of the House, Mohamed Osman Jawari, the Minister of Defence Abdikarin Hajji Mohamud Fiqi,and the Minister of Human Development and Public Services Dr Maryan Qasim all lined up to receive the drops of the oral polio vaccine.

“Polio has returned to Somalia after more than six years and now threatens not only our children but anyone who has not been vaccinated,” said President Hassan. “This is why we will be vaccinating everyone in Banadir, mothers, fathers, teenagers and elders as well as children. I call on the entire community to support this important health campaign. The vaccine is safe and effective and I will take it to ensure that I am protected.”

The launch was attended by the United Nations Humanitarian Coordinator, Philippe Lazzarini and the World Health Organization and UNICEF representatives Dr Ghulam Popal and Sikander Khan, who also took the vaccine.

“The leadership and oversight that both the President and Prime Minister have shown today in launching this polio campaign should be commended,” said Philippe Lazzarini.

“Since confirmation of the polio outbreak on 9 May, two campaigns have already been conducted in Somalia delivering lifesaving vaccines to children at risk of life long paralysis. This week more than four million Somalis will be vaccinated against polio in just eight days – an incredible achievement. The United Nations will continue to support the Somali people in every way possible in their efforts to rid the country of this preventable disease.”

Health experts are worried that the polio virus could spread into other parts of Somalia, including areas where many children and adults have not received adequate vaccinations, as well as internationally. To protect against any such spread, the response is taking several approaches. These include vaccination of different age groups and the set-up of permanent vaccination posts in places bordering areas with large numbers of unvaccinated people. Campaigns will continue to be conducted until polio is once more eliminated from Somalia.

The President expressed confidence that Somalia can again become polio free and thanked partners and supporters gathered at the launch.

“Somalia with the help of many partners and friends has eradicated polio before. On behalf of the Somali people I would like to thank the United Nations, WHO and UNICEF for their continued efforts to assist us develop as a nation with strong health systems and services. Together we can make a stronger, better, healthier Somalia where people can live and flourish free from the threat of preventable diseases like polio.”

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.

A Somalian child is vaccinated against polio during a nationwide immunization campaign Christine McNab/WHO

NAIROBI, Kenya, 20 March 2011 – On the eve of celebrating four years without polio in Somalia, the country kicks off National Immunization Days on Sunday 20 March, with a focus on ensuring that no eligible child is left unvaccinated during the three days of the campaign. During 2011, two rounds of polio vaccinations are planned.

WHO Representative for Somalia, Dr Marthe Everard, noted the success of the polio immunization efforts in Somalia. “Somalia marks on 25 March 2011 the 4th anniversary of being polio-free. This shows that polio can be eradicated everywhere, even in the most challenging and difficult settings,” she said. “With Somalia still being at risk from polio virus importation and spread from countries where the virus is still circulating, we must remain ever-vigilant to do all efforts to maintain high immmunity of children under the age of five.”

This week’s National Immunization Days will play a critical role in protecting the Somali children from the crippling disease. During these days, over 1.8 million children under the age of five will be targeted across the country. The campaign is being spearheaded by health authorities at national and local levels, in collaboration with WHO, UNICEF, other polio eradication partners and the Somali communities.

UNICEF Representative for Somalia, Rozanne Chorlton, underlined the need to reach every child, saying “If we are to ensure that no new cases of polio emerge in Somalia, vaccination teams must be able to access every community, every household, and every child aged under-five.”

Insecurity and inaccessibility in some parts of the country, especially in South Central regions, remains a major concern to reach out to all targetted children . South Central Somalia is home to an estimated 70% of all children aged under-five. In 2010, over 800,000 children missed out on the opportunity to receive the two polio drops. The WHO and UNICEF Representatives have called on all parties to the ongoing conflict to respect the humanitarian mandate of the vaccination teams, and guarantee their safe passage across the country.

The Somali National Immunization Days are supported through financial contributions from a number of donors including the governments of Italy, Germany, and Norway, the US Centers for Disease Control and Prevention (CDC), Swedish International Development Cooperation Agency (SIDA), UK Department for International Development (DFID) and Rotary International. Each round of polio vaccination is estimated to cost around US$ 1 million.

Country: Somalia

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