Outbreak response

For many of the women and men who spent their careers fighting polio, retirement offers not rest and relaxation, but a continuation of their life’s work towards eradication. Across the Eastern Mediterranean Region, once and forever polio fighters are inspiring the next generation of eradicators with their commitment to the cause, and belief in the benefits of a polio-free future.

Meet some of the Region’s most beloved polio fighters as they look back on their careers and try to capture their unusual motivation to continue their quest, as long as it takes.

Dr Ali Farah, Somalia

Back in 1997, during the devastating civil war, Dr Ali Farah started a pilot project to conduct Somalia’s first-ever national immunization days. Today, that pilot project is one of the reasons Somalia hasn’t seen a case of wild poliovirus in more than seven years.

Dr Farah retired in 2015 after years of hard work in a highly complex, volatile, and risky context. Yet he continues to fight polio by providing technical support to the polio programme team, participating in social mobilization activities and training district-level polio officers and vaccinators.

“I always feel that we must keep working to fight polio. It’s a humanitarian action,” he said. “Technical staff still call me occasionally to receive guidance about AFP cases and other technical areas. I feel so happy to provide advice and support when needed.”

Dr Farah has also utilized his long experience with the polio programme to support COVID-19 immunization in Somalia.

“This COVID-19 campaign wouldn’t succeed if there was no polio infrastructure. We used the polio system and network to make it happen,” he said.

Professor Elsadig Mahgoub, Sudan

After completing his bachelor’s degree in 1969, Professor Elsadig Mahgoub trained as a physician and epidemiologist. He devoted his career to infectious diseases, largely focusing on disease surveillance. In February 2000, he focused his efforts on polio, particularly surveillance for acute flaccid paralysis (APF), the primary symptom of paralytic polio.

Although he retired four years later, Prof Elsadig hasn’t stopped working or providing his technical support to polio programmes in Sudan and across the Region.

“I’m obliged to continue working. My enjoyment is when I see progress towards polio eradication,” he said. “The service we’re providing is critical. We always need to be vigilant to avoid any setback to our achievements towards polio eradication. When we end polio for good, then I will truly resign.”

Dr Mohammed Hajar, Yemen

Yemen’s Dr Mohammad Hajar is one of the oldest, most veteran health professionals in Yemen, having served the health sector and combated infectious diseases, including polio, for around 50 years.

In 1977, Dr Hajar was one of the founders of Yemen’s expanded programme on immunization. He played a major role in planning and conducting the first-ever polio campaigns in the country, and he contributed substantially to setting up the epidemiological surveillance system for polio and other diseases.

“Even after reaching retirement age in 2009, I continued to work for the polio programme, which I consider as one of my sons. Until now, I follow up and evaluate the activities of the immunization programme and polio campaigns,” said Dr Hajar.

“I had the privilege of working with nine WHO representatives and more than ten ministers of health in Yemen to help Yemen reach a polio-free status.”

Dr Ibrahim Barakat, Egypt

When Dr Ibrahim Barakat was appointed as a manager of Egypt’s expanded programme on immunization in 2000, he was determined to achieve something remarkable – a polio-free Egypt.

“It was a hard journey, but we did it. Egypt was declared polio-free in 2006,” he said.

In 2009, Dr Barakat retired, but he hardly rested. “I cannot stop working when it comes to polio eradication. I take great comfort in working hard to combat this disease whether in Egypt or any place in the world.”

After 12 years of retirement, Dr Barakat still considers his office in the Ministry of Health as “a second home.”

“I continue going to the office every working day to plan, supervise and evaluate different polio activities, including polio vaccination campaigns, risk assessment and AFP surveillance. I can never be complacent,” he said.

“This is my life. My real retirement starts when I see this disease completely wiped out from all parts of the world.”

Mr. Alam and Mrs. Fatima, Pakistan

Khursheed Alam, 68, and Kaneez Fatima, 56, are a married couple who have spent 25 years working in the polio eradication programme in Batagram district of Khyber Pakhtunkhwa province, Pakistan.

Rain or shine, Mr. Alam and Mrs. Fatima have taken part in countless door-to-door vaccination campaigns, helping to vaccinate thousands of children.

“Now those little children have grown up, some have gotten married and had children who we have also vaccinated. This is fascinating and rewarding for us,” said Mr. Alam. “Wherever we go, people welcome us and don’t let us go without offering food.”

Mrs. Fatima personally knows every child in her neighborhood, including the newborns. She maintains close relationships with the mothers in her community and gives them health and hygiene advice.

Despite their age and medical complications such as asthma, their commitment to the polio programme remains strong.

“We take our work as a divine duty to serve our community for the sake of God. To see healthy children with smiles on their faces is our reward. This has kept us going for so long,” said Mrs. Fatima.

Dr Faten Kamel, Egypt

Dr Faten Kamel took a leading role in polio eradication efforts in the 1990s and early 2000s – years where the Global Polio Eradication Initiative made considerable gains against polio.

Growing up in Alexandria, Egypt, Dr Faten was exposed to the life-altering effects of polio on the people around her. She saw the human toll of the disease, and was inspired by the work of her father, a surgeon and Rotarian.

“We pushed the boundaries to make the programme more effective, shifting to house-to-house vaccination, detailed microplanning and mapping, retrieval of missed children and independent monitoring,” she said.

For Dr Faten, every child can, and must, be reached.

“If someone comes and says this area is inaccessible, this is not an answer for me. I ask: What should we do to reach? I like to make use of the ideas and experience that come from local people,” she said.

Dr Faten is proud to continue to be part of the polio eradication programme and looks forward to the day when polio eradication is achieved. After that, she plans to spend more time with her family in Australia.

“As a grandmother, I am especially determined to finish the job. I want my grandkids to grow up in a world free of polio. This will be my contribution to their futures.”

11 October 2021

Following careful review of safety and genetic stability data from mass immunization campaigns conducted with the novel oral polio vaccine type 2 (nOPV2), the Strategic Advisory Group of Experts on immunization (SAGE) today endorsed the transition to the next use phase for the vaccine. WHO’s independent Global Advisory Committee on Vaccine Safety (GACVS) and SAGE confirmed that there were no major safety concerns associated with nOPV2 after reviewing data from campaigns that used more than 65 million doses in Nigeria, Liberia, Congo and Benin earlier this year. Rollout of nOPV2 began in March and to date approximately 100 million doses have been administered to children across seven countries.

This decision marks the end of the vaccine’s initial use period and the removal of certain use criteria for countries affected by circulating vaccine-derived poliovirus type 2 (cVDPV2) outbreaks. It means that more countries will be eligible to use the vaccine under its WHO Emergency Use Listing (EUL) recommendation, once verified for use and as supply allows.

“The move is a positive and welcome advancement as GPEI and countries strive to bring cVDPV2 outbreaks to an end, and sees the achievement of a milestone outlined in goal 2 of our strategic plan: the goal to stop cVDPV2,” commented Aidan O’Leary, WHO’s director of polio eradication. “Not only does the decision inspire further confidence in nOPV2 as a safe and effective tool, it will facilitate a smoother preparedness process for countries looking to use the vaccine in the future,” he added.

“We are very pleased with the SAGE’s endorsement of transitioning nOPV2 to the next rollout phase. Progress like this is a result of strong partnerships at every level and we must continue forging forward together, using innovative tools like nOPV2, to reach every last child and end all forms of polio for good,” said Akhil Iyer, the UNICEF Director of Polio Eradication.

Ananda Bandyopadhyay, deputy director from the Bill & Melinda Gates Foundation and co-lead of GPEI’s nOPV2 Working Group stated, “Today is an important milestone in the road to polio eradication. Innovation has always been key to progress, and this tool – the first vaccine ever to be approved under WHO’s EUL pathway – is a shining example of how the GPEI responds to challenges, but the work is far from over.” BMGF is a core partner in GPEI and has funded the development of nOPV2 from its inception.

Requirements for rollout

Prior to this transition, countries were required to meet an additional set of strict criteria to use nOPV2 during its initial use period. These were developed by GPEI and endorsed by SAGE to allow for even closer monitoring of nOPV2’s performance during its introductory phase and early large-scale uses. While countries no longer need to meet these initial use protocols, use of nOPV2 remains subject to specific post-deployment requirements under EUL, such as monitoring for safety and effectiveness.

“As we move forward into the next phase of the vaccine’s rollout, countries will still need to meet special use requirements, but they will be less onerous,” said Simona Zipursky, WHO co-lead of the GPEI’s nOPV2 Working Group. “GPEI will continue to work with all countries who wish to roll out nOPV2 to help them meet these remaining criteria,” she added.

Optimal response with available vaccine

In addition to those who have already rolled out the new tool, 16 other countries are also verified as ready to use nOPV2 by GPEI and a further 17 are in the midst of preparations. More nOPV2 campaigns are due to launch later this year, however, supply of the vaccine is limited.

Active cVDPV2 outbreaks are ongoing in more than 20 countries across Africa and Asia and there have been recent detections of the virus in Europe. COVID-19 has impacted production of the vaccine, including by limiting supplies, available personnel and manufacturer capacity. GPEI is working with nOPV2’s manufacturer, Bio Farma, to increase supply as soon as possible and is accelerating efforts to bring a second manufacturer online. A GPEI prioritization framework will guide distribution of nOPV2 for the immediate term, until supply is increased.

“We are seeing sharp rises in demand for nOPV2, which is testament to the vaccine’s field performance, and we are working to increase supply as quickly as feasible,” said O’Leary. “We must be very clear though, that outside of nOPV2, there is no shortage of effective type-2 containing oral polio vaccines, and countries should not delay in responding to an outbreak. In line with SAGE’s guidance they should respond rapidly with whichever of the vaccines (mOPV2/nOPV2) is available to them,” he said.

With nOPV2 not yet WHO-prequalified, monovalent oral polio vaccine type 2 (mOPV2) ̶ nOPV2’s counterpart and close relative ̶ remains available to countries for outbreak response. The vaccine has a track record of successfully stopping cVDPV2 transmission and from 2019 to 2020, nearly 80% of outbreaks were closed following just two rounds of immunization. Trivalent oral polio vaccine (tOPV), containing all three vaccine serotypes, may be a more appropriate tool in situations where there is co-circulation of wild polio virus type 1 (WPV1) and cVDPV2.

“All OPVs can stop outbreaks,” said O’Leary. “Regardless of which vaccine is used, the key for any successful [outbreak] response is achieving high levels of vaccination coverage and quickly. That is what we need to remain mindful of and achieve. nOPV2 is only one of the effective vaccines in our toolkit and GPEI will continue to support countries to respond as rapidly as possible to outbreaks, as per the SAGE guidance.”

Next steps for nOPV2 development

Polio remains a Public Health Emergency of International Concern (PHEIC) under International Health Regulations, enabling nOPV2’s continued use through EUL. Field data collection and analyses will be ongoing to support the vaccine’s prequalification and full licensing, expected in 2023. Among other studies, a phase III clinical trial is currently underway in the Gambia.

Mohamed, the Regional Polio Eradication Officer for Banadir, Somalia, participates in an integrated immunization campaign held in September 2020 with strict COVID-19 safety measures in place. In addition to their polio duties, programme personnel have provided substantial support to the pandemic response. ©WHO/Somalia

As COVID-19 reached Somalia, Mohamed readied himself to respond. For years, he had been building strong relationships with local health officers and communities to deliver polio vaccines to every child. Now, he would use those relationships to try to track the spread of the pandemic.

In Nigeria, Dr Rosemary Onyibe, a Polio Eradication Zonal Coordinator for WHO, felt her duty was calling. “My expertise is needed to serve my community,” she remembers thinking. Within days, she was working on Nigeria’s COVID-19 response.

These two individuals are part of a team of 5923 polio eradication personnel, who pivoted in a matter of weeks to fight COVID-19 in some of the most vulnerable settings in the world. A recent report published by WHO comprehensively documents the significant role played by polio eradication personnel during the pandemic, and urges strong action to sustain this network to deliver essential public health services after polio is eradicated. By doing so, we can ensure we are ready to respond to established and emergent diseases in future.

The polio programme has a long history of stepping up during health emergencies to fill the gaps that no one else can. As COVID-19 changed lives around the globe, polio staff led outbreak response teams and trained laboratory staff to detect the virus. Polio disease surveillance officers searched for COVID-19 cases and thousands of frontline polio workers shared information on the disease with their communities. In some countries, polio emergency operations centres were converted for the pandemic response. As the situation has evolved, so have polio programme contributions – in coming months, the programme plans to use its expertise in immunization to help to deliver COVID-19 vaccines, as well as urgently reach at least 80 million children who have missed out on vital vaccines during the pandemic.

Dr. Samreen Khalil, WHO Polio Eradication Officer in Pakistan, collects a sample from Muhammad Shabir in order to test for COVID-19 in July 2020. ©WHO/Blink

As one of WHO’s largest operational workforces, comprising nearly 18% of the organization’s programme budget in 2020-21, the widespread utilisation of polio-funded infrastructure and human resources for COVID-19 has brought into focus why we must retain this network for the future. When polio is eradicated, funding for the programme’s vast infrastructure will end. Through the “polio transition” process, WHO is working to transfer the polio network to serve other public health goals, including the broader immunization, health emergencies and health systems strengthening agenda. This is no easy task – detailed planning and dedicated funding is needed to permanently integrate assets and functions into national health systems.

The report finds that COVID-19, whilst presenting challenges, provides an opportunity to accelerate this “transition” process. In the coming months, WHO regional offices will begin to launch ‘integrated public health teams’, which will bring together individuals with expertise in polio eradication, emergency response and immunization to work collaboratively on the next stages of COVID-19 response and recovery. Showing “transition in action”, these teams will exemplify one way via which health systems could be supported in future. Simultaneously, WHO is continuing work to support countries to develop detailed plans modelling how polio capabilities can be sustained.

The critical role that polio assets have played in tackling multiple health emergencies, in supporting immunization activities and in COVID-19 response, demonstrate that these assets have a clear role to advance future national and global health security. This will also help to sustain a polio-free world. In the South East Asia Region, which was certified free of wild polio in 2014, almost 2600 polio and immunization staff used their experience of managing immunization programmes in emergency settings to respond to COVID-19. Their work included undertaking training of health staff and village governors in Indonesia, acting as a focal point for the COVID-19 response in Cox’s Bazar, Bangladesh, and drafting vaccination plans for Rohingya refugees. In Nepal, the network supported COVID-19 field investigations and case clusters, whilst in Myanmar, personnel formed part of the pandemic incident management team, and supported disease surveillance. These contributions underline that sustaining polio and immunization capacity puts us in a better position to respond when health crises arise.

The report also details how polio assets were able to reach nomadic communities in Kenya to warn them about virus spread, deliver an integrated digital platform for tracking case investigations across the African region, and answer 70 000 calls a day through a polio call centre adapted for COVID-19 in Pakistan. In Uttar Pradesh, India, polio micro-plans were adapted to survey 208 million people twice in three months for COVID-19, resulting in the identification of over 200 000 individuals with symptoms of the virus. Such diversity of operations plays a key role in protecting our collective health.

In a time when sturdy public health systems are particularly vital, we must ensure that polio infrastructure is transitioned to tackle pressing health issues long into the future.

For a detailed costing of polio contributions to COVID-19 response and a country-level breakdown of how the polio network stepped up, please see the report annexes.

Dr. De Sousa has dedicated her career to ending polio in Angola. ©Alda De Sousa

From her first polio vaccination campaign in 1997 to the present day, Dr. De Sousa has never lost her passion for increasing access to immunization. The National Expanded Program on Immunization (EPI) Manager for Angola, she remembers her first impressions of the country, “At the time, I could see that most children in the country were not vaccinated and I was excited to help them.”

From the outset, she knew that taking on polio eradication would be challenging. “Angola had just emerged from an armed conflict and there were areas that were very difficult to access, due to dilapidated roads, broken bridges and mining activity, and for that reason there was low routine vaccination coverage. Nevertheless, I felt that I had a duty to fulfill for our children, so I accepted the challenge.”

In 1998, Dr. De Sousa was appointed by the National Directorate of Public Health to help implement the Epidemiological Surveillance System for Acute Flaccid Paralysis (AFP) – one of the primary symptoms of polio. It was a position that required grit and resilience.

She explains, “This was a big responsibility because highly sensitive surveillance for AFP, including immediate case investigation and specimen collection, are critical for the detection of wild poliovirus. AFP surveillance is also critical for documenting the absence of poliovirus circulation for polio-free certification.”

Dr. De Sousa speaks to a community member in Angola. ©Alda De Sousa

“One of my most vivid memories of the programme is from 1999 when I was trying to reach conflict-affected areas after a polio epidemic had registered more than 1190 cases and 113 deaths. I was early in my career with only two years of service and the sheer number of cases and deaths led me to be proactive and persistent in my day-to-day activities toward the eradication of the disease.”

“Another standout moment occurred on the second time that I went to coordinate a vaccination campaign in the province of Moxico; one of the vehicles in our convoy triggered a mine, so we were forced to stop the vaccination campaign as our colleagues were stranded in conflict zones for a few days. This incident captures the difficult circumstances we were operating in as health workers.”

Eradicating wild virus in Angola

For years the polio team worked to improve operations to detect polio and deliver vaccines, but the virus fought back. After registering a last case of indigenous wild poliovirus in September 2001, Angola recorded four successive outbreaks imported from India and Congo. Dr. De Sousa remembers that this caused many people to doubt that the eradication of polio would ever be possible.

“But I refused to be discouraged. I’ve never backed down from a challenge and I don’t plan to soon.”

After years of work, Angola finally received wild polio-free status in November 2015. Dr. De Sousa describes it as her proudest moment.

“I felt that I made a great contribution to my country and our children as the person managing the Extended Program on Immunization in Angola.”

A new challenge

In 2019, Angola’s immunization team faced a new challenge when the polio programme detected an outbreak of circulating vaccine-derived polio type 2, a type of polio that emerges in places with low immunity. Dr. De Sousa again found herself at the forefront of the action, starting by supporting the Government to respond with vaccination campaigns.

One of her key tasks since has been recruiting new immunization health professionals, who can help reach the children missed by routine immunization and polio campaigns. She explains, “my goal is to train my colleagues so that we can work together to reach the vast number of Angolan children missing out on lifesaving vaccines.”

In July 2020, Angola held its first polio campaign after a pause on vaccination activities in the early months of the COVID-19 pandemic. More than 1.2 million children were reached by over 4000 vaccinators.

Gender and leadership

Dr. De Sousa explains that being a woman leader in Angola isn’t easy. “It requires a lot of time, dedication and a balance with domestic, family, and social life, which has not been easy to manage. However, with the help of God and my family – especially my husband – I am managing to carry out my work.”

“It has all been worth it for the results I’ve helped to achieve, and even though we have some way to go in relation to vaccination coverage, I’m grateful for the opportunity to ensure the health of our children and serve my country.”

In Angola, at the provincial and municipal level, there are very few women compared to men. However, in public health programmes at the national level, women outnumber men. Dr. De Sousa says that, “In general, I think there should be more women leading and administering vaccination programmes”.

In 2021, the polio programme is aiming to implement more outbreak response vaccination rounds to reach children with low immunity to the poliovirus. Driven by her passion and sense of duty, Dr. De Sousa will continue to be on the frontlines of this effort.

13 Novembre 2020 – Aujourd’hui, le programme de préqualification de l’Organisation mondiale de la Santé (OMS) a émis une recommandation d’autorisation d’utilisation d’urgence au titre du protocole EUL pour un nouveau vaccin antipoliomyélitique oral de type 2 (nVPO2). Le déploiement du vaccin sera ainsi autorisé pour une utilisation initiale limitée dans les pays touchés par des flambées de poliovirus circulant dérivé d’une souche vaccinale de type 2 (PVDVc2).

L’émission de cette recommandation au titre du protocole EUL pour le nVPO2 vient au terme de plusieurs mois d’analyse rigoureuse des données issues d’essais cliniques qui ont démontré l’innocuité du vaccin et une protection contre la poliomyélite comparable à celle fournie par le VPO monovalent de type 2 (VPOm2) actuellement utilisé.

Le nVPO2 est une version modifiée du VPOm2, mis au point depuis près de dix ans grâce à la collaboration d’un vaste réseau d’experts mondiaux.^[1] Outre son innocuité et son efficacité, les essais cliniques montrent que ce vaccin est génétiquement plus stable que le VPOm2, ce qui réduit nettement la probabilité qu’il retrouve une forme pouvant entraîner une paralysie dans les milieux présentant un faible niveau d’immunité. Par conséquent, le nVPO2 réduit le risque de voir apparaître de nouvelles flambées de PVDVc2, même si le VPOm2 demeure un vaccin sûr et efficace qui protège contre la poliomyélite et qui a permis d’empêcher des flambées de PVDVc2 par le passé.

Qu’est qu’une autorisation d’utilisation d’urgence ?

La procédure EUL de l’OMS, anciennement connue sous le nom de procédure d’évaluation et d’homologation en situation d’urgence de l’OMS (Emergency Use Listing, EUL), a été créée pour évaluer et répertorier les nouveaux vaccins, traitements et produits diagnostiques qui ne sont pas encore homologués afin qu’ils puissent être utilisés de façon précoce et ciblée en réponse à une urgence de santé publique de portée internationale (USPPI).

Ce mécanisme a déjà été utilisé avec succès pour accélérer la mise à disposition de produits diagnostiques pour les virus Ebola et Zika et, fin septembre, une autorisation d’utilisation d’urgence au titre du protocole EUL a été émise pour un test de diagnostic rapide de l’antigène de la COVID-19 qui donne des résultats en 30 minutes.

Pour qu’un produit reçoive une recommandation d’utilisation au titre du protocole EUL, l’OMS et des experts indépendants examinent les données cliniques existantes afin de déterminer son innocuité, sa qualité et son efficacité, et la décision d’émettre une recommandation est fondée sur une évaluation approfondie des avantages et des risques au vu de l’urgence de santé publique.

Pendant toute la durée d’utilisation d’un produit au titre du protocole EUL, on continue à recueillir des données et à les suivre de près afin de déterminer si ce produit peut recevoir une autorisation d’utilisation d’urgence au titre du protocole EUL.

Pourquoi le protocole EUL est-il utilisé pour le nVPO2 ?

Compte tenu des situations d’urgence actuelles concernant le PVDVc2 en Afrique et en Asie et du fait que la poliomyélite est considérée depuis 2014 comme une urgence de santé publique de portée internationale (USPPI), au mois de février, le Conseil exécutif de l’OMS a prié instamment les États Membres d’accélérer les procédures d’autorisation de l’importation et de l’utilisation du nVPO2 au titre du protocole EUL au vu des résultats prometteurs de ce vaccin dans la lutte contre le PVDVc2.

Les flambées de PVDVc2 se produisent lorsque la souche affaiblie du poliovirus contenue dans le vaccin antipoliomyélitique oral (VPO) peut se propager au sein de populations sous-vaccinées pendant une période prolongée et retrouver une forme pouvant entraîner une paralysie. L’année dernière, il y a eu 366 cas de PVDVc2 dans le monde. Au cours des dix premiers mois de 2020, on a recensé 588 cas (données au 28 octobre 2020).

Outre la décision du Conseil exécutif, le Groupe stratégique consultatif d’experts (SAGE) sur la vaccination a approuvé dans son principe un cadre définissant les critères d’une utilisation initiale pour permettre le déploiement rapide et ciblé du nVPO2. À la suite de sa réunion du 5 au 7 octobre, le SAGE a également approuvé, sur le principe, que le nVPO2 devienne le vaccin de choix pour lutter contre les flambées de PVDVc2, une fois que l’examen de la période initiale d’utilisation sera terminé et que toutes les conditions d’utilisation de ce nouveau vaccin seront remplies.

Des études cliniques sur le nVPO2, menées en Belgique et au Panama, ont montré que le vaccin était sûr et efficace pour protéger contre la poliomyélite, et qu’il présentait moins de risque de retrouver une forme pouvant entraîner une paralysie dans des populations sous-vaccinées.

Au cours des six derniers mois, le programme de préqualification de l’OMS a minutieusement analysé les données émanant de ces études afin de déterminer si le nVPO2 répondait aux exigences du protocole EUL. Grâce à la recommandation au titre de ce protocole, le nVPO2 constitue désormais un moyen supplémentaire de la Stratégie de lutte contre le PVDVc2 de l’IMEP.

Quelle est la période d’utilisation initiale du nVPO2 ?

Comme le précise le cadre approuvé par le SAGE, la période d’utilisation initiale durera environ trois mois après la première utilisation du nVPO2 au titre du protocole EUL, et ce vaccin sera déployé de manière mesurée dans la lutte contre les flambées de PVDVc2.

L’IMEP travaille étroitement avec les pays touchés par des flambées de PVDVc2 afin de déterminer où le nVPO2 peut être utilisé pendant la période initiale. Cette décision s’appuiera notamment sur la situation épidémiologique actuelle et sur la capacité du pays à mener la surveillance renforcée requise en termes d’innocuité et d’efficacité du nVPO2 pendant son déploiement.

Il est important de noter que toute décision d’utiliser le nVPO2 sera prise par le pays et soumise à l’accord des responsables concernés dans le pays et des autorités de réglementation nationales. Le VPOm2 restera disponible pour faire face aux flambées dans les pays qui ne répondent pas aux critères d’une utilisation initiale ou qui décident de ne pas utiliser le nVPO2 initialement.

L’utilisation initiale du nVPO2 devrait avoir lieu environ cinq à huit semaines après la publication de la recommandation d’utilisation au titre du protocole EUL, en tenant compte des processus réglementaires et des approbations définitifs, de l’achat des vaccins, de l’expédition et de l’état de préparation du pays. L’IMEP continue de travailler en étroite collaboration avec les pays à haut risque, en les aidant à se préparer à utiliser le nVPO2.

Perspectives d’avenir

On continuera à recueillir des données sur le nVPO2 pendant la période d’utilisation initiale, en plus des études en cours et de celles qui seront menées prochainement.

Parallèlement à l’utilisation initiale du nVPO2, l’IMEP poursuivra la mise en œuvre des autres volets de sa stratégie globale de lutte contre les flambées de PVDVc2. Cette stratégie consiste notamment à optimiser la riposte aux flambées en utilisant le VPOm2, à renforcer la vaccination systématique avec le vaccin antipoliomyélitique inactivé dans les zones à haut risque et à veiller à ce que les stocks de VPO soient suffisants pour que chaque enfant puisse en bénéficier.

En savoir plus sur le développement de nVPO2

^[1] Le nVPO2 a été mis au point grâce à un partenariat mondial réunissant de multiples agences et experts internes et externes à l’Initiative mondiale pour l’éradication de la poliomyélite (IMEP). Il s’agit notamment de Bio Farma, de l’Université d’Anvers, de la FIDEC (Fighting Infectious Diseases in Emerging Countries), du NIBSC (National Institute for Biological Standards and Control), de l’UCSF (University of California San Francisco), des CDC (Centers for Disease Control and Prevention des États-Unis), de PATH et de la Fondation Bill et Melinda Gates.

Version française

13 November 2020 – Today, the World Health Organization’s (WHO) Prequalification (PQ) program issued an Emergency Use Listing (EUL) recommendation for the type 2 novel oral polio vaccine (nOPV2). This will allow rollout of the vaccine for limited initial use in countries affected by circulating vaccine-derived poliovirus type 2 (cVDPV2) outbreaks.

The PQ program’s issuance of an EUL recommendation for nOPV2 follows months of rigorous analysis of existing data from clinical trials of the vaccine, that have shown it to be safe and provide comparable protection against polio as the currently used type 2 monovalent OPV (mOPV2).

nOPV2 is a modified version of mOPV2 and has been in development for close to a decade thanks to the collaboration of an extensive network of global experts.^[1] In addition to nOPV2’s safety and efficacy, clinical trials show the vaccine to be more genetically stable than mOPV2, making it significantly less likely to revert into a form which can cause paralysis in low immunity settings. This means a reduced risk of seeding new cVDPV2 outbreaks compared to mOPV2, which remains a safe and effective vaccine that protects against polio and has successfully stopped cVDPV2 outbreaks in the past.

What is an Emergency Use Listing?

The WHO’s EUL procedure, previously known as the Emergency Use Assessment and Listing (EUAL) procedure, was created to assess and list new and yet-to-be licensed vaccines, therapeutics and diagnostics to enable their early, targeted use in response to a Public Health Emergency of International Concern (PHEIC).

This mechanism has previously been used to successfully accelerate the availability of diagnostic products for Ebola and Zika virus, and in late September, EUL was issued for an antigen rapid diagnostic test for COVID-19 that provides results within 30 minutes.

For a product to receive an EUL recommendation, existing clinical data is scrutinized by WHO and independent experts to determine its safety, quality and efficacy, and a decision to list is based on a thorough benefit-risk assessment considering the public health emergency.

Throughout a product’s use under EUL, data continues to be collected and closely monitored to help inform decisions about whether the emergency listing can be maintained.

Why is EUL being used for nOPV2?

In light of ongoing cVDPV2 emergencies across countries in Africa and Asia, coupled with polio’s status as a Public Health Emergency of International Concern (PHEIC) since 2014, the WHO Executive Board urged Member States in February to expedite the processes for authorizing the importation and use of nOPV2 under the EUL given data showing the vaccine’s promise against cVDPV2s.

cVDPV2 outbreaks occur when the weakened poliovirus strain contained in the oral polio vaccine (OPV) is able to spread among under-immunized populations for a prolonged period and reverts to a form that can cause paralysis. Last year, there were 366 cases of cVDPV2 globally, while in the first 10 months of 2020 alone there have been 588 cases (data as of 28 October 2020).

In addition to the Executive Board decision, the Strategic Advisory Group of Experts (SAGE) on Immunization endorsed in principle an initial use criteria framework to support early, targeted nOPV2 rollout. Following its 5-7 October meeting, SAGE also endorsed, in principle, that nOPV2 become the vaccine of choice in response to cVDPV2 outbreaks after review of the initial use period is completed and all requirements for nOPV2’s use are met.

Clinical studies on nOPV2, conducted in Belgium and Panama, have shown the vaccine to be safe and efficacious in protecting against polio, while carrying less risk of reverting into a form that can cause paralysis in under-immunized populations.

Data from these studies has been subject to WHO PQ program’s rigorous analysis for the past six months to determine if nOPV2 meets requirements for EUL. The EUL recommendation means nOPV2 is now an additional tool in the GPEI’s Strategy for Control of cVDPV2.

What is the initial use period for nOPV2?

The initial use period, as detailed in the SAGE-endorsed framework, will last for approximately three months following the first use of nOPV2 under EUL and will see nOPV2 deployed in a measured way to tackle ongoing outbreaks of cVDPV2.

The GPEI is working closely with countries affected by cVDPV2 outbreaks to determine where nOPV2 can be used during the initial period. Factors that will inform this decision include the current epidemiology and the country’s ability to conduct the required enhanced monitoring of nOPV2’s safety and effectiveness during rollout.

Importantly, any decision to use nOPV2 will be country-led and subject to agreement from relevant in-country officials and national regulatory authorities. mOPV2 will remain available for outbreak response in countries that do not meet initial use criteria or choose not to use nOPV2 initially.

It is anticipated that the initial use of nOPV2 will take place approximately five to eight weeks after the EUL recommendation issues, factoring in final regulatory processes and approvals, vaccine procurement, shipping and country readiness. GPEI continues to work closely with high-risk countries, supporting with preparations to use nOPV2.

Looking ahead

Data on nOPV2 will continue to be collected during the initial use period, in addition to further nOPV2 studies that are underway and will be conducted in the near future.

Alongside nOPV2’s initial use, the GPEI will continue to implement the other strands of its comprehensive strategy to control cVDPV2 outbreaks. This includes optimizing outbreak response using mOPV2, strengthening routine immunization with inactivated polio vaccine in high-risk areas, and ensuring adequate supplies of OPV are available to reach every child.

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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 vaccine is administered to a child during a polio immunization campaign. ©WHO/AFRO

From a small prefabricated container where the walls host detailed maps and desks prop up computer screens beaming data, tables and graphics, the Rapid Response Team at the World Health Organization’s (WHO) Regional Office for Africa coordinate polio outbreak response. The team work across the continent, where 12 countries are battling the vaccine-derived strain of the virus.

Dr Ndoutabe Modjirom, a former Chadian university professor-turned WHO medical officer, coordinates the multi-agency team, which was formed in September 2019. It is composed of twenty experts in operations and vaccination management, epidemiology, logistics, and communications. They are drawn from the core partners of the Global Polio Eradication Initiative (GPEI): WHO, the United Nations Children’s Fund (UNICEF), Rotary International, the US Centers for Disease Control and Prevention, the Bill & Melinda Gates Foundation, and Gavi, The Vaccine Alliance.

The team is mobilized whenever a new polio outbreak is confirmed in the African region.

The first 72 hours

“Our work 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 after the lab confirmation means that the poliovirus is circulating and risks infecting more children,” says Dr Modjirom.

Within the first 72 hours, the Rapid Response Team deploys Team A. This team includes the GPEI Coordinator alongside an epidemiologist, an operations officer, a vaccine manager and a communicator for development. The team works closely with the health authorities in the affected country along with the relevant WHO and UNICEF country offices to prepare a risk assessment and outbreak response plan. The emergency response vaccination campaign, called ‘Round Zero’, starts within 14 days.

Team B takes over from Team A after the first eight weeks and continues the outbreak response activities.

According to standard operating procedures for responding to outbreaks, the polio programme must implement three rounds of high-quality vaccination campaigns in response to every outbreak. Parallel to vaccination, countries must intensify disease surveillance activities to detect new cases of acute flaccid paralysis, a clinical symptom of poliomyelitis.

“Priorities are constantly shifting for the Rapid Response Team,” says Dr Christopher Kamugisha, who has been working with WHO since 1998. He has been a member of the Rapid Response Team since its inception and like the rest of the team has been chasing new polio outbreaks across the region.

“In August I was in Somali Region in Ethiopia supporting the outbreak response, conducting the first vaccination campaign round. On the second day of the campaign, Dr Ndoutabe informed me that a new case was detected in Cheporoni in Ghana and asked me to go and provide technical support,” Dr Kamugisha recalls.

The Rapid Response Team discuss their next deployments. ©WHO/AFRO — The Rapid Response Team gathers to discuss their next deployments. ©WHO/AFRO

Within 24 hours, he was on a plane to Accra through Addis.

“I arrived at noon the next day and went straight to support the national technical team in their preparations and risk assessment. I assisted with ensuring that their plans are in line with the international standard operating procedures set by the GPEI,” Dr Kamugisha says.

No cure for polio

Polio is a viral disease, multiplying in the intestines and transmitted from person to person mainly through a faecal-oral route or, less frequently, through contaminated water or food.

While there is no cure for polio, the disease can be prevented through administration of a simple and effective vaccine. That is why efforts are underway across the country to rapidly boost immunity levels in children and protect them from polio paralysis.

Thanks to the efforts of the GPEI and country governments, 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.

In 2020, the central challenge for the African Region is overcoming outbreaks of circulating vaccine derived poliovirus. Vaccine-derived polioviruses are rare, but can affect unimmunized and under-immunized populations living in areas with inadequate sanitation and low levels of polio immunization.

Countries 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. Reasons these outbreaks have occurred include weak routine vaccination systems, vaccine hesitancy, difficulty accessing some locations and low-quality vaccination campaigns, which have made immunization of all children challenging.

In addition to the response activities, the Rapid Response Team work to build the capacity of health workers and decision makers in countries that are not experiencing polio outbreaks, training them to be ready to respond if virus is ever detected.

The team also aims to recruit more women with expertise in outbreak response. Achieving gender balance amongst personnel through a more equitable recruitment process forms part of the GPEI Gender Equality Strategy 2019 – 2023, which was launched in May 2019.

By supporting countries during outbreaks, and building health system resilience in vulnerable settings, the polio programme is working to establish a sustainable legacy that will improve health long after global eradication of the virus.

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In Karachi’s Gadap Town, many families lack basic health and municipal services. To fill the gap, the Polio Emergency Operations Centre in Pakistan’s Sindh province has recently renovated an abandoned hospital to create an Emergency Response Unit (ERU). The unit provides polio vaccination to communities alongside PolioPlus activities to improve overall health. The unit was built with the support of Rotary International, WHO, UNICEF and the Bill & Melinda Gates Foundation.

Click through the gallery to see how the Gadap Emergency Response Unit has changed health delivery:

Compared to the busy streets of Hargeisa, Somaliland, just 20 kilometres outside of the city are broad stretches of barren land—home to the nomads. Nomadism is part of Somalia’s culture, and there are thousands of families throughout the country who lead pastoral lifestyles, raising livestock and moving their animals and families as the seasons change. Their frequent movement means that children are not always nearby a health clinic to receive their scheduled vaccinations on time. Such disruption or delay in receiving vaccines can result in low or no protection against common childhood infections.

If children are not immunized against polio, they risk contracting the virus and developing paralysis. They also risk passing polioviruses to other under-immunized children. But the polio eradication teams are committed to reach every last child with polio vaccine notwithstanding challenging terrains.

Look through the lives of polio vaccinators in Somaliland on the third day of the vaccination campaign activities as part of the larger efforts to reach over 1.1 million children with the oral polio vaccine.

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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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Makoko is a floating water world on the coast of Lagos, Nigeria. Photo: © UNICEF/Peter Idowu

“Our area is a pretty difficult terrain because we live in the water and it is not easy for the teams coming from outside the community to gain access. So, the (hand-drawn) maps make it possible for us to identify areas we have yet to reach during the immunization exercise”, says Peter Idowu, a veteran community mobilizer and team supervisor in Makoko — a riverine shanty town located on the coast of mainland Lagos city, southwest Nigeria. Native to the village, Peter is the man to go to whenever the polio immunization teams face challenges navigating the waterways or the community.

Immunizing a small boy on a canoe as they ferry across their village, Makoko. © UNICEF/Peter Idowu

The sprawling water city Makoko is a slum located across the Third Mainland Bridge on the lagoon. It is a largely low-income community with half the population on water and the other half on land. Informal, makeshift houses with corrugated iron roofs sit precariously atop stilts. Down below, narrow wooden boats act as a form of aquatic taxi ferrying goods and people around the bustling community. Nobody knows the exact population of this slum district of Lagos, but it is estimated to be as high as 100 000. It is mostly a fishing community inhabited by the Egun people.

“My goal is to see that all the kids in our community are immunized and live healthy lives. That is why I engage our teams in sensitizing parents all the time on the importance of routine immunization and the dangers of polio. As a member of the community and with a passion of becoming a health worker myself, I kept on mobilizing our people for easy accessibility, because our language is different from Yoruba and most of the Polio teams can’t speak the language. It is always easy with me being in the Polio team as our people will readily accept the vaccine without rejecting,” says Peter.

Nigeria is the only country in Africa and one of the only three in the world endemic to wild poliovirus, alongside Afghanistan and Pakistan. Nigeria is also affected by circulating vaccine-derived poliovirus type 2 (cVDPV2) outbreaks.

UNICEF works closely together with Global Polio Eradication Initiative (GPEI), key polio partners and the Nigerian government. There is a vast network of over 20 000 community mobilizers focusing on demand creation and improving health-seeking behaviors of caregivers.

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Amidst a poliovirus outbreak in Papua New Guinea, legions of women health workers and leaders are playing a critical role in ensuring children are fully protected from lifelong paralysis. In the current emergency outbreak response, women have emerged as a strong, reliable, and a decisive group that continue to administer key services in the outbreak response implementation. From medical doctors to surveillance officers to community mobilizers to health workers, women are active and present on all fronts.

World Immunization Week—celebrated in the last week of April— aims to encourage the use of vaccines as one of the safest methods to protect against diseases, including poliovirus. This year’s theme – Protected Together: Vaccines Work! – highlights “heroes” who are ensuring that people of all ages, all across the world are protected through vaccines. Women on the frontlines of the outbreak response in Papua New Guinea are a fitting example who continue to inspire the public health community across the world.

Here is a roundup of some of the extraordinary vaccine “heroes”:

Dr Fiona Kupe

Dr Fiona Kupe is a Paediatric Medical Officer at the Gerehu General Hospital in the National Capital District, Papua New Guinea. She is, in effect, a one (wo)man army as she dons multiple hats in the polio eradication efforts in her home country by searching for children with acute-flaccid paralysis (AFP) at Port Moresby General Hospital and Gerehu General Hospital. She also leads the mapping of communities – or microplanning – for all Supplementary Immunization Activities (SIAs) across three districts.
Along with that, she finds time to train vaccinators and community volunteers, all the while carrying out her clinical duties as a child specialist.

“As a paediatric doctor and a mother…every day, I keep (my) passion alive to overcome challenges and basically to do everything I can to check on children’s vaccination status whenever they come to see me for check-up. As a mother, I know that vaccines save lives. I want my child to survive with good health and I would definitely want the same for all the mothers and children I see.”

Melanie Serei

Seen most days with her trusty pet dog by her side, Melanie works in one of the most challenging areas for immunization activities as a health worker in a remote village of Terapo in Kerema, Gulf province. Geographical inaccessibility aside, Melanie constantly juggles issues of insecurity, violence and community vaccine hesitancy. But, she tries every single day to overcome barriers in her mission to reach every last child with the life-saving polio vaccination.

Building community trust and demand for vaccination were considered key tenets in the risk communication for the polio outbreak response. Melanie successfully carried out door-to-door checks on all the children in the village. Thanks to her diligence, she was quickly able to notice polio symptoms in a child that allowed adequate and rapid actions.

Dr Winnie Sadua

Working as a paediatrician in Angau Memorial General Hospital in Morobe province, Dr Winnie treats one very special patient: six-year-old Gafo—the first reported case of polio in PNG in over 18 years, triggering a national outbreak emergency.

Dr Winne Sadua with her star patient, Gafo, at Angau Memorial General Hospital in Morobe province. ©WHO/PNG

Since his diagnosis, Gafo has gone on to become somewhat of a celebrity, a symbol of hope, and a staunch advocate for polio eradication. Through timely treatment and physiotherapy by Dr Winnie, Gafo can now walk with his signature gait. He is now healthy and excited to start school next year.

With all the patients that come to her, Dr Winnie makes sure to remind all the parents to take heed from Gafo’s case and get their children vaccinated.

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Jean-Marc Olivé, Chairman of the Technical Advisory Group (TAG), addressing the participants. WHO/L.Dore

From the 27 – 29 November, the Technical Advisory Group (TAG) met in Nairobi to review the outbreak response in Somalia, Ethiopia and Kenya, and preparedness measures in Yemen, Uganda, Tanzania, Sudan, South Sudan and Djibouti in case of international spread.

Jean-Marc Olivé, Chairman of the TAG, spoke to WHO about the recommendations made to address the challenges faced by countries, his hopes for eradication and his life in the programme.

What are the main challenges faced by the countries of the Horn of Africa in the drive to stop the outbreaks?

The major challenges have been the same for a long time – like, the issue of inaccessibility due to conflict and humanitarian crises. If we cannot access populations then it is very difficult to cover them properly during vaccination campaigns and so it is hard to stop poliovirus transmission. This is not a programme-related issue, it is a political one. Until we have access, it will be very difficult to make it.

I have said it before and I will say it again: access is success.

I think the second challenge is – and this is one of the reasons why we still have the transmission of circulating vaccine-derived poliovirus in the Horn of Africa – is persistently low vaccination coverage. There are still remote areas, rural areas, heavily populated urban areas where routine immunization has really never been able to offer the same services and coverage as in more accessible areas with fewer challenges.

Since last TAG meeting in the Horn of Africa, what progress have you seen?

I have seen the capacity really building up in the Horn of Africa. The biggest shift is that we now have collected a lot of data about surveillance, about immunization coverage, vaccination campaigns, communications, and also data by the type of population we are reaching and not reaching. What is missing now, and what was the focus of this TAG, is to use this data to monitor progress and orient the programme toward those difficult areas. We have to use the data to tell us a story about what is happening and what to do next.

Jean-Marc Olivé vaccinating a child in Kandahar, Afghanistan. © WHO/Afghanistan

What were the most important recommendations made by the TAG this time around?

I think the most important is to follow the plan that has been set up for the three outbreak countries to interrupt transmission. Secondly, the countries that have not been yet infected by the virus should have a preparedness plan to ensure that if there are any problems they can move swiftly into action.

The Horn of Africa has seen several outbreaks in the past. What must be done to break the pattern and keep the region polio-free once and for all?

They have identified the problems. They just have to implement the solutions! We need to be sharing and analysing knowledge, information, and building capacity at the local level to ensure that we are on the right track to success.

I say to all the countries, go to the areas where you know you have problems and engage local communities and health authorities. Most of the issues can only be addressed at local levels by local people who understand the situation. Help them to do that, and monitor progress.

This is your thirteenth TAG; what have you learned about the process of international review?

First, you have to work as one team in support of National Teams, all agencies together. There cannot be any agency that claims, “This is us, we are doing that, this is WHO, this is UNICEF…”; this is the Global Polio Eradication Initiative, working together with all committed partners, using the competencies that each of them has. If you don’t address issues comprehensively as one, effective interventions are much more difficult to implement.

How long have you worked on polio eradication? What lessons have you learnt from this experience?

I was involved in the eradication of polio in the Americas. We started in 1985. We did it from A to Z in 9 years. We had very good leadership, commitment from the Government and partners, clear guidelines, very strong monitoring, and solid and reactive support to the field. Then we moved on into measles elimination with the same engagement – and the same results.

Because I have seen it happen, I know it is feasible. I think this is what keeps me so motivated. Polio eradication is a fantastic initiative. If we focus on weak and problematic areas within countries, if Governments and Partners continue to be engaged, we will make it. It’s going to be tough, mainly because of inaccessibility.

Is there anything else you want to add?

The people working in this programme, particularly local people working in the countries are amazing. They are the basis of any future public health intervention. In Pakistan and Afghanistan, woman are more and more playing an important role. This is an incredible advancement and an incredible contribution that was previously thought to be impossible.

But nothing is impossible – you just push, go slowly and constructively you will manage to gain ground over the virus.

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©Gavi/2018/Brendan Esposito.
A health worker administering polio vaccine to a young child.

In the wake of a polio outbreak confirmed on June 26 2018, the Government of Papua New Guinea declared polio a national health emergency. It was imperative that all children under the age of five be vaccinated, even those living in the most inaccessible regions of the country.

As part of the outbreak response, a team from Madang Provincial Health Authority, supported by WHO, travelled for over half a day by road and helicopter to reach the Hagahai people who live in the highlands of Madang province in Papua New Guinea, which is one of the most geographically isolated places in the world.

Ever wondered what it is like to be on the forefront of the fight against polio? Watch and learn how the team made their way to the remote mountain top to deliver vaccines.

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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.

Related resources:

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

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

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

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

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

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

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

Recommendations made

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

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

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

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

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

Polio eradication efforts in Kenya

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

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

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

Related Resources

What is polio surveillance?

One of the most challenging aspects of polio eradication is timely disease surveillance: knowing where the poliovirus is lurking, so we can roll out targeted immunization activities quickly and effectively. With new tools, eradicators are getting the information they need in real time.

For the past three decades, there have been two approaches to find polio: passive and active surveillance. Passive surveillance involves health workers routinely reporting cases of acute flaccid paralysis (AFP) as they find them in health facilities. Active surveillance takes place where there is a higher level of concern that polio might be present. Experts go to hospitals, clinics and even community healers to search out cases of AFP. This approach, often called active case searching, reduces the risk that cases are missed due to human error – people forgetting to report AFP or health care workers or community healers not knowing that they need to report the case.

However, in active case search the key steps of detecting, reporting and investigating the case might not always be happening consistently in all health facilities. There can be a delay of two months or more between a child being paralyzed, experts finding out and alerting the polio surveillance system. In an outbreak setting, this can be long enough for the virus to infect and paralyze more children, moving from one area to another. There was an obvious need to make the surveillance system even more reliable and time-sensitive to ensure the polio surveillance framework is as robust as ever.

Never missing a beat again

©WHO EMRO/Sara Williams
With the Integrated Surveillance and Routine Immunization Supervision system, surveillance officers use an app on their mobile phones to document active case searching as it happens, by tagging the location of every healthcare facility they visit and check.

In order to ensure that active search is conducted timely with real time evidence the polio surveillance systems in Kenya, Ethiopia, Uganda, Eritrea, South Sudan, and Tanzania have adopted an easy-to-use, portable disease surveillance monitoring tool. It delivers unprecedented accuracy across huge areas. The best bit? Most people already have the basic component in their pockets: their mobile phones.

The tool is known as Integrated Surveillance and Routine Immunization Supervision. The idea is simple: surveillance officers use an app on their mobile phones to document active case searching as it happens, by tagging the location of every healthcare facility they visit and check.

“This provides real-time monitoring in the field. Previously, officers would report having done active case searching after the fact – like, ‘I was here and I did x, y, z’. But this is vulnerable to human error in remembering accurately. Sometimes, before we introduced it, someone would go to a distant, rural area and not be able to pinpoint their location on a map for others to follow up. Now, we are sure we are not missing things.” said Christopher Kamugisha, WHO’s Horn of Africa Outbreak Coordinator.

©WHO EMRO/Sara Williams
The map that is generated at the national level allows public health experts responding to the polio outbreak the opportunity to see where the gaps in surveillance for polio are in real time.

The app guides surveillance officers through a checklist (questions cover resources available at the facility, polio, measles and routine immunization) that they fill out and send then and there, using their mobile phones, even without an internet connection. It can also provide on-the-spot data analysis so that the surveillance officer can take immediate, evidence-based action.

With a swipe of the screen, users marry surveillance findings to the facility’s location and send the information to a centrally generated map. This gives staff at the national level a clearer picture of where surveillance is working and where it is not, including data on where possible polio cases are, so they know where to direct extra resources.

It also means health workers actively searching for AFP do not have to spend extra time ensuring the information gathered in the field is being shared with the right people for them to take action. For the ongoing outbreak of circulating vaccine-derived poliovirus in the Horn of Africa, this means better disease surveillance – and a better chance to protect children against polio.

Gafo is the first case of polio in Papua New Guinea in almost two decades. WHO PNG/J.Rivaca

For six-year old Gafo that fateful April 2018 morning was supposed to be the start of just another day full of running around and playing with friends. Ignoring the pain in his legs, Gafo tried to get out of bed, but he fell and struggled to get back up. Over the course of the next two days, Gafo’s condition continued to deteriorate. On the third day, Gafo and his family visited the Angau Memorial General Hospital in Lae, Morobe, in the central northern coast of Papua New Guinea, only to find out that he had polio.

As soon as Gafo’s story broke, a National Emergency was declared by the Government and a mass polio vaccination campaign was initiated. Gafo became the foremost champion of polio awareness, and served as a cautionary tale for families and young children to get vaccinated.

Since his diagnosis, Gafo has made progress. Though he can now walk with his signature gait, Gafo and his parents understand that polio is irreversible, but is preventable and eradicable. Gafo hopes to become a doctor one day. Read about his entire journey from being an ordinary child to breaking news, and how his story has helped contain polio in Papua New Guinea.

This story is originally from the Papua New Guinea Polio Outbreak Response First 100 Days report.