GPEI-Reaching the Hard-to-Reach: Overcoming Physical Obstacles

Reaching children with polio vaccine can be notoriously difficult and dangerous. In fact, polio transmission and outbreaks in some areas can be directly related to inaccessibility. When we talk about inaccessibility, many people think about insecurity. And that is definitely a critical factor in some areas, for example in Borno, Nigeria, or Syria at the moment. But in most areas, other elements contribute to the difficulties faced by vaccinators in reaching every child with the vaccine. For example, children living in dense urban neighbourhoods or children who are part of nomadic or mobile communities are often hard to reach.

In some parts of the world, significant environmental and geographic challenges make it difficult for vaccinators to reach children. It is important for health workers to be aware of these different physical barriers when planning vaccination campaigns, as each requires different strategies to make sure we reach even the hardest to reach child.

Many countries working to vaccinate their children against polio have a dry season and a wet or rainy season. When the rains come they can be relentless, altering the landscape and the environment dramatically. For example, rivers that are easily crossed can become torrents of rushing water, impossible to traverse or to even see across. Populations can be suddenly cut-off for months at a time, and reaching them with vaccines becomes much more difficult. The polio programme must then adapt to the local physical landscape and come up with solutions. One of the last hideouts of wild poliovirus in India was the floodplain of the Kosi River in Bihar state; the virus was stopped here by careful planning of vaccination campaigns, mapping of temporary settlements and increasing the number of personnel on the ground.

Infrastructure factors can affect access: children can live in extremely remote locations in places where there are no roads or easy means of transport. In parts of the Democratic Republic of the Congo, some settlements are deep in dense forests, and are not clearly mapped or identified. Says Mohammed Mohammedi, polio eradicator since 1997, “In some countries, we simply might not even know where exactly these places are or if children live there, not to mention the challenge of actually reaching such remote environments. Rains can turn dusty roads in to muddy swamps. Cars and other vehicles risk getting stuck in the mud, causing significant delays to operations.” The polio programme overcomes such challenges with both old-fashioned means – muscle power to dig out vehicles from the mud or donkeys to transport vaccines – and new tools such as satellite imagery to find human habitations or airlifting in vaccine with helicopters.

Mohammedi advises, “For the environmental factors, forward planning is key. We try to schedule vaccination campaigns right before the rainy season starts, and right after it finishes.” The rainy season often coincides with ‘high season’ for polio, with increased transmission during these wetter months, so the pre-rainy season campaigns are critical to make sure children are protected, even when populations become cut off from vaccinators. In some places, vaccines are pre-positioned ahead of the rains, so that local health workers can continue to operate in those areas once regular access is cut off.

“We need to focus on leaving no child unvaccinated,” reminds Mohammedi, “no matter how difficult it is to reach them. This means we need to first identify all the factors that are hampering access, and then respond with tailored strategies that specifically address each situation.”

The programme has years of experience responding to a whole host of inaccessibility factors, and is constantly using this knowledge to make sure every child is immunized against polio.

Read more in the Reaching the Hard to Reach series

This little girl is Kapia. She lives in a small village, surrounded by jungle, in a remote part of the countryside. There are no medical doctors in her village. The nearest clinic is hundreds of kilometres away. And she has just received two drops of polio vaccine, protecting her from the potentially paralytic disease.

A few days ago, health workers arrived in her village with one simple goal – to immunize every child under five against polio. Kapia’s village is one of many hundreds of settlements, villages, towns and neighbourhoods that will be visited by vaccinators with this same simple goal, to reach every child with the polio vaccine.

While the goal is simple, achieving it is much more complex. Vaccination campaigns need to reach hundreds of thousands of children over large areas of land, often involving difficult environmental, cultural and political challenges. A huge amount of detailed information gathering and planning is needed to ensure every piece of the campaign puzzle is first discovered and then analysed and slotted in to place to ensure every child is immunized against the disease.

Enter the microplan.

The foundation of every successful vaccination campaign is a comprehensive microplan, which captures in great detail all the different, yet interrelated components of the campaign.

The first piece of the microplanning puzzle involves discovery – finding out about communities in the vaccination area, how many children live in in the area, and where they are located. This informs a range of other planning and logistical elements of the campaign.

Health workers use a wide variety of resources to gather the most accurate and detailed information possible about communities, to make sure all children are reached with the vaccine. This includes working with the communities themselves, as well as NGOs on the ground and government to make sure even the most remote settlements and hard to reach children are reached in the vaccination campaign. This must take into account groups that are mobile, such as nomads, the internally displaced, or migrant workers’ families. Where are these groups, how many children do they have who need vaccine, what are the routes they use and the transit points through which they pass?

When all these puzzle pieces have been revealed, health workers can start putting them together, building on each piece of information to create the whole microplan picture – a comprehensive and detailed plan for the campaign.

In the microplan, every community is listed, along with estimated number of children, and important areas in each community where children can be reached: whether playgrounds, water collection points, markets or government clinics. Communities are also plotted on maps, along with distances, population spread, landmarks, population movements and seasonal and environmental specifics, such as floods and challenging roads.

This information is also used to calculate the amount of vaccine needed for the campaigns, the logistics for getting the vaccine to where it needs to go, and the number of health workers, vaccination teams and supervisors needed to carry out the work.

Once all of this is established, vaccinators can be identified who are appropriate for that community, and detailed activity plans can be created, allocating vaccination teams to cover specific mapped areas on specific days. Special plans are also made for vaccination teams to vaccinate at major transit points, and to cover hard to reach populations, such as nomadic populations or people living in areas with disputed borders.

Each team is provided with a team microplan, which includes the number of houses and children to be reached, and a detailed description and map of each area to be covered including start point, route to be taken, end point, important landmarks and special sites, like schools and playgrounds, that should be covered to ensure all children receive the vaccine. This functions as a systematic guide to vaccinators as they carry out their work.

Other detailed plans are made covering vaccine distribution and logistics, social mobilization and communications plans, and reporting plans.

Slotted together, every small piece of information and planning combines to give a highly detailed picture of the forthcoming campaign, leaving no situation to chance or guesswork. This ensures every child like Kapia, no matter how remote or hard to reach, receives the protection they need against polio.

A doctor greets a Syrian child in a refugee camp, where children are vaccinated against polio and other diseases. Photo: WHO

In recent years, the global drive to eradicate polio has seen the virus cornered in fewer places than ever before. Yet polio’s final strongholds are some of the most complicated places in the world to deliver vaccination campaigns. Insecurity and conflict are some of the challenges to delivering vaccines, as well as populations on the move, testing terrain and weather, and weak health systems.

In 2013, polio outbreaks in Central Africa, the Horn of Africa and the Middle East paralysed hundreds of children. The Global Polio Eradication Initiative (GPEI) developed strategies to deliver vaccines and stop the virus, even when access seemed impossible. All three of these outbreaks were put to an end just a year later, by not letting the complexity of the situation undermine the quality of vaccination campaigns.

The valuable lessons learned by the GPEI in tackling these outbreaks are now being used to end polio in the final polio endemic countries – Afghanistan, Nigeria and Pakistan – as well as to stop a newly-detected circulating vaccine-derived polio outbreak in Syria.

Challenges to immunization in emergencies

Disruptions to routine immunization systems and mass displacement caused by conflict can rapidly reduce population immunity, making individuals much more vulnerable to polio outbreaks. Polio eradication relies on being able to repeatedly access over 95% of children with vaccines. Yet emergency settings can interrupt systems that gather data about a population, functioning health facilities, health care personnel, vaccine supplies, cold chains to keep vaccines safe, power supply, financial resources, population demand for vaccines, and disease surveillance. When these factors are at play, the GPEI calls on past experience and adopts new approaches to reach every last child.

Lessons learned in conflict zones

Community acceptance and trust

When there are barriers to access, the first step is to have community trust and acceptance of vaccination. Every community and context is different and calls for a targeted approach to communicate exactly why immunization campaigns need to take place. The polio eradication programme identifies and trains vaccinators from local communities, engages religious figures to support the campaign and gets local leaders on board to advocate for, plan and implement vaccination efforts. The polio programme has seen time and time again that when securing access is a challenge, the answer often lies in the very communities we are trying to reach.

In Pakistan, a number of Religious Support Persons have been recruited based on the guidance of the Islamic Advisory Group for polio eradication, to address concerns of local communities about polio vaccinations in some challenging areas of the country. This has resulted in enhanced community acceptance of immunization, with refusal rates of less than 1.5%, as well as broader child welfare interventions.

Opportunistic vaccination campaigns

When different forces make populations periodically inaccessible, vaccination schedules can be interrupted and leave pockets of people unprotected against polio. In these situations, health authorities try to reach children in whatever ways are possible. Transit points can be set up around insecure areas, to vaccinate children as they enter or leave; vaccinators work with local leaders to track and reach populations on the move; communities within the inaccessible areas can store and deliver vaccines themselves; and brief periods of calm can be used to bring vaccines and other essential health services into villages through a health camp.

In Pakistan, over 350 transit points have been set up in recent years along borders and near areas with access challenges. This is one of the innovative approaches that have reduced the percentage of children missed on vaccination campaigns from 25% in 2014 to 5% in 2017.

Negotiated access

In the most challenging situations, when all other approaches are not able to overcome the severity of vaccination challenges, the programme has negotiated access by engaging non-state actors, governments, religious figures and local leaders. Reiterating the humanitarian principle of “neutrality,” the GPEI works with all parties to a conflict to highlight the importance of vaccination campaigns, and secure agreements to access targeted communities for specific periods of time.

In the past, negotiating access to conflict zones was comparatively simple to today. In the 1980s, days of tranquillity were first used in the Americas, through negotiation with two groups – often the government and the opposition group. In many areas where polio persists, there are many different actors and groups engaged in conflict, so negotiation is more complex. It includes identifying who is appropriate to negotiate with in any given district or area, and, importantly, finding appropriate negotiators. Often, third party partners such as the International Committee for the Red Cross are engaged to negotiate operations of vaccination campaigns in security-compromised areas, and in areas where vaccination bans have been imposed by local authorities.

Conflict and insecurity continue to pose significant challenges to eradication. Our best chance of ending polio for good in conflict zones lies in learning from these lessons and adhering to the principles of neutrality in health.

Read more in the Reaching the Hard to Reach series

A circulating vaccine-derived poliovirus type 2 (cVDPV2) outbreak has been confirmed in the Deir-Ez-Zor Governorate of the Syrian Arab Republic. The virus strain was isolated from two cases of acute flaccid paralysis (AFP), with onset of paralysis on 5 March and 6 May, as well as from a healthy child in the same community.

Outbreak response plans are being finalized, in line with internationally-agreed outbreak response protocols, including plans for targeted vaccination campaigns to rapidly raise population immunity. An initial risk analysis has been conducted, finding low overall population immunity levels in the area but solid levels of disease surveillance. Active searches are being conducted for additional cases of acute flaccid paralysis. Surveillance and immunization activities are also being strengthened in neighbouring countries.

Although access to Deir-Ez-Zor is compromised due to insecurity, the Governorate has been partially reached by several vaccination campaigns against polio and other vaccine-preventable diseases since the beginning of 2016. Most recently, two campaigns have been conducted in March and April 2017 using bivalent oral polio vaccine (OPV). However, only limited coverage was possible through these campaigns. Syria also introduced two doses of inactivated polio vaccine in the infant routine immunization schedule in 2018.

The detection of the cases demonstrates that disease surveillance systems are functional in Syria. The polio programme is working with local authorities and organisations on the ground to respond immediately, using proven strategies. In 2013-2014, Deir-Ez-Zor was the epicentre of a wild poliovirus type 1 (WPV1) outbreak, resulting in 36 cases at the time. This outbreak was successfully stopped; the now-detected cVDPV2 strain is unrelated to the WPV1 outbreak.

Circulating VDPVs are extremely rare forms of poliovirus, mutated from strains in the oral polio vaccine (OPV) that can emerge in under-immunised populations. OPV has been a critical tool in eliminating 99.9% of polio cases worldwide, and while cVDPV is rare, the GPEI is actively working with countries to eradicate both vaccine-derived and wild polio. The same strategies that are eliminating wild poliovirus also stop cVDPV – it remains critical that all countries maintain strong disease surveillance and ensure all children are vaccinated.

More information on Syria

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

“Are you watching me?” “Yes, ma’am.”

“Are you seeing me?” “Yes ma’am.”

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

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

Trust

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

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

Ante-Natal Care

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

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

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

Birth registration

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

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

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

Routine Immunization

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

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

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

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

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

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

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

Naming ceremonies

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

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

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

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A child is given two drops of the oral polio vaccine to protect them against polio in Lao PDR. @ WHO/ R. Tangermann

As of May 2017, Lao People’s Democratic Republic (PDR) is officially no longer infected with circulating-vaccine derived polio virus (cVDPV), according to the International Health Regulations (IHR) Emergency Committee on the international spread of poliovirus.

After an outbreak of circulating vaccine derived poliovirus type 1 (cVDPV1) in 2015 and 2016, the country has now been without cases for over 12 months, with the last case reported in January 2016.

Since the outbreak, WHO, UNICEF and other partners have supported Lao PDR in their outbreak response efforts. This included support for multiple rounds of supplementary immunization activities, expanded social mobilization to raise community awareness and desire to vaccinate, and enhanced acute flaccid paralysis (AFP) surveillance activities to find the virus.

Ending the outbreak

In general, an outbreak is considered over following a period of 12 months without the detection of any new polioviruses from an AFP case, a healthy individual or an environmental sample, and with confirmed certification-standard disease surveillance.

An outbreak response assessment (OBRA) team visited the country in March to confirm the virus had, in fact, been stopped. The team, made up of representatives from WHO, UNICEF, and the US Centres for Disease Control and Prevention, concluded that all evidence suggested the outbreak had been successfully stopped, with all immunity and surveillance indicators meeting rigorous international standards.

At the OBRA meeting, development partners commended the Ministry of Health on its leadership in response to the outbreak. Tremendous progress was made in micro-planning, cold chain and vaccine storage at all levels, as well as nationwide social mobilization and strengthening of AFP surveillance.

Deputy Health Minister of Lao PDR, Dr. Phouthone Muangpak, noted that the Ministry of Health and local authorities need to take ownership to further improve surveillance sensitivity in the country.

Lessons from the outbreak response

Both adults and children were vaccinated through the response to make up for low levels of vaccination over an extended period of time. @ WHO /R. Tangermann

A challenging landscape and diverse ethnic communities added to the challenge of running vaccination schedules in Lao PDR. As the outbreak occurred in an area where vaccination levels had been very low for an extended period of time, campaigns were extended to reach all children under 15, and in some cases even adults. The nuanced cultural, lingual, religious and social needs of the Hmong community called for a response tailored to local needs, especially building an awareness of the importance of vaccines. Impromptu cinemas were set up against bamboo walls to pull in interested families and share information about vaccination campaigns after dark.

Find out more about the response in Lao in this photostory.

Meeting International Health Regulations standards

Information and conclusions from OBRAs are taken into consideration by the IHR Emergency Committee on the Spread of Poliovirus, resulting in this instance in the IHR classification as a state no longer infected with cVDPV1.

Despite being classified as polio-free, the IHR Emergency Committee still categorizes Lao PDR as vulnerable to reinfection. The country must continue to strengthen routine immunization to ensure all children are protected from any polio outbreak that may happen in the future and to maintain the improvements in disease surveillance, to ensure the virus is detected and stopped wherever it may emerge.