Fifty-seven year-old Khalida, a striking figure on her four-wheeler motorbike, is a supervisor of one of the female vaccinators’ teams in Karachi, Pakistan’s largest city.
“I have been working as a supervisor for three years, but I have been associated with polio vaccination campaigns for many years as volunteer,” she explains. The community in the area where Khalida works is mostly from Pakistan’s tribal areas in the north-west of the country, and distrustful of outsiders. Traditionally, this mistrust involved not accepting vaccination. Today, all families in the area accept polio drops.
Khalida had worked in different jobs but wasn’t satisfied until she was offered a job of polio team supervisor. Her influence in the area has been critical to overcome myths about vaccination and build knowledge and trust.
Having women like Khalida working on the frontlines is a game changer for polio eradication. The fact that she is well known and trusted in her community means that mothers and fathers are more likely to allow her and her team to take the crucial step across the thresholds of their homes to vaccinate their children. The Pakistan Polio Programme’s emphasis on local, motivated, full-time, community-based female vaccinators has been improving immunization coverage figures. Across the country, the proportion of vaccinated children increased from 85% in August 2016 to 92% in May 2017, according to independent post-campaign monitoring.
In my community, the number of polio cases has decreased drastically. The progress is visible with the naked eye. We hold rigorous polio campaigns which are being carried out frequently in the area to reach every child multiple times with vaccines and keep them safe against paralysis. In this regard the contribution of the frontline health workers I supervise is remarkable, as they work hard to ensure each and every child is protected from this crippling disease.
Polio eradication is very important to have a healthy generation; as healthy generations, these children will be able to better serve the country – Khalida
For Khalida, vaccinating children against polio is a true mission. “Since I began working to end polio, I feel like I am a soldier. Just as an army fights to protect a country, similarly I fight against a virus which is disabling our beloved children. I will fight against this crippling disease until the virus is permanently eradicated and our beloved children are fully protected”.Khalida’s work spans a large area, with temperatures in the summer reaching 40°C, making the work of vaccinators very challenging. To provide supervision to the polio teams under her care, Khalida uses a motorbike specially designed for her for this very purpose – it has four wheels and is capable of crossing the rocky terrain and getting her where she needs to go at top speed. The sight of Khalida coming into a settlement on her motorbike has become a well-known, welcome sight.
Pakistan is one of only three last polio endemic countries, along with Afghanistan and Nigeria. The number of cases has declined dramatically in the past years: from 306 in 2014 to 20 in 2016. As of June 2017, the number of polio cases reported in Pakistan was three.
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
Aminatu Zubairu, in her trademark blue VCM shawl, displays the birth registration cards she will carry back to mothers in her village. @ UNICEF/R.Curtis
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.”
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.
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.
