Surveillance

A young girl from Kano state, Nigeria, receiving the life-saving polio drops. © WHO

The WHO African Region is expected to be certified free of wild poliovirus on 25 August 2020. Chair of the WHO’s International Health Regulations Emergency Committee and of the AFRO Regional Immunization Technical Advisory Group Helen Rees explains the current cVDPV situation in Africa and its implications ahead of regional wild polio-free certification.

Q. Fifteen countries (as of 14 August 2020) in the World Health Organization’s African region have reported cases of circulating vaccine-derived polio type 2 (cVDPV2) in 2020. The total number of outbreak countries is 16. How does that impact the region’s upcoming wild polio-free certification?

First, it’s important to clarify that cVDPV is a different virus from the wild poliovirus, and will undergo a separate process to validate its absence once wild polio has been eradicated globally.

Second, I want to underscore that the ongoing cVDPV2 outbreaks in Africa do not affect the programme’s confidence that wild polio is gone from the region. Certification is backed by extensive data and a thorough evaluation process that demonstrates wild polio transmission has been interrupted on the continent.

In Africa, an independent body of experts called the African Regional Certification Commission for polio eradication (ARCC) oversees this process by carefully reviewing country documentation and analyzing the quality of surveillance systems and immunization coverage. With this intensive monitoring of polio programmes across the continent, the ARCC is able to confirm with 100% certainty that wild polio is gone from the region.

But for the ARCC, national polio programmes and GPEI partners, the work does not end here. Stopping cVDPVs remains an urgent priority. African countries will need to strengthen their efforts to reach all children with polio vaccines to protect them from cVDPVs and any importation of wild polio from the remaining endemic countries, Pakistan and Afghanistan.

How do cVDPV outbreaks happen? And why has the number of cVDPV cases in Africa increased more rapidly in the past couple years while wild cases have not?

cVDPVs can occur if not enough children receive the polio vaccine. In under-immunized populations, the live weakened virus in the oral polio vaccine (OPV) can pass between individuals and, over time, change to a form that can cause paralysis—resulting in cVDPV cases. This means that the cVDPV outbreaks we’re seeing today are revealing pockets across the continent where immunization rates are too low.

The reason for the increase in cases can be explained by low immunity to type 2 poliovirus, which causes the vast majority of cVDPV cases. This is in part due to a global vaccine switch that occurred in 2016, when countries stopped using the trivalent OPV (which protects against all three forms of polio) and replaced it with the bivalent OPV (which protects against just type 1 and 3).

The GPEI, following the advice of the Strategic Advisory Group of Experts, decided to make this vaccine switch based on extensive evidence that showed it would decrease the number of cVDPV outbreaks. However, immunity to type 2 poliovirus was lower than predicated at the time of the switch and so there were actually more cVDPV2 outbreaks. In response to the cVDPV2 outbreaks monovalent oral polio vaccine type 2 (mOPV2) has been used to interrupt transmission. But with increasing numbers of children who do not have type 2 immunity, mOPV2 vaccines have had to be used longer and in larger quantities than was initially anticipated. This larger and more extensive use of mOPV2 vaccines has seeded new outbreaks especially in areas of low immunization coverage and on the borders of outbreak response zones.

All this said, mOPV2 is an effective tool to stop cVDPV outbreaks if children are properly immunized.

If cVDPV outbreaks can only affect under-immunized communities, doesn’t the increasing number of outbreaks indicate that polio immunity levels are too low across the region? Why were countries able to stop wild polio then?

For years, the wild poliovirus has only existed in a small area on the continent. Nigeria reported its last case of paralysis due to wild polio four years ago, but most other countries haven’t seen a wild polio case in quite some time.

Across the continent, population immunity levels to type 1 polio (the only type of wild polio that remains in the world) and surveillance networks have continued to protect against any wild polio importation from remaining wild polio endemic countries.

However, the increasing number of cVDPV outbreaks across Africa is a reminder that countries cannot afford to let their guard down, and must continue reaching every child with the polio vaccine.

A young child receiving polio vaccination. ©WHO/Nigeria

What is the programme doing to address cVDPVs in Africa?

The same tactics that stop wild polio can be used to stop cVDPVs – high vaccination coverage and strong surveillance. The polio programme in Africa has proven experience and strategies to address cVDPV outbreaks. But we know that we cannot rely only on existing tactics, which is why the programme is innovating and adapting its strategies to address the challenge of cVDPVs specifically.

In early 2020, the GPEI released a comprehensive new strategy to stop cVDPV outbreaks currently affecting countries in Africa, Asia and the Middle East.

This includes revising outbreak response standard operating procedures to improve response time, doubling the size of the African Rapid Response Team, forming a global Rapid Response Team and prioritizing the GPEI’s ground presence in high-risk areas.

To raise immunization coverage, the GPEI partners – including Gavi, the Vaccine Alliance – are working to build and strengthen immunization systems in at-risk countries and expand routine immunization with the inactivated polio vaccine (IPV).

The strategy also includes the development of an additional tool to help stop cVDPV2 outbreaks – novel oral polio vaccine type 2 (nOPV2). nOPV2 is a modified version of the existing mOPV2 used to respond to cVDPV2 outbreaks that is less likely to change to a form that can cause paralysis.

The GPEI is confident that with strengthened commitment from country governments and full implementation of the tactics laid out in its strategy, cVDPVs can be wiped out across Africa.

Has COVID-19 affected the programme’s ability to stop cVDPV outbreaks in the region?

The recent pause in house-to-house polio campaigns to help control the spread of COVID-19 is expected to increase cVDPV transmission across affected countries.

The GPEI is taking a number of steps to get back on track. Even while campaigns were paused, surveillance activities continued so that as immunization activities ramp up the programme can target campaigns in areas that are most at risk.

The GPEI recently recommended that all countries with active polio transmission resume vaccination activities as soon as it is safe to do so, in line with WHO and national COVID-19 guidance. Burkina Faso and Angola were among the first countries to start implementing cVDPV outbreak response campaigns after the pause.

These campaigns are closely following safety guidelines and social distancing measures to protect communities and health workers against COVID-19. Measures including the use of masks and gloves, frequent handwashing and no-touch vaccination.

COVID-19 undoubtedly represents a setback for polio eradication, but not the first one the programme has faced. The GPEI and African countries’ national polio programmes are committed to ensuring that countries are ready to tackle the remaining challenge of cVDPVs and to recover lost ground once polio activities can safely ramp up.

A mobile vaccination team provides polio immunization to nomadic communities during the accelerated immunization campaign in October 2019 in Rehaid locality, on the border of Sudan and CAR. ©WHO/Sudan

Sudan borders a number of countries facing outbreaks of circulating vaccine-derived poliovirus, including Chad and the Central African Republic (CAR) to the west, and Ethiopia and Somalia to the east. Population movements between these countries increase the risk of importation of polio to Sudan. The World Health Organization and national health authorities in Sudan are scaling up efforts to reduce the risk of poliovirus transmission to the country.

To prevent a possible outbreak, health authorities have been working amidst immense operational challenges to carry out vaccination campaigns and strengthen disease surveillance. Public health teams in Sudan and CAR are collaborating to share details of vaccinated refugee children with their country of origin, and exchange information on upcoming supplementary immunization activities and reported cases of Acute Flaccid Paralysis.

Sudan was declared free of wild poliovirus in 2015, but remains at considerable risk for poliovirus importation or a VDPV outbreak. Much of the risk is shaped by Sudan’s unique population dynamics, and by the devastating effect of population movement, conflict and instability affecting routine immunization. Additionally, nomads, who account for around 10% of Sudan’s population, regularly move across borders to graze animals in Chad and CAR.

Over 8 million children under the age of five are estimated to live in Sudan – an age group considered to be most vulnerable to contracting and being paralyzed by poliovirus. Sudan also has large numbers of internally displaced people and refugees, many in the areas of the country with the lowest levels of routine immunization, such as the Darfur region.

In September and October 2019, states on the border between Sudan and CAR implemented accelerated routine immunization to provide children with coverage against a variety of vaccine-preventable diseases. Teams conducted reviews of vaccination facilities and posts in border areas, and orientation sessions were held in healthcare settings to reinforce reporting cases of Acute Flaccid Paralysis. Children received oral polio vaccine, pentavalent vaccine, and inactivated polio vaccine. Initial data from the campaigns suggests a spike in coverage, with teams reaching many children previously unprotected.

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In October

190,909 million children were vaccinated during the October Case Response Campaigns.
2.2 million children were vaccinated at 377 Permanent Transit Points.

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In November:

Two cases of wild poliovirus were reported
5.6 million children were vaccinated.
Permanent transit teams vaccinated 1,723,859 children and cross-border teams vaccinated 163 775 children

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WHO medical officer Dr Aisha Alhassan conducts an acute flaccid paralysis examination in Jere Local Government Area, Borno State. ©WHO/Nigeria

In Jere Local Government Area, in Borno State, Nigeria, a team of male surveillance officers have been dispatched to look for the poliovirus.

They make a first stop at the home of Hajiya Liman Bello, a mother of three and a housewife.

“Who are all of you and what do you want?” Hajiya asks.

“We are health workers please. We need to collect stool samples from your children as there has been a case of Acute Flaccid Paralysis (AFP) in this area”, they reply.

Hajiya isn’t comfortable with the idea of a male health worker handling stool sample collection for her children. She requests that surveillance officers return with a female colleague if they wish to go ahead.

Recognising the links between gender and disease surveillance

In line with the Global Polio Eradication Initiative’s gender strategy, Nigeria’s polio programme has been quantifying the gender aspect of its work. While women make up 95% of frontline workers delivering polio vaccines, a 2017 study conducted by the World Health Organization found there were significantly more men than women engaged in polio surveillance activities in Nigeria.

In 2016 there were 29 men employed in Nigeria as state epidemiologists compared with just eight women doing the same job; 23 male state disease surveillance and notification officers (DSNOs) compared with 14 women, and at a Local Government level, 609 male DSNOs versus 218 female.

The results of the study prompted reflection by programme staff. Gender, like other factors such as age, education and socioeconomic status, is an important determinant of health-seeking behaviour and outcomes. In the case of disease surveillance officers, gender diversity amongst personnel helps the programme build trust and acceptance amongst parents.

“I believe gender strongly influences disease surveillance and access to immunization services,” says Dr Kabir Yusuof, a health worker who has worked with the Nigerian Government polio programme for over ten years.

Dr Alhassan explains the key signs of acute flaccid paralysis to a pharmacist in Borno State. ©WHO/Nigeria

“Nigeria is generally a culturally attuned country. There are some communities where men only feel comfortable with female health workers, especially when it comes to house-to-house outreach and matters of maternal health. For this reason, I believe the role of women in both polio surveillance and response cannot be overlooked.”

Surprisingly, the report showed there were more men than women working as surveillance focal points in health facilities in northern zones of Nigeria, compared to the south. Using gender-disaggregated data helped the programme see where things need to change.

“WHO advocates for breaking…illusions that women cannot ‘fit in’ when it comes to disease surveillance practice,” says Dr Fiona Braka, Team Lead for the Expanded Programme on Immunization at WHO Nigeria.

Polio eradication was the first disease programme at the World Health Organization to develop a dedicated gender strategy. The Nigeria AFP surveillance gender study had never been done before and has helped lay the groundwork for further examination of the programme through a gender lens. The authors of the study found that the number of AFP cases detected in boys and girls was similar, as were polio vaccination rates.

Dr Braka observes, “Integrating or mainstreaming gender into all facets of socio-economic life is key to tackling gender inequalities.”

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A WHO team trains community volunteers and health workers on the user of AVADAR in Gurai, South Sudan. ©WHO/AFRO

Health workers and community volunteers in remote and security-compromised areas across ten African countries now rely on an SMS-based application to ferret out any possible poliovirus hiding in their midst.

The application is called AVADAR, short for “auto-visual AFP detection and reporting”, with AFP referring to acute flaccid paralysis, which is the main visible clinical symptom of poliomyelitis. AVADAR is an SMS-based mobile application used for reporting, monitoring and surveillance of poliovirus. It was developed in 2016 by the World Health Organization (WHO), in collaboration with the Bill & Melinda Gates Foundation and the Swiss software company Novel-T, to ensure that every case of wild poliovirus is detected.

On a weekly basis, the health workers and volunteers in selected hard-to-reach districts use the AVADAR application to report whether they have noticed any child with paralysis of a limb. The districts are selected based on being deemed high risk yet having the sufficient telecommunications infrastructure that allows the health workers and community volunteers to communicate with the investigations team.

“In the last mile of polio eradication, we are not sparing any resources to reach a polio-free world. That is why we developed the AVADAR app,” says Dr Pascal Mkanda, WHO Regional Coordinator of the Polio Eradication Programme for Africa.

In the WHO African Region, no outbreaks of wild poliovirus have been detected since 2016, when the last case was found in Nigeria’s Borno State. This brings the region closer towards being certified free of wild poliovirus in 2020.

Health workers and community volunteers use AVADAR to recognize and report cases of acute flaccid paralysis, which is the sudden onset of paralysis or weakness in any part of the body that can be caused by polio, among children younger than 15 years. Acute flaccid paralysis could be caused by other diseases than poliomyelitis.

“Polio eradication requires that the surveillance system is sensitive enough to detect all acute flaccid paralysis cases -regardless of the disease behind it- and that such cases are promptly reported and investigated by disease surveillance personnel. This system starts at the community level,” Dr Mkanda adds.

WHO team training community volunteers and health workers on the use of AVADAR in Cameroon. ©WHO/AFRO

Health workers and community volunteers first received training in workshops on how to use AVADAR and then they were each handed a smartphone with the application installed. On a weekly basis, the app sends them video reminders illustrating acute flaccid paralysis cases. The app then asks: “Have you seen a child with weakness of the legs or arms that you have not previously reported?” They then select between yes or no. If yes, the health workers and community volunteers input extra information about the case, such as the child’s name, date of onset of symptoms and geographic information.

Once the health worker presses the “send” button, a text message is sent to a system that triggers the sending of an SMS to the government and a WHO team that will investigate the case.

“In the AVADAR training workshops, we realized that some health workers and the majority of volunteers do not know the implications of acute flaccid paralysis and are unable to accurately identify such cases within their communities. The weekly AVADAR reminder videos helped improve that significantly,” says Dr Godwin Akpan, WHO Regional Polio Data Manager for Africa.

Dr Godwin is part of the team behind the innovation of the AVADAR application and trains health workers and community members on its use.

AVADAR was first piloted in Nigeria in 2016 and has been rolled out since 2017 in 99 districts of ten African countries: Burkina Faso, Cameroon, Chad, Democratic Republic of the Congo, Liberia, Mali, Niger, Nigeria, Sierra Leone and South Sudan.

As of October 2019, AVADAR has detected 1019 confirmed acute flaccid paralysis cases after health workers and community volunteers sent out 25,747 alerts through the application. None of those cases were polio cases. This marks a significant enhancement to the existing surveillance system that faces difficulties in remote and high-risk areas.

“Innovation and new technologies are our hope to finally make the feat of eradicating polio a reality. Thanks to the Global Polio Eradication Initiative, today, we are closer than ever to eradicating polio,” concludes Dr Mkanda.

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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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Reposted with permission from Rotary.org

Ready for a long day—vaccines are put in cold boxes as a part of the cold chain to reach as many children as possible in the door-to-door vaccination campaigns. © Rotary International.

From the epidemics in the 1950s to the 1000 cases per day in the 1980s, polio’s devastation has seeped across generations. That is, until Global Polio Eradication Initiative and anchoring partners, Rotary International, WHO, UNICEF, CDC, and most recently, the Bill & Melinda Gates Foundation, united efforts and resources to develop a comprehensive polio eradication infrastructure.

Ranging from cutting edge research to dedicated laboratories to community engagement to sewage sampling, the polio infrastructure is as widespread as it is comprehensive. With presence in over 200 countries, the polio programme is second to none, making it one of the largest public-private health partnerships in history.

While the polio eradication infrastructure helps get us closer to a polio-free world, did you know that it is also used to fight and protect against other diseases, too? Here are five examples of the polio infrastructure at work:

The cold chain

The Oral Polio Vaccine (OPV) requires constant refrigeration and vaccine must be kept cool between 2-8 degrees, or it risks losing its effectiveness. This is no easy task in countries and areas where electricity is either unavailable or unreliable.

So, the programme developed what is known as a cold chain system — made up of freezers, refrigerators, and cold boxes — to allow polio workers to store the vaccine and transport it over long distances in extremely hot weather. In Pakistan, a measles immunization program now relies on the same system. With the help of the cold chain, Sindh province recently reached its goal of immunizing more than 7.3 million children against measles.

Microplanning

A critical component in immunizing more children against polio, especially in remote regions, is microplanning. A microplan allows health workers to identify priority communities, address potential barriers, and develop a plan for a successful immunization campaigns.

The workers collect as many details as possible to help them reach and vaccinate all the children. This strategy has helped keep India polio-free for five years. Now the Mewat district of India is using microplanning to increase its rates of vaccination against measles and rubella.

Surveillance

The polio surveillance system helps detect new cases of polio and determines where and how these cases originated. Environmental surveillance, which involves testing sewage or other environmental samples for the presence of poliovirus, helps workers confirm polio cases in the absence of symptoms like acute flaccid paralysis (AFP).

In Borno state in Nigeria, the AFP surveillance system is now being used to find people with symptoms of yellow fever and was one of many tactics used during a 2018 yellow fever outbreak that resulted in the vaccination of 8 million people.

Contact tracing

Since polio is a transmittable disease, health workers use contact tracing to learn who has come in contact with people who might be infected. Contact tracing was also critical to containing an Ebola outbreak in Nigeria in 2014. When a traveller from Liberia was diagnosed with Ebola, Nigerian officials were able to quickly trace and isolate the traveller’s contacts, helping prevent the disease from spreading further.

The polio programme is meticulous in making sure we reach every child in every corner of the world. ©WHO/Chad

Emergency operations centres

An important part of the polio infrastructure that Rotary and its partners have built is the emergency operations centres network. These centres provide a centralized location where health workers and government officials can work collaboratively and generate a faster, more effective emergency response. The emergency operations centre in Lagos, Nigeria, which was originally set up to address polio, was adapted to handle Ebola, and it ultimately helped the country respond quickly to an Ebola outbreak. Only 19 Ebola cases were reported, and the country was declared Ebola-free within three months.

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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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After concerted efforts spanning decades, polio eradication efforts are in the homestretch and experts are advising how to fast-track the last mile.

The SAGE convened in Geneva from 2-4 April 2019 to discuss all things related to vaccines and immunizations, including poliovirus and the global eradication efforts around it. SAGE reviewed the latest global polio epidemiology, the new Global Polio Eradication Endgame Strategy 2019-2023, and what the post-eradication world could look like.

Interruption of wild poliovirus continues to be a priority for the success of GPEI at the latest SAGE meeting. ©WHO

Double down and escalate the fight to end wild poliovirus

While SAGE noted the achievements and the progress of the Global Polio Eradication Initiative—reducing the incidence of polio by 99%, absence of wild polio virus type 3 cases, and evidence of Nigeria being wild poliovirus free for over two years—the group displayed cautious optimism about meeting the timeline set out for global eradication of wild poliovirus.

The remaining challenges to fill vaccination coverage gaps—including restricted access, socio-political challenges, and large mobile populations—complicate the efforts to rid the world of poliovirus. However, the GPEI has developed a clear-cut five- year plan to secure a decisive win, the GPEI Polio Endgame Strategy 2019-2023, developed in broad consultation with stakeholders, including SAGE members.

Inactivated Polio Vaccine (IPV)—progress in roll-out continues

From the public health standpoint, Inactivated Polio Vaccine (IPV) can be used indefinitely even after polio eradication. As of April 2019, all 33 countries which had not yet introduced IPV into their routine immunization activities have now done so.

The projected IPV supply is thought to be sufficient enough for the introduction of a two-dose IPV schedule in all countries by 2022, and to catch-up all children missed due to earlier supply shortages, by 2020/2021.

Guidelines Endorsed

As per SAGE recommendations made in October 2016, GPEI developed guidelines for poliovirus surveillance among persons with primary immunodeficiency. After reviewing the guidelines, the SAGE endorsed the guidelines for implementation in high priority countries.

The meeting report will be published in the WHO Weekly Epidemiological Record by May 2019.

Strategic Advisory Group of Experts

The Strategic Advisory Group of Experts (SAGE) on Immunization was established by the Director-General of the World Health Organization in 1999 to provide guidance on the work of WHO. SAGE is the principal advisory group to WHO for vaccines and immunization. It is charged with advising WHO on overall global policies and strategies, ranging from vaccines and technology, research and development, to delivery of immunization and its linkages with other health interventions. SAGE is concerned not just with childhood vaccines and immunization, but all vaccine-preventable diseases.

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In a control room at the World Health Organization (WHO) Regional Office for Africa in Brazzaville, the smart screen projects the South Sudan map with a scattering of red dots—and even more popping up every now and then. These red dots are geo-coded locations for every healthcare facility being visited by surveillance officers to document active case search in real-time as it happens.

By simply using an application on their smart phones, the surveillance officers send their reports, even without internet connection, to the centrally generated map. Here in the control room, public health experts can quickly analyze data, visualize surveillance gaps, and conduct active case searches for priority diseases and routine immunization assessments at health facility levels. This is a game changer.

Maps and chart visualization of electronic surveillance system in South Sudan on the smart screen ©WHO/Sudan

“Since the advent of the mobile-based surveillance, it has made it possible to prioritize areas and the required interventions for immunization and surveillance,”, says Dr Atem Anyuon, Director General of the Primary Health Care Ministry of Health South Sudan. He also said that other stakeholders that support the EPI programme would have access and utilization of the mobile technology.

Bridging surveillance gaps through touch screens

Data collected by health workers and community informants from the field is aggregated on database servers, and then displayed on touch interactive screens. With just a touch, maps can be viewed, and charts and dashboards of data streaming in from the field can also be monitored.

Explaining the innovation, WHO Representative, Dr Olushayo Olu says, “Interacting with real-time data through the smart visualization screens helped us recognize gaps in surveillance and intuitively navigate the interactive maps of South Sudan”. Dr. Olu is optimistic that the platform will help inform actions to improve and support surveillance and other primary health services in the country.

Monitoring of the Immunization campaign in South Sudan using mobile phones for real-time data collection. ©WHO/Sudan

Progress towards certification standard documentation

In South Sudan, the technology has made clear where there are gaps in surveillance of Acute Flaccid Paralysis (AFP) – a symptom of polio – in hinterlands without internet. It also makes it easier and more transparent for staff to report what they are doing. . One of the achievements for South Sudan has been the active identification of over 6,000 cases of priority diseases across all the counties, with 85% of the AFP cases validated through geo-coordinates.

Cutting cost of active surveillance

“For me, my enthusiasm about innovating on this has been the fact that we can collect data with geographic information in places that do not have any form of network coverage and it sends the information whenever the health worker gets an internet source”, Mr Godwin Akpan, Data Management Officer of the Regional Office for Africa says.

WHO Representative and Polio Team Lead with colleagues in Juba, South Sudan, interacting with the data streaming on the real-time dashboards. ©WHO/Sudan

Akpan stresses that “There are the exciting possibilities of country teams having the freedom to slice and dice the data with various analytics on the smart screen; appropriate technology hitherto used for weather analyses by mega news conglomerates is being harnessed and is now available for use by countries in the African region – a first of its kind built around open source technologies at no recurrent cost except for the hardware.”

With the interactive smart screens, the Ministry of Health and WHO can now interactively analyze data from AVADAR (Auto visual AFP detection and Reporting), Esurv (electronic Surveillance), Immunization Campaign Monitoring, Mortality monitoring as well as the ‘Lots Quality Assurance’ survey.

The initiative is facilitated by the WHO Regional Office for Africa, with support from the Bill & Melinda Gates Foundation.

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On 15 March 2019 in Islamabad, representatives from the Embassy of Japan and the Japan International Cooperation Agency (JICA) were given a general update on the progress of the Polio Regional Lab and the surveillance network. Thanks to Japan’s funding, 70% of the latest molecular biology equipment has been procured, installed and made operational. JICA representatives also toured the facility and the works in process.

Representatives from JICA and the Embassy of Japan touring the Pakistan Regional Polio Lab facilities. ©WHO/Pakistan

The Government of Japan through JICA is a long-standing and committed donor to the polio eradication efforts by funding initiatives and broader immunization activities in Pakistan since 1996.

As a part of its more recent commitment, JICA is supporting Pakistan in strengthening disease surveillance through a state-of-the-art equipment of the Regional Reference Laboratory at the National Institute of Health in Islamabad.

The Pakistan Regional Polio Lab will go a long way in facilitating poliovirus detection in stool samples and the environment. At present, the lab tests more than 30,000 stool samples from people with paralysis and 950 environmental samples each year, including samples from both Afghanistan and Pakistan. The new soon-to-be operational lab equipment will speed up the ability to process and respond quickly wherever the poliovirus may be hiding. This is critical work in ensuring Pakistan targets its last remaining core reservoirs of poliovirus.

In this last mile of polio eradication, support from JICA is crucial and much appreciated. Pakistan is one of the last remaining polio endemic countries in world, along with Afghanistan and Nigeria. The political and financial commitment from the Government of Japan over the years has already helped Pakistan in reducing the number of polio cases by 96% since 2014. With only 12 cases reported in 2018, Pakistan has a fighting chance of finally consigning polio to the history books.

The Japan International Cooperation Agency (JICA)

The Japan International Cooperation Agency (JICA) assists and supports developing countries as the executing agency of Japanese ODA. In accordance with its vision of “Inclusive and Dynamic Development,” JICA supports the resolution of issues of developing countries by using the most suitable tools of various assistance methods, such as technical cooperation, ODA loans and grant aid in an integrated manner.

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Reuben Opara Ngofa (left) of WHO’s Africa Regional Office helps roll out the real-time surveillance system in Burkina Faso. ©WHO/Reuben Ngofa

In close collaboration with the Bill & Melinda Gates Foundation, WHO’s Regional Office for Africa is continuing to roll-out an innovative disease surveillance platform, enabling the real-time detection of suspected polio cases anywhere on the continent.

Thousands of health workers, volunteers and members of local communities across the continent have been equipped with geo-coded mobile phone technology, and trained to conduct regular and active surveillance visits to health centres across Africa. Professionals and volunteers are tasked to regularly visit local health clinics and actively check for the presence of any child with polio-like symptoms (known as acute flaccid paralysis – AFP), or to look for children in their communities presenting such symptoms. This information is subsequently fed back in real-time to national and regional authorities, enabling for rapid action and immediate dispatch of an investigative team as needed.

Real-time surveillance data in the Brazzaville GIS control room. ©WHO

“This really is the future of disease surveillance,” comments Reuben Opara Ngofa of WHO’s African Regional Office in Brazzaville, who was instrumental in developing this innovative system and who recently returned from Burkina Faso where he helped roll out the system in remote areas. “Particularly in remote or hard-to-reach areas, we need to know immediately if we have polio circulating in the area, and this system allows for real-time information, which in turn allows for an immediate real-time response. If one of our informants identifies a child with polio-like symptoms anywhere, we will know about it immediately. We are really giving the poliovirus nowhere to run.”

In addition to polio, this system helps detect and respond to other vaccine-preventable diseases, such as measles, yellow fever and neonatal tetanus. Across west Africa, measles vaccination coverage is being assessed through this system, and a cholera outbreak in 2018 in Ethiopia was actively tracked. It is a clear example of the polio infrastructure adding value over and beyond merely eradicating polio.

Thanks to such innovations, and efforts of dedicated professionals and volunteers across Africa, the continent stands on the brink of a historic public health success: the certification of wild poliovirus eradication. In 1996, when Nelson Mandela launched the Kick Polio Out of Africa campaign, wild poliovirus paralysed more than 75,000 children every year, across every African country.

No wild poliovirus has now been detected since 2016, and this real-time GIS surveillance system will provide crucial additional surveillance data, to truly validate the absence of wild poliovirus. Data generated through this system will be critically evaluated by the independent African Regional Certification Committee on polio eradication, when evaluating whether the Region as a whole can be certified as free of wild poliovirus in early 2020.

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The WHO AFRO Polio Team giving first-hand demonstration of ‘real-time’ surveillance system to delegates from KOICA. © WHO/AFRO — The WHO AFRO Polio Team giving first-hand demonstration of ‘real-time’ surveillance system to delegates from KOICA. ©WHO

During a visit to WHO’s Regional Office for Africa (AFRO) in Brazzaville by a delegation of officials from the Korea International Cooperation Agency (KOICA), delegates received a first-hand demonstration of the ‘real-time’ surveillance system for polio on the continent.

The WHO AFRO Polio Team giving first-hand demonstration of ‘real-time’ surveillance system to delegates from KOICA. © WHO

Dr Pascal Mkanda, head of AFRO’s polio eradication effort and his team demonstrated the newly-launched and real-time innovative mobile surveillance system, aimed at strengthening polio surveillance across the continent. Thousands of medical officers and health officers across the continent are dispatched to health clinics to actively search for cases of acute flaccid paralysis (i.e children with polio-like symptoms). Results of visits are communicated right back from the field level to the regional office in real time, via mobile phone technology.

This system is providing valuable and real-time evidence of poliovirus circulation, and helps drive strategic implementation. At the same time, the system is now being used to conduct active surveillance for other diseases, including cholera, NNT, measles, HIV and yellow fever, allowing for rapid response.

Developed in close coordination with the Bill & Melinda Gates Foundation, and are part of ongoing efforts to fill remaining subnational surveillance gaps, particularly in the lead-up to potential regional certification of wild poliovirus eradication (which could occur as early as late 2019/early 2020).

Africa’s polio eradication effort is generally supported by key private and public sector partners, including Rotary International. The Republic of Korea is a key partner in the effort, having contributed more than US$6 million to the effort, directly through KOICA. Support has been strategically allocated to supporting outbreak response and strengthening disease surveillance, and this visit builds further on Korea’s support to the global eradication effort. Strong disease surveillance is the underlying key strategic strategy, enabling rapid outbreak response as needed.

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Global health leaders at the opening session of the 144th Executive Board Meeting. © WHO

WHO Director-General Dr Tedros Adhanom Ghebreyesus opened the Organization’s Executive Board (EB) on 24 January with a report from his first visit of the year, to the polio endemic countries of Afghanistan and Pakistan: “This year I have taken over as chair of the Polio Oversight Board. That’s why my first trip of the new year was to Afghanistan and Pakistan. These are the two countries that are the last frontiers of wild poliovirus. We are so close to ridding humanity of this disease, and I am personally committed to ensuring that we do. I was really impressed by the commitment of the governments of Afghanistan and Pakistan.”

The Executive Board, comprised of 34 Member States’ designated experts in the field of health, convened in Geneva in late January to discuss a wide-ranging agenda on the most pressing and urgent health concerns of our times, including the urgency to rev up efforts in this last mile of polio eradication efforts.

The EB was encouraged by the progress achieved through the Endgame Strategic Plan 2013-2018, which has led the world to the brink of polio eradication and laid the groundwork for the new strategy – the Global Polio Eradication Initiative Strategic Plan 2019-2023. The new strategy will aim to sharpen the tools and tactics that led to the global progress in bringing down the case load from 350 000 annual wild polio virus cases in 1988 to only 33 cases in 2018. Success in the coming years will hinge on harnessing renewed financial and political support to fully implement the plan at all levels, with our one clear goal in sight: reach every last child with the polio vaccine to end this disease once and for all.

In a time of many global challenges and priorities, the coming year will require more than ever a singular commitment from the governments and partners as we near zero. On the sidelines of the EB, the DG held a stakeholder consultation to ensure that the 2019-2023 Strategic Plan reflects a transparent and inclusive stakeholder participation. The DG stressed the need for strengthened and systematic collaboration between partners, health, and non-health actors across cross-cutting areas of management, research and financing activities for polio eradication. Given that polio eradication effort continues to be a global priority, one of the salient features of the consultation was a renewed commitment to transparent long-term budgets for eradication efforts, including key post-certification costs such as stockpiles and inactivated polio vaccine to help protect more than 430 million children from polio each year.

“In a time of many global challenges and priorities, the coming year will require more than ever a singular commitment from the governments and partners as we near zero.”

Voicing similar sentiments earlier, Chairs of the effort’s main advisory bodies issued an extraordinary joint statement, urging all stakeholders, partners, countries, and individuals to strengthen their collective resolve to seeing polio fully eradicated for good. Polio continues to be a global health risk as confirmed at the end of last year, the Emergency Committee reiterated its advice that polio remains a public health emergency of international concern.

Polio resources for over three decades have helped reduce the number of endemic countries from 135 down to only 3 (Pakistan, Afghanistan, and Nigeria), eradicate polio from some of the most challenging areas in the world, and continue to enable countries around the world in advancing other national health goals.

With the continued commitment of all donors and partners, 2019 may very well become the decisive year when we finally stop wild polio virus transmission in Afghanistan and Pakistan.

The Endgame Plan through 2018 brought the world another year closer to being polio-free. While we had hoped to be finished by now, 2018 set the tone for the new strategic plan, building on the lessons learned and mapping out a certification strategy by 2023. 2018 was also marked by expanded efforts to reach children with vaccines, the launch of innovative tools and strategies, critical policy decisions and renewed donor commitment to the fight.

Dr Tedros Adhanom Ghebreysus, WHO Director General and Chair Polio Oversight Board, administering polio drops to a young child in Pakistan. WHO/Jinni — Dr Tedros Adhanom Ghebreysus, WHO Director General and Chair Polio Oversight Board, administering polio drops to a young child in Pakistan. © WHO/Jinni

Cornering wild poliovirus

Circulation of wild poliovirus (WPV) continues in the common epidemiological block in Afghanistan and Pakistan. However, both countries steadily worked to improve the quality of their vaccination campaigns in 2018 through National Emergency Action Plans, with a particular focus on closing any immunity gaps to put the countries on track to successfully stop WPV in the near future. Given the priority on polio eradication, WHO Director General, WHO Regional Director for the Eastern Mediterranean and President, Global Development at Bill & Melinda Gates Foundation started off the new year with a four-day visit to meet the heads of state and have a first-hand experience of the on-the-ground eradication efforts in both the countries.

In August, Nigeria marked two years since detecting any WPV. With continuing improvements in access to the country’s northeast, as well as efforts to strengthen surveillance and routine immunization, the entire African region may be eligible for being certified WPV-free as early as late this year or early 2020. What’s more, the world has not detected type 3 WPV since 2012 and the strain could be certified eradicated sometime this year.

Program innovation

The programme is constantly developing new ways to more effectively track the virus, vaccinate more children and harness new tools to help end the disease for good.
In Nigeria and the surrounding region, health workers launched new tools to enable faster, more comprehensive disease surveillance. e-Surve, a smartphone app, guides officers through conversations with local health officials, offering prompts on how to identify and report suspected cases of disease. Then, with the touch of a button, responses are submitted to a central database where health officials can analyze and track outbreaks across multiple districts in real-time.

Beyond surveillance, health workers worked tirelessly to bring the polio vaccine to the remote communities of Lake Chad. Dotted with hundreds of small islands, the lake is one of the most challenging places on earth to deliver health services. Vaccinators must travel by boat on multi-day trips to deliver polio vaccines to isolated island villages, using solar-powered refrigerators to keep their precious cargo cool. In 2018, vaccination campaigns on the lake reached thousands of children for the first time – children who would otherwise have gone unprotected.

Lake Chad Polio Task Team wave to polio vaccinators and community members on Ngorerom island, Lake Chad. © Christine McNab/UN Foundation

The programme also took important steps in developing new tools including, novel oral polio vaccine (nOPV), if studies show to be successful, could provide a safer form of OPV that provides the same level of protection without the small risk of vaccine-derived polio in under-immunized populations.

Battling circulating vaccine-derived poliovirus

In 2018, the Democratic Republic of the Congo, Niger, Nigeria, Papua New Guinea, Kenya, Somalia and Mozambique experienced outbreaks of circulating vaccine-derived polio (cVDPV). Although these cases are still rare – and only happen in places where immunity is low. The polio eradication initiative has two urgent tasks: eradicate WPV quickly as possible and stop the use of OPV globally, which in tandem will prevent new cVDPV strains from cropping up.

The program uses the same proven strategies for stopping wild polio in responding to cVDPV cases. These strategies, coupled with the rapid mobilization of resources on the ground, can bring outbreaks under control.

In December, an international group of public health experts determined that the 2017 cVDPV2 outbreak in Syria has been successfully stopped. This news follows 18 months of intensive vaccination and surveillance efforts led by the GPEI and local partners in conflict-affected, previously inaccessible areas. In Papua New Guinea, the programme carried out 100 days of emergency response this past summer and is continuing to vaccinate and expand surveillance across the country.

Bringing an end to ongoing cVDPV outbreaks remains an urgent priority for the program in 2019.

New policy decisions

At the World Health Assembly in May, Member States adopted a landmark resolution on poliovirus containment to help accelerate progress in this field and ensure that poliovirus materials are appropriately contained under strict biosafety and biosecurity handling and storage conditions. The programme also finalized a comprehensive Post-Certification Strategy that specifies the global, technical standards for containment, vaccination and surveillance activities that will be essential to maintaining a polio-free world in the decade following certification.

Recognizing the ongoing challenge posed by cVDPVs, the Global Commission for the Certification of Poliomyelitis Eradication (GCC) met in November and recommended an updated process for declaring the world polio-free. This plan will start with the certification of WPV3 eradication, followed by WPV1, and include a separate independent process to validate the absence of vaccine-derived polio.

Comprised of members, advisers, and invited Member States, the 19^th IHR Emergency Committee met in November. The Committee unanimously agreed that poliovirus continues to be a global emergency and complacency at this stage could become the biggest hindrance. “We have the tools, we need to focus on what works, we need to get to every child,” commented Prof. Helen Rees, Chairperson of the Committee. “The reality is that there is no reason why we should not be able to finish this job, but we have to keep at it.” “We have achieved eradication of a disease once before, with smallpox,” Rees concluded. “The world is a much better place without smallpox. It’s now more urgent than ever that we redouble our efforts and finish this job once and for all as well.”

Six-year old Gafo was the first polio case in Papua New Guinea in decades, which prompted a national emergency and an outbreak response. © WHO/PNG

Spotlight on gender

In 2018, the GPEI took major steps in adopting a more gender-responsive approach and strengthening gender mainstreaming across its interventions. The GPEI Gender Technical Brief highlighted the programme’s commitment to gender equality and included a thorough analysis of various gender-related barriers to immunization, surveillance and communication.

The programme introduced new gender-sensitive indicators to ensure that girls and boys are equally reached with polio vaccines, to track the timeliness of disease surveillance for girls and boys, and to monitor the rate of women’s participation as frontline workers in the endemic countries. The GPEI continues to regularly collect and analyze sex-disaggregated data and conduct gender analysis to further strengthen the reach and effectiveness of vaccination campaigns.

Donor and country commitments

Throughout 2018, political leaders around the world voiced their support for the programme’s efforts, including Prime Minister Trudeau, WHO Director General Dr Tedros, Prime Minister Theresa May, His Highness Sheikh Mohamed bin Zayed Al Nahyan and His Royal Highness Prince Charles. Leaders demonstrated commitment by advocating for a polio-free world at various global events, including the G7, G20, CHOGM, and the annual Rotary Convention.

Donor countries made new financial contributions to the programme in 2018. Polio-affected countries also demonstrated continued political commitment to eradication efforts. The Democratic Republic of the Congo signed the Kinshasa Declaration committing to improve vaccination coverage rates in sixteen provinces throughout the country, and Nigeria approved a $150 million loan from the World Bank to scale up immunization services and end polio.

Looking ahead: 2019 and beyond

Over the last five years, the programme has been guided by the 2013-2018 Polio Eradication & Endgame Strategic Plan, helping to bring the world to the brink of polio eradication. This spring, the programme will finalize a new strategy –GPEI Strategic Plan 2019-2023– which will aim to sharpen the tools and tactics that led to this incredible progress. In 2019, the GPEI will also launch its first-ever Gender Strategy to further guide its gender-responsive programming and to increase women’s meaningful and equal participation at all levels of the programme.

Success in the coming years will hinge on harnessing renewed financial and political support to fully implement the plan at all levels, with our one clear goal in sight: reach every last child with the polio vaccine to end this disease once and for all. Echoing similar sentiments, Chairs of the effort’s main advisory bodies issued an extraordinary joint statement, urging all to step up their performance to end polio. 2019 may very well be the watershed year that the world will finally eradicate polio, thanks to the global expertise and experience over 3 decades.

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In an extraordinary joint statement by the Chairs of the main independent, advisory and oversight committees of the GPEI, the Chairs urge everyone involved in polio eradication to ensure polio will finally be assigned to the history books by 2023. The authors are the chairs of the Strategic Advisory Group of Experts on immunization (SAGE), the Independent Monitoring Board, the Emergency Committee of the International Health Regulations (IHR) Regarding International Spread of Poliovirus and the Global Commission for the Certification of the Eradication of Poliomyelitis (GCC).

The Endgame Plan through 2018 has brought the world to the brink of being polio-free. A new Strategic Plan 2019-2023 aims to build on the lessons learned since 2013.

The joint statement urges everyone involved in the effort to find ways to excel in their roles. If this happens, the statement continues, success will follow. But otherwise, come 2023, the world will find itself exactly where it is today: tantalizingly close. But in an eradication effort, tantalizingly close is not good enough.

The statement therefore issues an impassioned plea to everyone to dedicate themselves to one clear objective: to reach that very last child with polio vaccine. By excelling in our roles. It means stepping up the level of performance even further. It means using the proven tools of eradication and building blocks that have been established in parts of the world that have been free of polio for years.

The Chairs remind us that as a global community, we have stood where we stand today once before, with smallpox. And we achieved the eradication of smallpox. And the world is a much better place without smallpox.

So, let us make the world again a better place. Together. Let us eradicate polio.

Joint statement by of the main, independent, advisory and oversight committees of the GPEI

Response to the statement by WHO Director-General and Chair of Polio Oversight Board Dr Tedros Ghebreyesus

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

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

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

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

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

Gaining high-level political goodwill

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

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

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

A regional response to support high-risk populations

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

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

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

Using technology to reach more children

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

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

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

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

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

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

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

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

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

Recommendations made

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

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

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

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

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

Polio eradication efforts in Kenya

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

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

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

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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.