Statement on polio from Dr Ahmed Al-Mandhari to the 73rd World Health Assembly
When we last convened, it was a very different world. The COVID-19 pandemic was hitting its early stride, and the polio programme in our Region had just stepped forward bravely to meet this new public health challenge, working alongside national health programmes and, in countries with limited or weakened health infrastructure, stepping into the breach.
In the intervening months, I observed as the polio programme in some of the most complex countries in this Region – Pakistan, Afghanistan, and others – paused their polio eradication activities and applied their considerable skills to the COVID-19 pandemic.
1243 staff were engaged in COVID-19 response. Polio’s contact tracing systems, surveillance networks and workforce were rapidly deployed in a chaotic, fast-changing operating environment to identify COVID-19 cases, their contacts, surveil for symptoms and roll out waves of testing and health education. What was apparent to me in the mid-year months was that the investments we have made in polio eradication are actually investments in broader public health infrastructure and pandemic response.
Unfortunately, COVID-19 exacted a heavy toll on the polio programme. More than 200 of our polio personnel have been infected since the start of the pandemic, and three of them lost their lives due to COVID-19.
The pandemic cost us the opportunity to vaccinate 50 million children. Meanwhile both wild and vaccine-derived polioviruses spread unchecked. In July, polio vaccination campaigns re-started, with vaccinators equipped with PPE and using no- and low-contact techniques. We have successfully carried out large-scale campaigns in Pakistan, Afghanistan, Syria and parts of Yemen since the restart. Polio workers across the region are to be commended for the speed at which they trained on new COVID-era techniques and behaviours, and their successful and ongoing resumption of campaigns.
We celebrated the certification of African Region as free of wild poliovirus and are redoubling our own efforts as the last remaining polio endemic Region. Now is the time to be shoring up the polio programme and mobilizing funding, including domestic funds, so that this remarkable public health and pandemic response mechanism can remain robust and can be integrated into broader public health services across the region. Now is the time for full regional solidarity and mobilization.
I am pleased to report that the Regional Committee reaffirmed its commitment in a resolution to complete wild poliovirus eradication and polio transition. The Member States resolved to stop all cVDPV outbreaks and prepare for the introduction of the novel OPV type 2. I am also particularly pleased by the commitment of Ministers of Health in our region to bring their own wisdom, influence and authorities in the newly established Regional Sub-Committee for Polio Eradication and Outbreaks. Moreover, I have given polio transition my close attention, establishing and chairing the Regional Steering Committee on Polio Transition. The committee has been working towards adapting our polio transition strategies and coordinating with priority Member States in the evolving context of COVID-19. The contribution of the polio programme to the pandemic has highlighted the added value and feasibility of cross-programmatic integration, with the setting up of integrated public health teams in priority countries in the region. It is very important for us to move ahead in implementing polio transition strategies, to strengthen national immunization programmes and support country readiness for the introduction and equitable distribution of COVID-19 vaccines, as well as strengthen emergency preparedness and response, and health systems.
Listen to Dr Al-Mandhari’s statement, presented in the fourth meeting of Committee A, Item 11 (Pillar 1)
Region galvanizes around polio eradication during the 67th Regional Committee
Renewed political commitment drives likely formation of new subcommittee for polio eradication and outbreaks.
14 October 2020 – Yesterday the 67th Regional Committee for the Eastern Mediterranean discussed a resolution on polio, which includes the creation of a new ministerial regional subcommittee to focus on the most critical barriers standing in the way of polio eradication.
Following the certification of the African Region as free of wild poliovirus, the Eastern Mediterranean Region is the only region in the world still harbouring wild poliovirus. After a bruising 2019 where we saw wild poliovirus on the rebound in Afghanistan and Pakistan, 2020 dawned with high hopes that the programme would be able to shift gear and make up for lost ground. The COVID-19 pandemic put the brakes on those plans and added untold layers of complexity to the provision of health care, but it hasn’t destroyed the dream. The new subcommittee, if adopted, will be a strong demonstration of Member States’ political commitment and solidarity towards getting polio eradication back on track.
The risk of international spread of poliovirus remains a public health emergency of international concern. During 2020, the Region has experienced new outbreaks of vaccine-derived poliovirus in Sudan and Yemen, even as the outbreaks in Somalia, Afghanistan and Pakistan continue to paralyse children. The new subcommittee would aim to intensify support to these countries. An immediate priority is advocating for the domestic and international financial resources needed to close outbreaks and eradicate the disease once and for all.
In the next few months, the polio programme plans to roll out a new type 2 oral polio vaccine, specifically designed to tackle vaccine-derived outbreaks. This is likely to have a transformative effect on our abilities to protect children and stop outbreaks spreading further. But the introduction of a new vaccine does not negate the importance of other tactics to fight vaccine-derived polio, including high quality disease surveillance, building community vaccine acceptance and strengthening routine childhood immunization.
The messages the subcommittee would likely convey in its reports to WHO's governing bodies apply to all polioviruses: that routine and supplementary immunization systems must improve across the Region, and every child must receive the vaccines they need. The subcommittee would also work to promote political and social neutrality and facilitate access to all children living in conflict-affected areas.
The subcommittee would be made up of health ministers from interested Member States of the Region, with special invitations extended to representatives from Afghanistan and Pakistan. The group would meet four times a year.
During the Regional Committee meeting, the Governments of Egypt, Islamic Republic of Iran and Pakistan expressed a desire to lead the charge by joining the subcommittee. If the resolution is adopted, WHO will be inviting all ministers of health to express their interest in becoming members.
The Pakistan representative stated, “The Government of Pakistan welcomes and supports the establishment of a subcommittee of polio eradication. Dr Faisal Sultan, the Special Assistant to the Prime Minister on Health, has expressed his willingness to take part in the subcommittee, which will undoubtably provide an ideal platform to strengthen regional cooperation and support Afghanistan and Pakistan in successfully eradicating poliovirus across the shared epidemiological block.”
Dr Hamid Jafari, WHO Regional Director for Polio Eradication, thanked Member States for offering their support for the creation of the subcommittee, and the entire resolution, saying, “This is a crucial step forward to regain ground lost against the poliovirus in the last two years. Strong political commitment to the polio eradication goal is paramount for us to defeat this disease”.
In the run up to World Polio Day on 24 October, the adoption of the resolution would be a meaningful step forward towards achieving a polio-free future for all children in the Eastern Mediterranean Region. The WHO continues to emphasize the importance of high-quality immunization for every child, and advocates for access to every community in order to reach all children with vital health services.
Statement on polio outbreaks in the Eastern Mediterranean Region
6 September 2020 – The polio programme is responding to 2 new polio outbreaks in the Eastern Mediterranean Region: one in Sudan, and one in Yemen. Both outbreaks are consequences of increasingly low levels of immunity, and each has paralysed children in populations that have been difficult or impossible to reach with routine or supplementary polio vaccination for extended periods of time.
In Sudan, the polio programme is responding to paralytic polio caused by vaccine-derived poliovirus type 2 (VDPV2). The virus has been detected in children in 9 states, as well as in 3 sewage samples in Khartoum, indicating widespread circulation. Vaccine-derived poliovirus type 2 is a strain of poliovirus that emerges and paralyses children in communities where immunization levels against polio are too low. Sudan is at high risk of further virus spread due to extensive population movement by nomadic communities and people displaced by conflict, and frequent movement between neighbouring countries.
In Yemen, paralytic polio caused by vaccine-derived poliovirus type 1 (VDPV1) has been detected in Sa’adah governorate, in the war-ravaged country’s north-west. The cases in Yemen are clustered in an area that has very low routine immunization levels, has been inaccessible to the polio programme since late 2018, and has been a source of growing concern for those reasons.
Confronting outbreaks in Somalia
While the COVID-19 response dominates community health concerns, every missed opportunity for vaccination puts the fragile gains made against polio in Somalia at risk of being undone
22 July 2020 – For Somalis, COVID-19 is the most immediate crisis in a seemingly unending cycle of floods, food insecurity, conflict and outbreaks of vaccine-preventable diseases like measles, cholera and polio. Against this backdrop, WHO’s polio programme is working to steer the COVID-19 response and, more broadly, maintain vaccine immunity levels and improve access to health care. It’s no easy feat.
Dr Mohamed Ali Kamil, the outgoing WHO Polio Team Lead and COVID-19 incident manager for Somalia, is in awe of the commitment shown by health staff. He recently phoned a polio logistician diagnosed with COVID-19 who was experiencing symptoms to insist he stop working remotely from his sickbed. Dr Kamil recalls he said, “No sir, I will continue.”
Since the first COVID-19 case was diagnosed in Somalia on 16 March 2020, the polio programme has fought the pandemic from the ground up. Dr Kamil explains, “No other health programme has comparable expertise to serve the Somali population during the COVID-19 outbreak. During their time in the programme, members of the polio team have responded to many different disease outbreaks. This meant they were well placed and well trained to respond to COVID-19.”
“The polio programme has spent years building staff capacity and systems to implement vaccination campaigns and detect poliovirus in the community. In some ways, the team are the first and last line of defence.”
The response includes education, case identification, contact tracing, case management and data support. As of June 2020, polio staff working as part of rapid response teams had reached 2.6 million people with messages about COVID-19 prevention. District Polio Officers within the teams have led the investigation of over 4500 people with suspected COVID-19 across the country. The country has set up 3 COVID-19 testing facilities and the polio structure established for the collection and shipment of stool samples from acute flaccid paralysis (AFP) cases has been used for the transportation of COVID-19 samples.
Throughout, polio personnel have continued their full-time work to end the circulating vaccine-derived poliovirus (cVDPV) outbreaks that have thus far paralyzed 16 children since 2017.
The team are driven by a humanitarian commitment to the Somali population, who have suffered over 30 years of protracted conflict and insecurity. At least 5.2 million people are in need of humanitarian assistance, and secondary and tertiary health care is virtually non-existent outside of a few large cities. Health literacy is low, and populations are highly vulnerable to diseases like polio, measles, cholera and now COVID-19. In November 2019, widespread flooding brought further turmoil and danger to Somali families.
The team’s work is made more difficult by the emotional toll wrought by the pandemic. To date at least 143 health workers have been identified with COVID-19 infection. In April, Ibrahim Elmi Mohamed, a District Polio Officer who spent 19 years striving for a polio-free Somalia, died of a COVID-19-related illness. His death, one of the many of frontline staff around the world due to COVID-19, remind us of the risks they face every time they go to work.
Challenges lie ahead to defeat polio
Dr Kamil is clear that the polio programme will require ongoing funding and the support of authorities, partners and communities in order to maintain polio activities amid the pandemic.
“To sustain the immunity gains we must implement a number of polio vaccination campaigns each year until the routine immunization programme can reach every Somali child with all polio vaccines. Somalia is extremely fragile and at high risk of becoming endemic for poliovirus if we do not maintain and support the polio infrastructure,” he says.
Since the cVDPV outbreaks were first detected in 2017, the programme has streamlined disease surveillance for cases of AFP and other preventable diseases, including by introducing mobile technology to record details of suspected cases. For the first time, environmental disease surveillance was introduced. Over 3 years, frontline health workers have implemented more than 15 polio campaigns, including integrated campaigns with the measles programme.
Dr Kamil explains, “We still don’t know where the virus is coming from exactly. There are many inaccessible areas, where we cannot deliver vaccines or respond with immunization campaigns. We suspect that the virus is circulating among vulnerable children and communities living in these areas.”
Dr Kamil feels strongly that the polio programme has a duty to support other health interventions. He says, “COVID-19 shows what the frontline polio staff can achieve and the strength of surveillance and response systems.’’
Despite the challenges, Dr Kamil retains his belief that with ongoing funding and support, the cVDPV outbreaks in Somalia can be brought to a close. He reflects, “COVID-19 is a huge emergency in Somalia. Our staff are working flat out, and we expect to see many more cases, but at the same time we must continue to fight polio. The Somali community and the world deserve to be free of this disease.”
“We must reschedule our March polio vaccination campaign which was delayed because of the COVID 19 outbreak. We must do everything possible to keep health workers safe from COVID-19. It’s a hard situation, but we must not stop until we overcome both viruses.”