It Ends Here

Polio still lurks in three countries. Our local experts explain why.

We are tantalizingly close to ending polio. Of the disease’s three strains, we haven’t seen a case of type 2 since 1999 or of type 3 since 2012. All the polio cases in the world now stem from only three countries: Nigeria, Pakistan, and Afghanistan. If we can end polio in these three nations, we will shut the door on the disease forever.

Technological advances have facilitated our progress: We can target our vaccines to specific strains and use mapping software to help ensure that health workers reach children everywhere. We’ve received funding commitments from everyone from governments to international institutions to nonprofits – and you. One of the biggest remaining challenges is security; violence in all three of the endemic countries threatens to keep the vaccine away from children.

In late July, the leaders of Rotary’s polio eradication efforts in these countries – Tunji Funsho, chair of the Nigeria PolioPlus Committee; Aziz Memon, chair of the Pakistan PolioPlus Committee; and Mohammad Ishaq Niazmand, chair of the Afghanistan PolioPlus Committee – came to Evanston to discuss their progress, challenges, and opportunities.

NIGERIA

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A Rotary volunteer monitors polio vaccinations in Kano.

Of the three remaining endemic countries, Nigeria is closest to stopping the transmission of polio. As of 6 August, it had only five recorded cases in 2014, compared with 42 at the same time last year. And four of those five cases were clustered in the northern state of Kano. Routine immunization coverage jumped from 36 percent of children in January 2013 to 55 percent in December 2013. “Routine immunization is what will get us there,” Funsho says.

Strengthening the health care infrastructure is key to achieving broad acceptance of the polio vaccine in Nigeria (and all the endemic countries), where other childhood diseases such as malaria, diarrhea, and respiratory illnesses are at the forefront of people’s minds. In May, Rotary began funding health camps, where doctors and nurses supplied by the government meet primary health care needs – and administer polio vaccine. The camps have been a “game changer,” Funsho says. “It’s a magnet to draw people out of their homes to get the OPV [oral polio vaccine].”

While the country has never been closer to ending polio, violence in northern Nigeria threatens to impede progress. Boko Haram militants have killed thousands of people, including polio vaccinators, during their five-year insurgency, and are behind the kidnapping of more than 200 schoolgirls that made headlines earlier this year (as of press time, they still had not been released). For several months in 2013, health workers couldn’t vaccinate children in Borno State at all. But recent military action by the Nigerian government drove the insurgents out of cities, Funsho says, and immunizations have resumed: In March, 12 percent of Borno’s children could not be reached, down from 45 percent in July 2013. Rotary and its partners are implementing techniques to reach children in volatile places, such as concentrating health teams at the borders of unsafe areas and sending in many teams at once to vaccinate as quickly as possible when security analysts say it’s relatively safe.

PAKISTAN

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Police escort health workers in Karachi, where militants have murdered vaccinators. Polio cases are on the rise in Pakistan after the Taliban issued threats against immunization efforts, but recent military action may make it easier for vaccinators to reach children.

The fight to end polio has reached a critical moment in Pakistan. More than half the country’s cases are in North Waziristan, a Taliban-controlled area bordering Afghanistan, where militants banned all health workers in 2012. The result was an explosion of cases in the country, from 58 in 2012 – when eradication seemed within reach – to 93 in 2013, and 104 already this year as of 6 August. But in June, Pakistan’s military launched a massive operation to flush the Taliban from the area, and vaccinators have since reached 350,000 children who were previously inaccessible. The fighting produced an estimated 1.5 million refugees, who have fled to other parts of the country and into Afghanistan. “That area is now free,” Memon says. “It’s a blessing and a challenge because displaced persons are a big issue, a human issue.”

To reach these and other children, Rotary and its partners are using a multipronged approach that includes health camps; vaccinations at transit points such as bus stations, railways, and airports; permanent immunization facilities; and, following a model successful in India, polio resource centers in high-risk areas, which involve local activists in educating their communities. The Pakistan PolioPlus Committee has established eight of these centers so far.

Rotary and its partners are piloting a cell phone project to help keep better health data on children in the country. In nine districts in Pakistan, 572 midwives received cell phones pre-loaded with software that allows them to track pregnant women and the birth and immunization of their children. The information is shared with the World Health Organization and UNICEF and entered into their databases. Rotarians also partnered with Coca-Cola Beverages Pakistan to build a reverse osmosis water filtration plant near a school in Malir, in Karachi, battling polio at its source: drinking water contaminated by human waste.

“Rotarians are fully committed, and risking their lives in these troubled areas,” Memon says.

AFGHANISTAN

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Health workers have received letters of safe passage from the Afghan Taliban, which has supported polio eradication. Only one case of polio endemic to Afghanistan has been reported in the last 18 months; the rest of the country’s cases are genetically related to poliovirus from Pakistan.

As Pakistan goes, so goes Afghanistan. “We are interconnected,” Niazmand says. Only one case of polio endemic to Afghanistan has been reported in the past 18 months; the remaining cases, including eight this year as of 6 August, are genetically related to poliovirus from Pakistan. (The most recent case was carried over from Pakistan to Afghanistan by a child displaced by the military action in North Waziristan; an estimated 100,000 refugees from Pakistan have entered the country since June.)

Unlike the Pakistani Taliban, which has repeatedly attacked health workers, the Afghan Taliban, which is loosely related, has for years cooperated with Rotary and its partners to eradicate polio. Vaccination teams received letters guaranteeing safe passage, and case counts decreased from 37 to 14 from 2012 to 2013. But in March, the Taliban temporarily halted vaccinations in Helmand Province, where they accused health workers of spying on their leaders. Two National Immunization Days have been canceled, depriving an estimated 655,000 children of the vaccine. “The challenges are the same in all our countries,” Niazmand says. “Insecurity is the biggest challenge. It’s the challenge for the program. And it’s the challenge for those vaccinators who are the vanguards, who are the real heroes for the program.” Another challenge: the transition period around the recent presidential election (the run-off was held on 14 June, and as of press time, the race was still contested) and uncertainty about whether the new government will provide the support necessary to complete eradication.

Niazmand and other Rotarians in the country represent Rotary in all national-level polio eradication forums. (At press time, there was only one active Rotary club in Afghanistan.) Rotary has also directly paid for the vaccination of 18,800 people on average per month traveling from Afghanistan to India. And, like in other countries, Rotary and its partners are holding health camps and working to improve the primary health care system to win local support and reach more children. “When you constantly say ‘polio, polio, polio,’ that is creating a kind of polio fatigue,” Niazmand says. “Serving other health needs is an incentive to the communities.” — Diana Schoberg