What we've learned about reaching every last child

By Hamid Jafari 19 May 2015

A health worker in Pakistan marks the fingers of children with indelible ink to show that they have been vaccinated against polio. For the first time in history, polio has paralyzed children in only two countries. Photo by: A. Zaidi / UNICEF

There was a time when nearly every country in the world had children paralyzed by polio. But this year, for the first time in history, polio has paralyzed children in only two countries.

The Global Polio Eradication Initiative, a public-private partnership, has managed to reach and vaccinate almost every last child on earth in a bid to rid the globe of this disease. The lessons of this effort that has spanned two decades provide a blueprint to both eradicate the disease and reach the most vulnerable human beings in the world with health services.

Perhaps the most important lesson from the polio success is the oft-repeated mantra of the importance of government ownership. Governments of nearly every country in the world, from Bangladesh to Bolivia, have owned the polio eradication program and delivered on their promise to end the disease.

India, which eight years ago led the world in the number of children paralyzed by polio, instituted rigorous accountability at every level of government, which meant that no poliovirus went unfound and no child went unvaccinated: India is now polio-free. Nigeria, the only country in Africa where polio had never been stopped, has invested substantial financial and human resources in recent years to establish strong accountability and performance indicators. This commitment is what powers innovation and spawns results. For the first time ever, nine months have passed without a single child being paralyzed by wild poliovirus in Nigeria or the rest of Africa.

Polio eradication has opened doors for the overall delivery of health services. Poliovirus has forced us to find numerous ways to reach every child — and we are still counting.

In our quest to know where unvaccinated children are and get to them faster than the virus can, we have harnessed old methods as well as new, from talking to village elders to find out about settlements in the bush to using the latest technology to put those settlements on a map and ensure vaccinators reach them. Governments have responded to what communities want and provided health camps in which polio and other immunizations are offered alongside other health interventions and information. In countries with large polio eradication infrastructures, such as Chad, the immunization campaigns for diseases such as measles, meningitis and yellow fever are carried out through the polio network. More than 125 countries are moving rapidly to introduce a new, inactivated poliovirus vaccine to optimize the protection of their children.

History has shown us repeatedly that the communities are at the heart of a health intervention. Many countries have established formal systems of engagement with the community through a range of mechanisms: traditional and religious leaders, women’s and youth groups, mobilizers in hard-to-reach settlements, volunteers vaccinating in their own communities, and last but not least, survivors of polio. The full involvement and indeed leadership of these groups have been key to our ability to reach every last child with polio vaccine.

Finally — and most poignantly in Afghanistan, Nigeria, Pakistan, Somalia and Syria — polio eradication has shown that we can deliver services even in the most difficult humanitarian situations. We don't have to delay protecting children while waiting for peace and tranquillity.

Understanding that poliovirus now scrambles to find unvaccinated children among the hardest-to-reach communities or in conflict zones, health workers tailor their tactics to reach those most vulnerable communities. When people are on the move to escape conflict, the polio program sets up vaccination on the roadside, at toll booths, on buses to reach children in transit and in the communities hosting the displaced. Where there are political barriers, workers are enabled and resourced on each side of the conflict to vaccinate within their own communities. If conflict prevents people from accessing vaccination services, as soon as there is an opportunity, a series of short vaccination campaigns are run to get in and out of an area quickly.

What we need now is to fine-tune and continue to innovate as we apply these lessons to get us across the finish line and ensure no child ever again suffers from this crippling disease. So far this year, there have been 23 cases of polio in Pakistan and one in Afghanistan. These 24 paralyzed children are a stark reminder that we’re not done. Continued government commitment and a focus on the communities where children are still being missed are keys to the improvements we need to make sure Afghanistan and Pakistan succeed in joining the polio-free world.

When we prioritize and refine our strategies based on these lessons, one clear priority is strengthening surveillance to find polio. As there is less and less poliovirus in the world, we will have to look harder for it. We have to make sure we find the virus so that we can respond quickly.

We must also intensify our focus on vaccinating missed children rather than overall vaccination coverage — a significant shift in mindset. This means using all methods possible to vaccinate those children who are most vulnerable, on the move, living in insecure and conflict-affected zones, and where we have not effectively engaged communities. When the “missed” children are protected, the virus will be left with nowhere to hide.

We owe it to every last child out there to finish this job. Not only will polio eradication mark another major achievement for mankind, but the lessons, the knowledge and the expertise we have acquired on this journey will also help us reach crucial future health goals.

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About the author

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Hamid Jafari

Dr. Hamid Jafari is the director of global polio eradication operations and research at the World Health Organization headquarters in Geneva. Before this appointment in March 2012, Jafari served as the project manager of WHO's National Polio Surveillance Project in India. He also served as director of the global immunization division at the U.S. Centers for Disease Control & Prevention and as the medical officer for polio eradication in the regional office of WHO for Eastern Mediterranean.


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