Joining hands to ensure polio transmission remains at zero in Ethiopia

AWBARE, Somali region– Ermias Amare and Salah Kedir, health workers in Ethiopia’s Somali region, zip through the arid plains kicking up a trail of dust as they ride their motorcycle to the next settlement where they will be administering polio vaccines to children under the age of 5 years.

It is campaign time in Ethiopia’s Somali region, and the two health workers are on a mission that is critical for the well-being of Ethiopia’s children.

Ermias and Salah are taking part in the National Immunisation Days (NIDs) campaign, vaccinating children against polio with the oral polio vaccine (OPV) in the Somali region. Vaccination against polio is essential to prevention of this crippling, disabling and potentially fatal disease which, is easily contracted from person to person, and especially dangerous to individuals and populations when there is not sufficient immunity, or protection, against the virus. The consequences of polio disease are devastating, for a child, for a family, and for a community.

Salah Kedir, clinical nurse (left), fills out vaccination records outside the hut of Sophia Abdi in Dudejirma sub-district, Rer Hassen Settlement,Tulugulid District, Fafan Zone. Three year old Sehardid Ali Hassen (standing) and his baby brother Umer Keyir Ali Hassen, one years old, have been vaccinatied by clinical nurse Ermias Amare (right), during the Polio NIDs campaign in Somali Region, 9 February 2015. THe half-tick mark on the hut's opening flap indicates that not all the children who live their under the age of five have been vaccinated.Sophia's eldest daughter (five years old) is out wtending the families goats, and the vaccination team makes an appointment to return the next day to vaccinate her as well. ©UNICEF Ethiopia/2015/Getachew
Salah Kedir, clinical nurse (left), fills out vaccination records outside the hut of Sophia Abdi in Dudejirma sub-district, Rer Hassen Settlement,Tulugulid District, Fafan Zone. Three year old Sehardid Ali Hassen (standing) and his baby brother Umer Keyir Ali Hassen, one years old, have been vaccinatied by clinical nurse Ermias Amare (right), during the Polio NIDs campaign in Somali Region ©UNICEF Ethiopia/2015/Getachew

Most of the children in the village visited by Ermias and Salah have their finger marked with ink, indicating that they have already been vaccinated during this present campaign.

In August 2013, the Dollo zone of Somali region, in the southeastern corner of Ethiopia bordering Somalia, was hit by a polio outbreak. Tragically 10 children were paralysed as a result of wild poliovirus (WPV) infection. Since the beginning of the polio outbreak, 15 National and Sub-national Immunisation Days (NIDs/SNIDs), have been conducted to date to respond to the outbreak. The total number of WPV cases reported since the start of the outbreak remains at 10 – the last case confirmed 18 months ago. Maintaining the momentum of response efforts has been be critical to ensure no more polio cases are seen in Ethiopia.

Social Mobilisation  

Communication and social mobilisation efforts have been instrumental in the interruption of the WPV transmission in the Somali region. In Lafaisa kebele (sub-district) of Awbare (woreda) district, a town crier mobilizes the community through a megaphone to alert parents that children under the age of 5 years will be receiving polio vaccinations during the campaign.

Nearby, a village Sheikh, trained by the Somali Regional Health Bureau (SRHB) in partnership with UNICEF and the Islamic Affairs Supreme Council, gathers mothers and children for a discussion about the campaign where he explains the benefits of immunisation and urges them to have their children vaccinated. Among the strategies deployed by the SRHB and UNICEF to meet the need for information was to engage religious leaders to council the pastoralist communities, particularly women, about the importance of vaccinating their children, for every round. The eminent position that religious and clan leaders hold in pastoral Somali communities and their ability to mobilize the population, has become a key factor in the success of immunisation activities.

Town crier in Lafaisa subdistrict, Awbare District, using a megaphone to alert parents that children five years and younger will be receiving polio vaccinations during the Polio NIDs Campaign in Somali Region, 9 February 2015. ©UNICEF Ethiopia/2015/Getachew
Town crier in Lafaisa subdistrict, Awbare District, using a megaphone to alert parents that children five years and younger will be receiving polio vaccinations during the Polio NIDs Campaign in Somali Region, 9 February 2015. ©UNICEF Ethiopia/2015/Getachew

“In the past when we informed communities about upcoming campaigns, because they didn’t have an understanding about it, some would refuse to bring their children forward,” said Ermias. “There were many challenges. They would refuse to have their children vaccinated. But today, we vaccinated an infant who was born today. In the past, that would be unheard of.  Now, if they have a child out at their farm when we come for the vaccinations, they will tell us we missed one and to come back the next day.”

Cross Border Vaccination

The success of the polio eradication efforts hinges on successful cross-border collaboration between neighbouring countries, such as Somalia and Kenya. Immunisation activities in Ethiopia’s Somali region are therefore held in coordination with health institutions across the borders. Border vaccination points have been set up, and all children under 15 years of age crossing the border receive polio vaccination.

“All the children under 15 years of age who cross the border from Ethiopia to Somaliland or the other way are vaccinated,” said Nemo Alele, head of the Awbare Health Center, located near the border with Somaliland. “This is a border area and we explain to the mothers very carefully what harm can happen if there is transmission of the disease. We have good relations with our counterparts in Somaliland and have discussions on a monthly basis.

There is a similar vaccination centre on the other side of the border where they are doing similar work, and we are both committed that no child should cross without being vaccinated.” Sophia Ege Bulale lives with her three month old grandson Hamad Mukhtar Dayib, in Lafaissa kebele. Sophia has been caring for her grandson ever since her daughter-in-law left Hamad with her son, who lives in Hargeisa in Somaliland, to raise on his own. “I travel back and forth between Lafaissa and Hargeisa with Hamad,” said Sophia. “We didn’t have these vaccinations when I was young and I have seen children who grew up disabled as a result of polio. I am therefore happy that vaccinators come to our house to make sure that my grandson will be protected, whether he is here or in Hargeisa.”

Campaign Support

Clinical nurses Ermias Amare (front) and Salah Kedir, traveling on motorcycle between pastoral settlements in Tulugulid District, Fafan Zone, Somali Region, to provide polio vaccinations for children five years and younger during the Polio NIDs Campaign, 9 February 2015 ©UNICEF Ethiopia/2015/Getachew
Clinical nurses Ermias Amare (front) and Salah Kedir, traveling on motorcycle between pastoral settlements in Tulugulid District, Fafan Zone, Somali Region, to provide polio vaccinations for children five years and younger during the Polio NIDs Campaign, 9 February 2015 ©UNICEF Ethiopia/2015/Getachew

In February, the polio NID aimed to reach nearly 14 million children under the age of 5 years with OPV. According to the national administrative coverage, 99.7 per cent of children were reached with the polio vaccine nation-wide; and over 98 per cent in the Somali region. This is a remarkable achievement, particularly within the context of the highly mobile pastoralist communities of Somali region.

Mobile health and nutrition teams (MHNTs) have helped to reach communities with polio and routine vaccination.  In the Somali region, 24 MHNTs operate to reach pastoralist and remote populations. The teams work 5-6 days a week in selected operational sites on a fixed schedule, and with the support of local social mobilizers who continuously inform the target community of the arrival of health teams. They reach over 1,000 clients per month, of whom, over 40 per cent are children under the age of 5 years.

Reaching all targeted children with the polio vaccine is neither an easy nor simple task. More than 90 million doses of the OPV were provided for all polio outbreak response campaigns to date. Much effort has been exerted by all stake holders to bring the polio vaccine from the manufacturer, to the vaccination teams, to the mouths of children, in a timely, safe and good condition to help protect every child against polio.

It is through the leadership of the Federal Ministry of Health and the generous support of polio donors such as the European Union, the Bill and Melinda Gates Foundation and Rotary International, and others that more children have been reached with the polio vaccine, and that interruption of the outbreak has been possible. In partnership, alongside health workers like Ermias and Salah, together, we can ensure polio transmission remains at zero in Ethiopia.

From the Sheikh and Imam to the Nomad: Engaging a Network of Allies to End Polio in Ethiopia’s Somali Region

 

By Jasmine Pittenger, UNICEF consultant and writer

For many nomads in Ethiopia’s Somali Region, home is a hand-sewn tent.
For many nomads in Ethiopia’s Somali Region, home is a hand-sewn tent. To reach families that are constantly on the move, it is essential to tap into the nomads’ own communication networks. This house-marked tent shows children were reached with the polio vaccine during the campaign. Awbare woreda of the Somali Region, November 2014. © UNICEF Ethiopia/2014/Rozario.

The patches that make up the nomad’s tent say it all. Yellow, orange and red cloth is sewn together with broad stitches — even a pair of trousers is sewn into the mix. Yet the tent is greater than the sum of its parts. It protects a large family from scorching desert sun, from cold nights and rain.

When a polio outbreak struck the Horn of Africa in 2013, WHO and UNICEF with the help of the European Union had to find a way to reach every last child across Somalia, Kenya and Ethiopia. It was a daunting task to deliver multiple doses of OPV (Oral Polio Vaccine) into the mouths of some of the world’s hardest-to-reach children – from war-torn parts of Somalia to the diverse landscapes of Kenya and Ethiopia. Among the very hardest-to-reach are nomads in Ethiopia’s Somali region, which shares a porous 1,600 kilometer border with Somalia. Here, over 80 per cent of the 5 million people are nomadic, herding cattle, camels and goats across broad stretches of desert in search of water and pasture. For many families, home is a tent sewn together from patches of cloth and carried from one watering hole to another on the back of a camel.

To end the outbreak, it was crucial to deliver messages to families constantly on the move. Yet only 11 per cent of people here have access to newspapers or radio. How, then, do you inform families about polio’s risks and the need for children to take OPV? What is the patchwork that makes up this particular community? How do the nomads themselves pass on life-saving information, and receive it? And who is in a position to mobilize families?

One answer is with the Sheikhs and Imams. The Somali Regional Health Bureau and UNICEF reached out to the Somali Region’s IASC (Islamic Affairs Supreme Council). This part of Ethiopia is close to 100 per cent Muslim, and the IASC Sheikhs and religious leaders, are amongst the most respected and influential personalities amongst nomadic communities here. The communities have faith and belief in what they say, and seek out their teachings even as they’re on the move. Once the highest-level Sheikhs and Imams became engaged in warning parents about polio’s risks and the need for OPV, Islamic leaders at all levels got on board.

“We have partnered with UNICEF and WHO because we believe this is a noble cause that is completely in line with our religion, Islam,” says Sheikh Abdel Rahman Hassan Hussein, President of the IASC in Jigjiga, capital of the Somali region. “From the city to the most remote villages, you will find every person working in this project motivated and doing his/her best. They know they are doing something that almighty Allah will reward them for, at the last day. They know they are saving the lives of children and their future by protecting them from this disease, polio. We take every occasion to tell people about this – from Friday prayers to feasts.”

Another answer: children themselves. Messages about polio and OPV are also being taught in schools, including the religious schools or madrassas that many children attend.

School children
School children – like these, at a religious school near the border with Somalia – can be powerful advocates for polio eradication. Awbare woreda, Somali Region, 2014. © UNICEF Ethiopia/2015/Mohamed.

“How many drops of the polio vaccine must be taken, every time the vaccinators come, by each and every child in your home?” asks a teacher at a small IASC-run madrassa on the border with Somalia. “Two drops, two drops!” shout the school children. “How do you know when a child has been vaccinated?” “The finger! The mark on the pinkie finger!” Children clamor to show off where the ink-marks should go on their fingers. Children can be great transmitters of polio messages to their parents. Says 10-year-old schoolboy Hassan: “At home I tell my mother and father about the importance of immunisation to protect little ones under the age of five.”

Parents pay attention – especially when the messages their children bring home are backed up by their local Imams, clan leaders and female community mobilisers who work for polio eradication. In Lafa’isa kebele 04 in the Awbare woreda of the Somali Region, Mrs. Hibo Abdikarim Ibrahim, mother of one-and-a-half-year-old baby boy Mohamed-Amin Abdusalam Abdosh proudly shows his vaccination certificate:

Hibo Abdikarim Ibrahim proudly shows the vaccination certificate for her son
Hibo Abdikarim Ibrahim proudly shows the vaccination certificate for her son, Mohamed-Amin Abdusalam Abdosh, which is a record of his completed routine immunisation schedule. Lafa’isa kebele, Awbare woreda, Somali Region, November, 2014. © UNICEF Ethiopia/2014/Rozario.

“I am so happy my child is fully immunized now. Every National Immunisation Day I also immunize him to protect him from polio. I learned all of this from our lady community mobilizers and we heard the same message in the mosque.”

From Sheikh and Imam to female community mobiliser to clan leader from madrassa student to mother and baby – this is how a movement is built. Each forms a piece of the patchwork to protect children from polio. Just like each dose of polio vaccine, generously funded by the European Union, strengthens the immunity of the community.

Yet there is still much to be done. In the last campaign, 5 per cent of children reached were “zero dose” – they had never before received even a single dose of OPV. This is both hopeful, we are reaching children never reached before, and potentially troubling – are there further pockets of zero dose children we have not yet reached, who are entirely unprotected from polio? And while OPV and Routine Immunisation can go a long way toward protecting children from ten life-threatening, vaccine-preventable diseases, ongoing threats to child health and survival in Ethiopia’s Somali region, and across the Horn of Africa, are great.

Like the patches that make up the nomad’s tent, no single square of cloth is enough on its own. When we join together, from the Sheikh and Imam to the nomad to the international community, the whole is much greater than its parts. Together we can keep building a tent of protection to end polio and improve child health in the Horn of Africa – and to wipe the virus from the face of the earth for good. This can only be done with generous contributions from donors such as the European Union who have enabled the programme to reach the hardest to reach with life-saving polio vaccine.

Regional experts confirm the polio outbreak is successfully interrupted in Ethiopia and Kenya

Vigilance in Somalia and region still needed before the region is declared polio-free once more.

By Shalini Rozario

Dr. Jean-Marc Olive, Horn of Africa (HOA) Polio Technical Advisory Group (TAG) Chair, chairs proceedings of the HOA Polio Outbreak Final Assessment
Dr. Jean-Marc Olive, Horn of Africa (HOA) Polio Technical Advisory Group (TAG) Chair, chairs proceedings of the HOA Polio Outbreak Final Assessment, and is seated with representatives from the Kenyan Government, WHO, UNICEF and partners such as Rotary International, The Gates Foundation, CDC among others. ©UNICEF Ethiopia/2015/Rozario

17 June 2015, Nairobi, Kenya. Government representatives, technical experts, donors, and polio partners gathered on Wednesday, 17 June 2015 to review the polio outbreak status in the Horn of Africa (HOA) Region. The final assessment concluded the following:

  • The assessment team commends the overall robust outbreak response in the HOA with strong vaccination, communication strategy and strengthened surveillance.
  • The assessment team believes that transmission in Kenya and Ethiopia has been interrupted; however, continued undetected low level transmission cannot be ruled out in Somalia

Overall progress in the region was reviewed since onset of the outbreak in April 2013, which resulted in a total of 223 WPV cases across the region (10 in Ethiopia), and remaining challenges ahead were identified. Chaired by the Horn of Africa polio Technical Advisory Group (TAG) Chair, Dr. Jean-Marc Olive, the meeting gave opportunity to strategically reflect on the current outbreak status and required next steps for all three countries. Dr. Ephrem Tekle, Director of the Maternal and Child Health Directorate, Ethiopia Federal Ministry of Health responded positively to the wild poliovirus (WPV) interruption in Ethiopia, and also acknowledged the work ahead to further improve routine immunisation. “Successes achieved in the polio response are due to the political commitment and the support of partners,” said Dr. Ephrem. “We have been successful on SIAs (supplementary immunisation activities) and NIDs (National Immunisation Days). However, I don’t think we are yet fully successful on routine immunisation; there is a lot to do on routine immunisation even though WPV transmission is interrupted.” Dr. Ephrem acknowledged the strong focus on the involvement of religious and clan leaders in the Somali Region, and mobilisation of the community which have been instrumental to some of the immense achievements in the polio legacy process. He cited an example of community leaders asking for a generator so they could continue routine immunisation services. In moving ahead, Dr. Ephrem stressed the importance of sustaining the polio gains made, using the momentum to improve routine immunisation in the country, and also emphasised the importance to intensify the same efforts in regions bordering South Sudan, such as Benshangul Gumuz and Gambella, in light of the immense population migration. The HOA TAG Chair congratulated Dr. Ephrem and the Ethiopia team on their efforts and wished the country success for strengthening routine immunisation in the country, a challenging task. Closing remarks were provided by governments and partners such as Rotary International, CDC, The Gates Foundation, Red Cross, Core Group, USAID, Communication Initiative, UNICEF, WHO and the HOA TAG Chairman. Next steps for countries include working towards the polio legacy transition plan and using polio assets and achievement to further strengthen routine immunisation and beyond. Countries will continue to implement specific recommendations from the external assessment team, and the outbreak response in Somalia will be assessed again after three months. Following the Somalia assessment, the next HOA TAG meeting in August, and continual monitoring of regional progress, it is hoped that soon, the entire HOA region will be declared “polio-free.”

Through the generous support of polio donors and partners such as the Centres for Disease Control and Prevention; Crown Prince Court, Abu Dhabi, UAE; European Union; the Bill and Melinda Gates Foundation; National Philanthropic Trust; Slim Foundation; Rotary International; Swedish International Development Cooperation; and others, successful interruption of the outbreak in Ethiopia has been achieved. Continued collaboration is critical to sustain gains for polio and routine immunisation for healthy children and families in Ethiopia.

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Sida

In Ethiopia, Nationwide Polio Vaccination Campaign Reaches 13 Million Children

Sahro Ahmed vaccinates a child
Sahro Ahmed vaccinates a child in Warder, Somali region, Ethiopia. © UNICEF Ethiopia/2013/Sewunet

Somali Region, Ethiopia, 12 May, 2014 – Ethiopia kicked off a polio vaccination campaign on 3 October 2013, targeting 13 million children across the country following an emergency response that began in the Dollo Ado refugee camps in June 2013. In July 2013, Ethiopia Reports First Wild Poliovirus Case since 2008.

Ayan Yasin, a four-year-old girl, was one of the first confirmed polio cases in Ethiopia. Ayan lives with her father and mother, a typical pastoralist family, in their house, made of tin, wood and woven bed sheets in a remote secluded area three kilometres from Geladi Woreda in Ethiopia’s Somali Region. Living next to the Somalia border means that the family move frequently between Ethiopia and Somalia – making routine immunisation practices difficult.

When Ayan fell sick, her father took her to the nearest hospital in Somalia where he was told there was very little hope. After many visits to various health posts, Hergeisa Hospital finally confirmed she had Polio. “We call this illness the disease of the wind. We know that there is no cure for it, and that it can paralyse and even cause death. My daughter hasn’t died but it has disabled her forever,” says her father.

Close to 50,000 health workers and volunteers and 16,000 social mobilisers have been deployed all over the country as part of a campaign that includes remote and hard to access areas. With the support of the Crown Prince Court, Abu Dhabi, UAE, UNICEF has procured vaccines to support immunisation efforts particularly for children and the refugee population being hosted in the Somali Region. In total, 135,000 vials or 2.7 million doses of bivalent Oral Polio Vaccine (bOPV) were procured to immunise 2.43 million children with a polio vaccine – a critical input to immunisation activities in the Somali Region and Polio high-risk areas. The support from the Crown Prince Court has also helped to airlift the Polio vaccine to hard-to-reach zones of Afder, Gode and Dollo in the Somali Region.

Synchronised cross-border polio outbreak preparedness and response

Parents of Ayan Yasin Confirmed Wild Polio Virus (WPV-1) case in Degafur rural village
Parents of Ayan Yasin Confirmed Wild Polio Virus (WPV-1) case, lives in a border close to Somalia, in Degafur rural village, Somali region of Ethiopia. ©UNICEF Ethiopia/2013/Sewunet

Supplementary Immunisation Activities (SIAs) were conducted in Ethiopia, Somalia, Kenya, and Djibouti to accelerate progress towards ending Polio in the Horn of Africa. The synchronised SIAs were an outcome of the Horn of Africa Countries Cross-Border Polio Outbreak Preparedness and Response Meeting in Jigjiga, from 21 to 23 May 2014, where Ethiopia, Somalia, Kenya and Djibouti agreed to strengthen cross-border collaboration to eradicate polio from the Horn of Africa.

To reinforce support and strengthen Polio eradication efforts in the Somali Region, a high-level delegation consisting of Dr Kebede Worku, State Minister of Health, Mr Abdufatah Mohammed Hassen, Vice President of Ethiopia’s Somali Regional State and Head of the Somali Regional Health Bureau, Dr Pierre M’Pele-Kilebou, WHO Representative to Ethiopia, and Dr Willis Ogutu, Head of UNICEF programme in Somali Region, visited Warder in Dollo Zone, the epicentre of the wild polio virus outbreak in Ethiopia, on 14 June 2014. The delegation, together with the Warder Zonal Administration, launched the ninth round of Supplementary Immunisation Activities (SIAs) in the outbreak zone and formally inaugurated the Zonal Polio Outbreak Command Post, which had been established in April 2014 to improve coordination of response activities.

Sustained interventions to ensure long-term success

While the campaigns to vaccinate children against Polio in the Somali Region have been going well, ensuring long-term success in eliminating the disease will require sustained interventions.

Abdufatah Mohammud Hassen believes the best solution is to immunise every child and ramp up routine immunisation activities in the region. “The campaigns are just to stop the emergency but the main thing that we are doing is to reach every child by strengthening the routine EPI and ensuring that the health facilities have the capacity to respond to the demands of the public”

With the help of developing partners like the Crown Prince Court, Abu Dhabi, UAE, Rotary International European Commission of Humanitarian Department (ECHO) and Bill and Melinda Gates Foundation, UNICEF together with the Ministry of Health is continuing its efforts so that young children like Ayan Yasin living in the region are protected from the disabling symptoms of the Polio disease.