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.
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.
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.
“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.”
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.
By Jasmine Pittenger, UNICEF consultant and writer
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.
“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:
“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.
Addis Ababa | 14 July 2015. Ethiopian Minister of Health Dr Kesetebirhan Admasu, World Health Organisation (WHO) Director General Dr Margaret Chan, The Global Alliance for Vaccines and Immunisation (GAVI) Chief Executive Officer Dr Seth Berkley and UNICEF Deputy Executive Director Ms Yoka Brandt participated in a high level polio vaccination event at Selam Health Centre in Addis Ababa. Also present at the event were UNAIDS Executive Director Mr Michel Sidibe, US Ambassador Ms Patricia M. Haslach, Brazil Ambassador Mrs Isabel Cristina, President and CEO of PATH Dr Davis Steve, and Rotary National Polio Plus Committee Chairperson PDG Dr Tadesse Alemu as well as national and international EPI partners, health workers and mothers with their children. “Strong leadership, political will and coordination are key to sustaining the gains made in interrupting polio transmission in Ethiopia and Africa,” said Dr Margaret Chan, commending Ethiopia’s aggressive response to the 2013 outbreak of wild polio virus. “Horn of Africa countries should continue to immunise all at risk age groups until the threat drops to zero and eradication is achieved. And this is possible only through high quality immunisation activities for all communities.” When the wild polio virus outbreak in the Horn of Africa spread to Ethiopia in August 2013, the Government of Ethiopia intensified vigilance, surveillance and mass immunisation campaigns, together with partners like WHO, UNICEF, USAID, the US Centres for Disease Control and Prevention (CDC) and Rotary International. Fifteen supplementary immunisation campaigns were implemented with a focus on high risk areas. Cross-border coordination was heightened, with Horn of Africa countries coming together to implement synchronised response activities. It has been 18 months since the last case of wild polio virus was reported in Ethiopia, and 11 months since the last case in Africa. Dr Kesetebirhan Admasu said, “We will focus on equity and quality for every child and mother in Ethiopia,” adding, “The Government of Ethiopia continues to be committed to eradicating polio from Ethiopia, and Africa.” He further affirmed that “The Government of Ethiopia will continue to engage communities for active participation in routine immunisation, and will continue to build strong health partnerships.” With a view of sustaining the achievements in interruption of wild polio virus transmission, and strengthening the immunisation system, the Ministry of Health of Ethiopia, with support from partners, is currently implementing a two-year Routine Immunisation Improvement Plan 2014-2015. The plan pays special attention to low performing prioritised zones and accelerating efforts to support such vulnerable zones to improve performance, among other priority initiatives.
Ms. Yoka Brandt, asserted, “Immunisation, especially routine immunisation, is a core priority within UNICEF, and it will continue to be. With the availability of new innovations, new vaccines, and new research and evidence, we can go fast and far.” Immunisation is among the most cost effective interventions we can provide to our children. Yet, one in five children are not fully immunised worldwide. In Ethiopia and Africa, children in remote and marginalised communities are more likely to be missed. It is these same children that carry the highest risk of diseases that vaccines can prevent. Therefore we must refine our strategies to reach these children and include them in our services. Reaching every community is an approach that strives at inclusion of all communities, especially the marginalised children, ensuring resources and services are available and monitoring is in place. Dr Seth Berkley, highlighting GAVI’s commitment to strengthening routine immunisation, said, “Strong routine immunisation systems are a bedrock of healthy societies and are central to global plans for the eradication of polio. By working together, we are reaching more children than ever before with lifesaving vaccines and the GAVI partners are committed to supporting countries like Ethiopia to sustain and build on their progress on immunisation.” WHO, UNICEF, GAVI and other immunisation partners remain committed to support African governments in reaching every community with vaccination – the gift of life.
By Shalini Rozario
36 Rotarians from Ethiopia, Canada and the United States visited East Shewa zone in the Oromia region of Ethiopia to deliver polio vaccinations to more than 600 children under the age of five.
The visit marked the launch of the first round of polio National Immunisation Days in the country and the group also visited the country office of UNICEF Ethiopia, which is a partner in the global polio eradication initiative.
The visit coincided with an intensified immunisation campaign in Ethiopia, in response to the polio outbreak which began in August 2013, triggered by the Horn of Africa outbreak in Somalia and Kenya.
As of November 2014, 10 cases of Wild Poliovirus Type 1 (WPV1) had been confirmed in the Somali region of Ethiopia.
At the UNICEF Ethiopia offices, members of the Rotary Polio Advocacy Group were shown a video and presentation on polio eradication efforts in the country, followed by a discussion.
Patrizia DiGiovanni, Acting Representative to UNICEF Ethiopia, welcomed the Rotarians and thanked them for their continued support in efforts to eradicate polio, which included a recent grant.
The grant is part of a larger announcement by Rotary International marking World Polio Day of a pledge of $44.7 million to fight polio in Africa, Asia and the Middle East.
To date, Rotary has donated more than $1.3 billion to global eradication efforts, allowing the mobilisation of resources at the grass-roots level through volunteer leaders.
During their visit to the Oromia region, the Rotarians attended a colourful ceremony at a primary school, alongside Dr Kebede Worku, State Minister at the Federal Ministry of Health and Dr Taye Tolera, Special Adviser to the State Minister of Health.
They were joined by the Federal Ministry of Health Expanded Programme on Immunisation (EPI) team, staff from the East Shewa Zone Health Office, UNICEF, WHO and other partners.
The group visited several kebeles within East Shewa Zone to visit people’s homes and carry out vaccinations, accompanied by kebele Health Extension Workers and Health Workers.
The Lume district health office and Shara Didandiba Health Post organised a kebele launching ceremony to mark the Rotarians’ visit. The Rotarians handed out t-shirts and caps to children and parents at the event.
The visiting Rotarians have a range of backgrounds, but share a common interest in supporting polio immunsation, child health and development programmes in Ethiopia. Some members of the group have visited Ethiopia several times.
The visit was intended to inform and promote polio advocacy work in Canada and the US through advocacy and fundraising, as well as engagement with US Congressional leaders.
Rotary International is spearheading the Global Polio Eradication Initiative, alongside the World Health Organisation, Bill & Melinda Gates Foundation, US Centers for Disease Control & Prevention and UNICEF. It has been at the forefront of the global fight against polio for the last three decades.
By Elissa Jobson
GAMBELA, ETHIOPIA, 24 JUNE 2014 – At Pagak entry point, on the border between Ethiopia and South Sudan, a long line of parents and their children wait patiently in the intense heat of the refugee registration tent. They anxiously watch as four health workers swiftly administer life-saving vaccinations to the children ahead of them.
UNICEF, in conjunction with the Gambela Region Health Bureau, has rolled out a programme of vaccination for South Sudanese children seeking asylum in Ethiopia as a result of the deadly civil conflict currently raging in their home country. Since fighting began in December last year and the first refugees crossed into Ethiopia at the beginning of January 2014, UNICEF has helped vaccinate 91,785 children against measles and 74,309 against polio. A further 41,333 children have been given vitamin A supplements to help combat malnutrition.
“Registration and screening is done by ARRA (the Ethiopian Administration for Refugee and Returnee Affairs) and UNHCR,” says Lemmi Kebede, supervisor of supplementary immunisation at Pagak entry point and Kule refugee camp. Priority, he adds, is given to pregnant women and lactating women with children less than six months old. “After registration, the children come to the vaccination point. Because levels of immunisation are low in South Sudan, eligible children are given vaccinations irrespective of whether they have had them in South Sudan or not. They are given an immunisation card which they take with them when they are transferred to the refugee camps,” Lemmi explains.
Tesluoch Guak, just two and a half weeks old, is one of the beneficiaries of this programme. He cries as the health assistant gives him his measles injection. Despite her baby’s discomfort, his mother, Chuol Gadet, is pleased that Tesluoch is receiving his vaccination. “I understand that this is important for the health of my child,” she says.
So far, all the refugees have been willing to have their children immunised. “There is no resistance from the parents,” Lemmi confirms. “They are informed before they register as asylum seekers that their children will be vaccinated and why this is needed. There have been no refusals even though the parents haven’t previously received much health education. They have faced many challenges on the way to Ethiopia and they are open to our help.”
Chuol was heavily pregnant when she left her home in Malou county. She travelled on foot for days with her three children, aged 10, 7 and 4, to reach safety in Pagak where she delivered Tesluoch. Her husband, a solider in the government army, doesn’t even know that he has a new-born son. “The journey was hard for me. It wasn’t easy to find food and water. I don’t have words to express how difficult it was.”
The health situation of the newly arrived refugees is very poor. “In general, most of the asylum seekers are malnourished when they come from South Sudan. They have walked long distances without much food. Many have malaria and respiratory tract infections. They are really in a stressed condition,” says Bisrat Abiy Asfaw, a health consultant for UNICEF Ethiopia. This makes them highly susceptible to communicable diseases like measles and polio, he continues.
In February and March there was an outbreak of measles in Pagak – at the time more than 14,000 refugees were waiting to be registered and transferred to refugee camps within Ethiopia. UNICEF quickly rolled out a vaccination programme and helped ensure that children with signs of infection were quickly diagnosed, quarantined and treated.
“We were detecting new cases every day,” says Bisrat. “We tried to vaccinate all the children. We did a campaign on measles to increase and develop immunity within the refugee community.
The focus of the vaccination programme has been on the registration sites, although immunisation also takes place at the refugee camps. “Our strategy is to vaccinate the children as soon as possible after they enter the country, and that means working seven days a week. We are aiming for 100% coverage,” Bisrat says. And the strategy appear to be working. “The cases of measles has significantly decreased and we have had no reports of measles during the last 6 weeks,” Bisrat affirms.
By Demissew Bizuwerk
TERGOL, AKOBO WOREDA (GAMBELLA REGION)- Nyabiel Chamjock, a 20-year-old South Sudanese refugee, waits in line at the vaccination post with her nine-month-old daughter in her arms. She joins a long queue of other mothers with young children who are also waiting at the post to receive vaccinations. The growing queue is evidence of an effective community mobilisation campaign carried out in the last few days. In addition to the vaccination post where Nyabiel is waiting, three more posts have been made operational to cope with demand from the rising influx of South Sudan refugees. To ensure that vaccination posts are adequately stocked with supplies – two UNICEF boats regularly deliver vaccines. Nyabiel is one of the thousands of refugees who crossed into Tergol town in January in the Gambella Region of Ethiopia bordering South Sudan. Sadly, Nyabiel lost her husband during the tribal conflict between the Murle and the Lue Nuer tribes more than a year ago. She has recently had to face more tragedy. The eruption of violence in South Sudan, in December 2013, forced Nyabiel to flee into Ethiopia in search of safe refuge. After trekking most of the day on foot, clutching her child and a few selected belongings, she managed to cross the border.
Mass Vaccination Campaign for Refugees and Host Community
After waiting 30 minutes in the queue, Nyabiel’s daughter finally receives her required vaccines. She receives an injection against measles and drops to prevent her from contracting polio; she also receives vitamin A supplementation. In addition, her mid-upper arm circumference is measured to check her nutrition status. The chubby little infant looks surprisingly healthy despite the difficult conditions that her family is facing. Before Nyabiel leaves the vaccination post she is given a card confirming her daughter’s immunisation. She is also reminded that it is important to keep the card safe for future reference.
Nyabiel understands the importance of vaccinations for her child. “I know that my child will be protected from diseases after taking the vaccines. It is difficult in this area to keep a child healthy. As it gets dry and hot, children easily fall sick,” she said.
The mass vaccination campaign administered to South Sudanese refugees and members of the host community in Tergol, the capital of Akobo Woreda, is supported by UNICEF in coordination with the Regional Health Bureau. The campaign started at the beginning of January 2014 and more than 95 per cent of children have been targeted for immunisation.
UNICEF has prepositioned emergency vaccine supplies in the Gambella Region to ensure a timely response to the acute emergency needs of those fleeing from the violence in South Sudan and also to the vulnerable members of the host community. The mass vaccination campaign is crucial in preventing outbreaks like measles and polio. In the context of population movement across borders – especially in emergency situations – disease outbreaks can easily occur and prevention measures need to be in place to protect vulnerable mothers and children.
“This vaccination campaign is very important for the health of children both from the host community and refugees,” says Getachew Haile, UNICEF health emergency officer. “It protects the children from contagious viral diseases such as measles and polio,” he adds.
In addition to the provision for vaccines against measles and polio, vitamin A supplementation is also given to children aged between six months and five years. Since the Gambella Region is prone to malaria, a distribution of mosquito nets has also helped to reduce the incidence of malaria morbidity and mortality.
The emergency response to South Sudan refugees in Tergol is being coordinated by the Government’s Administration for Refugee and Returnee Affairs (ARRA) and UNHCR. UNICEF supports the health activities of ARRA and UNHCR in partnership with the Regional Health Bureau. Adequate planning and functional systems have been put in place to manage human resource and logistic arrangements. In addition, health workers from Gambella town and adjacent areas such as Gniengnang, Wantowa and Tergol have received a one-day orientation.
With the support of the local administration, vaccination posts have been set up in locations that are accessible to the host community and refugees. Community mobilisation work has been an integral part of the vaccination campaign to ensure that community members and refugees are aware of the campaign programme and its importance to the health of mothers and children.
Head of the Akobo Woreda health office, Samuel Yien, acknowledges the impact of UNICEF’s support. He says that the emergency vaccination campaign is going well and that the activities are monitored closely. “We are grateful for the support we received from UNICEF. We are coordinating activities together and so far the campaign is good,” he added.
The Akobo Woreda (district) is the most inaccessible area in the Gambella Region. To reach the woreda capital of Tergol, one has to take an eight-hour boat ride from Buribe town- the last town accessible by vehicle. Accessibility problems make the role of UNICEF boats essential in delivering vaccines and other supplies to the vaccination posts.
Thousands of civilians, mainly women and children, have been affected by the violence that broke out in South Sudan in mid-December 2013. At the beginning of April 2014, the UN refugee agency (UNHCR) estimated that more than 88,000 refugees crossed over the Ethiopian border through six entry points including Tergol, since the conflict began. These people are in desperate need of humanitarian assistance, including food, water and health services. Mothers and their babies are visibly weak after enduring the long trek to Tergol, while some of the children are malnourished. As the influx of refugees increases and puts food supplies under strain, the nutritional status of newly arrived children deteriorates.
Although some of the refugees in Tergol are being accommodated by the host community, there are still many more staying in makeshift shelters close to the Akobo River.
Nyabiel constructed her small makeshift shelter from sticks and rags to offer some protection from the piercing sun. Her new rickety home is shared with her child, her grandmother and a few scattered bags containing her belongings. She hopes better times await her child. She is keen to keep her daughter healthy and despite the challenges she faces – she is determined to send her to school because “an education will help bring her a better future,” she adds.