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Where polio hides

The discovery of the poliovirus in Nigeria last summer shocked eradication efforts. Here’s how Rotary is making sure it doesn’t happen again

By Erin Biba
Photos by Andrew Esiebo

For a 13-month-old boy whose family lives in northeastern Nigeria, escaping Boko Haram was only the beginning of a long, difficult journey.

When his family finally arrived at the Muna Garage camp for internally displaced people (IDP), they had walked more than 130 miles in three days. They were starving, and the camp was only a temporary setup with inadequate facilities, housing more than 15,000 people. But the worst news was yet to come. Health officials in the camp determined the baby had polio.

“It was heartbreaking,” says Tunji Funsho, chair of the Nigeria PolioPlus Committee and a member of the Rotary Club of Lekki Phase I. Funsho met the boy on a trip he took in August to three of the country’s IDP camps. “At least (the family was) able to escape Boko Haram. The child was able to walk but with a limp, and was quite malnourished.”

If it weren’t for the polio surveillance system that the World Health Organization (WHO) has in place at every one of Nigeria’s IDP camps, Funsho says, the boy’s polio could have easily gone unnoticed. In fact, it was a shock to the entire polio eradication effort in the country that a case existed at all. 

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An estimated 15,000 people live in the Muna Garage camp, an informal settlement on private land. 

The country hadn’t had a case since July 2014 and had been removed from the list of polio-endemic countries. But in August 2016, routine surveillance methods, which include sampling of sewage and wastewater to look for viruses circulating in the wild as well as monitoring and investigating all cases of paralysis in children, discovered two cases of polio in Borno state – one of them the 13-month-old. (Two more cases were subsequently reported.) Polio wasn’t gone from Nigeria after all. 

“The new cases devastated us. Even one case is unacceptable. It’s very unfortunate we are in this position, but we are recalibrating our efforts to end this disease,” Nigeria’s health minister, Isaac Adewole, told Rotary leaders during a meeting at Rotary International World Headquarters at the time. “We consider this situation a national emergency.”

The importance of surveillance

The polio surveillance system, carried out mostly by WHO and the U.S. Centers for Disease Control and Prevention (CDC), two of Rotary’s partners in the Global Polio Eradication Initiative, consists of several parts. First, doctors and other community health workers such as healers and traditional birth attendants monitor children for paralysis. “Most times cases are not discovered at a medical facility – they’re discovered at home by the volunteer community mobilizers and people who are paying regular visits,” Funsho explains. “They find a child that is limping or unable to use a limb they’ve used before. They’re trained and they know the questions to ask.” If they discover a paralyzed child, the health workers report the case to WHO, which sends a surveillance team to collect stool samples from the child and his or her siblings for testing. 

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The second part of the surveillance process involves local authorities collecting samples from sewage systems or, in places that don’t have adequate sanitation facilities, rivers and bodies of water near large settlements. The samples are sent to a lab, one of 145 in the Global Polio Laboratory Network, which looks for the poliovirus. If it is found, the samples go on to a more sophisticated lab where scientists perform genetic sequencing to identify the strain and map where and when it has been seen before.

The worldwide scale of these surveillance efforts is massive and costs roughly $100 million every year. For the most part, these activities take place only in countries that don’t have adequate health systems already established. In the U.S., for example, if a child showing signs of paralysis visits the doctor, the necessary tests for polio are already a part of the working health system. But in countries that don’t have such a robust system, WHO takes on that responsibility. That means investigating more than 100,000 cases of paralysis around the world every year to rule out polio.

In Nigeria’s IDP camps, surveillance is more complicated. Before people enter, they are screened by security agencies (there have been several cases of suicide bombers trying to infiltrate the camps). Next, at the camp’s health facility, doctors evaluate the new arrivals’ overall health and screen them for polio. Volunteers then document what villages they have traveled from, using the information to track who is in the camp, where they are within the camp, and who their family members are.

The challenge of mobile populations

Before the new cases were detected, the surveillance teams working in IDP camps were vaccinating and searching for suspected polio cases as usual. 

But in the official documents, when they were reporting their findings, the teams weren’t marking the displaced people as being located in their camps: They were being counted by their area of origination. However, surveillance teams and vaccinators weren’t actually traveling to some parts of the state where the displaced people had come from because the presence of the Boko Haram terrorist group made it difficult. 

The Nigerian army escorts people traveling through risky areas. 

“This gave the impression there was good surveillance (in those areas), when in fact there were major blind spots,” says Mark Pallansch, director of the Division of Viral Diseases at the CDC. “We knew this was an area of concern, so we implemented additional measures to try to strengthen surveillance.” 

The extra measures included scaling up environmental surveillance and sampling healthy individuals – including adults – for the presence of poliovirus as they exited inaccessible areas. Teams also searched IDP camps and host communities more frequently and reassigned the acute flaccid paralysis cases by place of onset. It was in part thanks to such strengthened activities that additional polio cases were found.

But the surveillance situation remains volatile, Pallansch confirms. “This really underscores the dangers of any low-level residual polio transmission in the face of any subnational surveillance gaps,” he says. “We still don’t have an exact idea of virus transmission in some areas of Borno. Operationally, we have to therefore assume that it remains an infected area and our focus has to be on reaching the children with the vaccine, all the while plugging the surveillance holes.” 

A major part of the problem is that in the area where the cases of polio were discovered in Borno, the health system is decimated, impeding the discovery and reporting of the poliovirus. In December, WHO health monitors reported that 35 percent of 743 health facilities in Borno were destroyed and 29 percent were damaged. Sixty percent of the remaining health sites have no access to safe water. 

But it’s not just the breakdown of the health system that is causing the problem. Until recent military incursions by the Nigerian government, Boko Haram occupied more than half of Borno. And, unlike the Taliban, which controls areas of Afghanistan (one of only two other countries that have yet to eradicate polio), Boko Haram does not negotiate with vaccinators who want to enter areas they are in. 

This five-year-old living in the camp was one of the four children with polio discovered in Nigeria in 2016 and is now receiving medical attention.

Nigeria isn’t the only area of the world that has regions with limited access. The GPEI has begun an extensive analysis of surveillance in other countries to ensure that the Nigerian “blind spot” isn’t a problem elsewhere. “Boko Haram makes many parts of the area virtually inaccessible. Depending on where Boko Haram is, that can be inclusive of bordering countries,” Pallansch says. “It will take some time to gather information and analyze it properly. But at a first pass it’s not quite as worrying as some may think, except in those areas we already know are problems. In places like South Sudan and parts of the Horn of Africa, the border of Afghanistan and Pakistan, we’re intensifying our efforts.

“In a sense, the situation in Borno is a good comparison to the global situation,” Pallansch says. “Ninety-nine percent of Nigeria is polio-free. But unless you eradicate the disease completely, the rest of the country will remain at risk. The same holds true globally: 99 percent of the world is polio-free. But all countries remain at risk until we finish the job everywhere.”

A surge in vaccinations

Through genetic testing of stool samples taken from the new polio patients, the GPEI traced the poliovirus to a strain that emerged in Chad almost five years ago and circulated through Chad and parts of Nigeria. It had been eliminated from accessible areas, but it turns out that it never left parts of northern Nigeria.

The discovery triggered an increase in vaccinations in other countries that have similarly inaccessible areas. In Nigeria alone, more than 850,000 children were vaccinated in the first five days after the cases were discovered, according to the country’s health minister. And Nigerian border countries coordinated efforts to increase protection of their own polio-free status. 

The very nature of the GPEI’s system being at once a very large network of worldwide organizations and small groups such as Rotary clubs made up of local residents is what helped the teams respond so quickly to the new information, Pallansch says. “The system itself means there is surge capacity. No one place has to stand on its own. There are always other places within the system that can help,” he says. Because of that, the Polio Eradication Initiative continues on pace – revealing weak points where they may exist and fixing them – but still marching toward that day when polio is gone for good.

After certification, the polio surveillance network is likely to continue providing services. It has already been used to help contain other deadly diseases such as Ebola and measles, and there are ongoing discussions about what the surveillance strategy will be after polio, according to a spokesperson at WHO. The biggest question is how that network can be maintained so that it can go on hunting for other diseases. 

• Erin Biba is a science journalist whose work regularly appears in Newsweek, Scientific American, and BBC.com.

• Read more stories in The Rotarian

https://www.rotary.org/en/how-rotary-stopping-polio-nigeria

How Rotary clubs are celebrating World Polio Day

From red ponchos to pub crawls, Rotary clubs are coming up with a variety of ways to promote polio eradication in October

By Arnold R. Grahl

In eastern Ontario and western Quebec, Canada, thousands of Rotary members will put on red ponchos and march through the streets of their towns to raise awareness for polio eradication on World Polio Day, 24 October.

Michael Kinsey, governor of Rotary District 7010, which spans the two provinces, ordered 2,000 of the special ponchos, which include the End Polio Now logo, for members to purchase for $10 each. Half of that goes to Rotary’s PolioPlus campaign, with the other half covering the cost of the poncho. Clubs are inviting local politicians and media to join the event, or holding small rallies to explain Rotary’s role in bringing an end to the crippling disease.

“I thought it was a good idea, but it’s really taking off,” says Kinsey. “Each club will be taking pictures and sending it to our public image coordinator, and we will promote it. Each walk will get a lot of media exposure in the community, and the impact of all 41 clubs in our district doing something is going to be huge.”

Rotary is encouraging clubs to hold events on or near World Polio Day this year and register the events at endpolio.org. Last year, supporters in 90 countries registered more than 1,400 World Polio Day events.

Get ready for our fifth annual World Polio Day event, co-hosted with the Bill & Melinda Gates Foundation. We will stream live from Gates Foundation headquarters in Seattle, Washington, USA, to bring together more than 50,000 viewers around the world. Join us as global health experts and celebrities share our progress on the road to polio eradication. Celebrate with us.

Kinsey says he got the idea after taking part in a walk with Rotary leaders during a 2011 regional training event in Vancouver. The participants all put on similar red ponchos to walk from their hotel to the 2010 Winter Olympics cauldron, housed at the Vancouver Convention Centre. 

“People were stopping me on the street and asking me what Rotary is about and saying how they thought polio was already eradicated,” says Kinsey. “It was an incredible conversation starter and that sparked this idea.”

Kinsey teamed up with the district’s polio committee chair and public image coordinator to send letters to every club in the district. He’s also promoted the idea as he visits clubs. 

“Our district is monstrous geographically, and many of our club leaders are used to traveling great distances for events and training exercises,” Kinsey said. “My theory with this was: ‘You don’t have to travel to do this.’ We are not even asking them to walk any certain distance. Just walk in your own community where you think it will be most effective.”

Some clubs are also using the march as a membership drive, holding a social event at the end and paying for a member’s poncho if they invite a friend.

Bob Scott, then chair of the International PolioPlus Committee, and Michael Kinsey don red ponchos to raise awareness for polio eradication during a regional training event in 2011.

Kinsey’s advice to other clubs or districts wanting to hold an event is to unite resources and find someone with passion to lead.

“If somebody is passionate about something, it’s going to happen,” Kinsey says. “Once you have that, you get behind them and support them and help them in the direction they want to go.”

Here are some other events Rotary members are planning to celebrate World Polio Day this year:

  • The Uganda PolioPlus Committee will mark World Polio Day with a cycling event named in honor of President-Elect Sam F. Owori, who died in July. Proceeds will go to the Sam F. Owori Memorial to Polio, created to honor his legacy. Owori served on both the Africa Regional PolioPlus Committee and the International PolioPlus Committee. Four-person teams of cyclists will compete in a 10 kilometer and 21 kilometer race at the Kololo Independence Grounds in Kampala, on 22 October, in partnership with the Uganda Cycling Association.
  • The Rotary Club of Simmern-Hunsrück, Germany, in conjunction with the city’s annual festival, will sell several varieties of soup while promoting polio eradication. All proceeds will go to PolioPlus.
  • Rotary members in Pollachi, Tamil Nadu, India, will hold a painting competition and oratory contest for elementary school students on 24 October. Students will be invited to a community center to display their work and read their compositions, while getting the opportunity to receive prizes. Posters are being printed in each school taking part in the contest, and raffle tickets are being sold, with proceeds going to support PolioPlus.
  • Two Rotaractors are cycling across India to raise awareness of polio, from late September to March. Read related story.
  • Members of the Rotaract Club of Pacific Beach, San Diego, California, USA, have organized a pub crawl for 14 October with special games, competitions, and discount food and drinks to raise money for polio eradication. Tickets to the six-bar event are $30. 
  • The Rotary Club of Thorpe Bay, Essex, England, is sponsoring a Purple4Polio benefit concert at the Palace Theatre in Westcliff-on-Sea on 22 October. Alex Mendham and his Orchestra will play 1930s tunes from George Gershwin, Cole Porter, Irving Berlin, and others.
  • The Rotary Club of Makati Central, Philippines, will hold a competition to crown Miss Earth 2017 on 21 October, with more than 500 business professionals invited to attend. The club will show videos of Rotary’s efforts to eradicate polio throughout the competition.

https://www.rotary.org/en/how-rotary-clubs-are-celebrating-world-polio-day

Five things to know about polio

5 things you might not know about ending polio 

The road to eradicating polio has been a long and difficult one, with Rotary leading the fight since 1985. Going from nearly 350,000 cases in 1988 to just 10 so far this year has required time, money, dedication, and innovation from thousands of people who are working to end the disease. 

Here are five things you may not know about the fight to end polio:

1. Ice cream factories in Syria are helping by freezing the ice packs that health workers use to keep the polio vaccine cold during immunization campaigns.

John Cena

2. Celebrities have become ambassadors in our fight to end the disease. 

They include WWE wrestling superstar John Cena, actress Kristen Bell, action-movie star Jackie Chan, golf legend Jack Nicklaus, Grammy Award-winning singers Angelique Kidjo and Ziggy Marley, Nobel Peace Prize laureate Desmond Tutu, anthropologist Dr. Jane Goodall, co-founder of the Bill & Melinda Gates Foundation Bill Gates, and world-renowned violinist and polio survivor Itzhak Perlman.

3. Health workers and Rotary volunteers have climbed mountains, crossed deserts, and sailed to remote islands, risking their lives to vaccinate children against this disease. Rotary has funded more than 1,500 motorbikes and 6,700 other vehicles, as well as 17 boats, to make those journeys. Vaccinators have even traveled on the backs of elephants, donkeys, and camels to immunize children in remote areas.

4. In Pakistan, the polio program emphasizes hiring local female vaccinators and monitors. More than 21,000 vaccinators, 83 percent of whom are women, are achieving the highest immunization coverage rates in the country’s history.

5. Thanks to the efforts of Rotary and its partners, more than 16 million people who otherwise might have been paralyzed are walking today. In all, more than 2.5 billion children have been vaccinated since 1988.

https://www.rotary.org/en/five-things-know-about-polio

It takes a community

Mobilizing more than 200,000 volunteers across 92 countries, the Rotary Community Corps expands Rotary’s reach by bringing the knowledge and talents of local people to projects in their communities.

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