Insecurity
Since 2010, armed conflict and insecurity have been major constraints to accessing children for polio vaccination in the endemic countries of Afghanistan, Pakistan and Nigeria, and countries that experienced outbreaks such as Somalia, Cote d’Ivoire, Syria, Democratic Republic of Congo, Mali, and Iraq.
Nevertheless, innovative communication and access strategies, such as employing local respected intermediaries to negotiate with anti-government elements, have overcome the barrier of insecurity in most countries. In Northeast Nigeria, where the militant Boko Haram group disrupted vaccination campaigns, temporary ‘health camps’ were established offering a range of health services in addition to the polio vaccine [12]. Visiting Afghanistan on behalf of the IMB, I witnessed several innovative efforts to overcome security barriers. In Kandahar province, permanent polio vaccination teams were established to take advantage of all opportunities to vaccinate children such as market days. In Jalalabad, ‘women’s courtyards’ provided safe spaces for women to discuss the benefits of vaccination.
Hostility to vaccination
The refusal by parents to vaccinate their children is due to a number of factors, ranging from ‘vaccination fatigue’, in countries where children may have been vaccinated 15 or more times, to outright bans by militant groups such as Al Shabaab in Somalia [13]. The situation is most toxic in Pakistan, where the Taliban has banned polio vaccination in North and South Waziristan and incited violence against vaccinators and their police escorts [14]. As recently as January 13, 2016, a suicide bomber detonated explosives outside a polio vaccination center in the city of Quetta, killing 15 and wounding 24 people [15].
A number of initiatives have been launched to counter misinformation about polio vaccine in the guise of religious doctrine. A meeting of Islamic scholars convened at Cairo’s renowned Al-Azhar University in March 2014, and led to the formation of an Islamic Advisory Group for Polio Eradication [16]. Fatwas supporting polio vaccination by the Grand Imam of Al Azhar and other leading Islamic clerics have since been widely disseminated and tens of thousands of social mobilizers have been trained to disseminate information on vaccination by word-of-mouth. During a visit to Chad on behalf of the IMB, I visited a community where the spiritual leader, Sheikh Ousman, preached that it was every parent’s duty to vaccinate their children against polio and other preventable diseases. As a result, according to local Chadian officials (unpublished data), a 100 % coverage in vaccination campaigns was achieved.
Vaccine-derived polio
As described earlier, vaccine-derived poliovirus may sometimes circulate, causing paralytic cases in populations with low immunity. Prior to 2015, most cases of cVDPV had been Type 2. Since there has been no case of WPV Type 2 since 1999, WHO’s Strategic Advisory Group of Experts on Immunization (SAGE) concluded, in October 2015, that the switch from trivalent to bivalent OPV (Types 1 and 3) should go ahead globally in April 2016 [17]. There was a resurgence of Type 1 cVDPV in 2015, with 17 cases reported in Laos, Madagascar, and Ukraine, reflecting diminished levels of immunity in these populations; for example, in mid-2015, only half of Ukrainian children had been fully vaccinated against polio [18].