Reaching every child in Afghanistan with polio vaccines
Afghanistan and Pakistan are the only two remaining polio endemic countries in the world. In Afghanistan, despite continuous concerted efforts by the polio programme to achieve polio free status, the battle to finish the last mile has become a pivoting challenge, resulting in an increase in the number of polio cases during the last three years.Unfortunately, poliovirus is currently spreading to the provinces that have remained polio free for a long time.
So far 16 provinces have been infected with 56 cases of world polio virus type 1 (WPV1).
However, the polio circulation remains high in the southern region, which has contributed to 66 per cent of the total national cases in 2020.
The polio programme in its efforts to disrupt the polio virus circulation, is compounded by a myriad of challenges, especially from the polio hotspot’s areas of the South, Southeast and East regions of the country. Political instability and prolonged conflict have contributed to humanitarian crisis, high population movement, under development, poor livelihoods, and weakened health systems. All these have further constrained vaccination efforts, leaving children vulnerable to the debilitating disease. The fear instilled during Taliban rule, where pro-polio leaders got killed, remains a key concern today, and most successors are still afraid and not motivated to endorse polio vaccination.
The ban on house-to-house campaign approach, since May 2018 by the Anti-Government Elements (AGE) has impacted negatively on the polio eradication progress, leading to 3.4 million children being missed in every round of a National Immunization Day (NID). The situation deteriorated further, when AGEs imposed a nationwide ban on all vaccinations in April 2019 for a period of 5 months, exposing nearly 10 million children to the poliovirus. Similarly, the emergence of COVID-19 pandemic, disrupted polio campaigns and other essential health services for over a period of 4 months creating additional immunity gaps, which have resulted in an increase in polio cases in the country.
Pockets of refusal families in the southern region remain adamant to vaccinate their children, despite interventions by the health workers and community influencers. They hold deep myths, misinformed religious beliefs and rumours. The polio challenge is also exacerbated by community fatigue, multiple door knocking and the inability to address some of the basic needs in most polio infected communities.
Routine immunization coverage remains low in the polio high risk provinces and requires strengthening, whereas the quality of Supplementary Immunization Areas (SIAs) needs improvement and backed by a strong surveillance system. For Afghanistan to eradicate polio for good, all children must be vaccinated. And, while there is an
increased community awareness on the importance of polio vaccination, efforts are still needed to dispel myths around the vaccine and to convince families who are afraid of immunization.
Partnering to eradicate polio
Partnering to eradicate polio
UNICEF is a key player in the Global Polio Eradication Initiative – a global public health initiative launched more than three decades ago. In Afghanistan, UNICEF is working with the Ministry of Public Health (MoPH) through the Emergency Operating Center (EOC), the World Health Organization (WHO) and non-governmental organisations in finding innovative ways to reach every child with vaccines, and to build demand for, and trust in the importance of vaccination campaigns.
Immunization support and COVID-19 prevention
National Immunization Days (NIDs) aims to reach nearly 10 million children through a house-to-house and health facility to facility-based approaches. In addition, several Sub-National Immunization Days campaigns and case response initiatives are conducted in priority districts throughout the year. UNICEF in collaboration with WHO and partners implement the polio programme and support vaccinators, community mobilizers, influencers, monitors, volunteers, campaign coordinators and supervisors to reach these children with polio vaccines.
In many high risk and inaccessible districts of Kandahar, Helmand and Uruzgan in the southern region of Afghanistan, populations have been cut off from essential basic services. Recent discussions with the Taliban have presented an opportunity to deliver polio vaccines through an integrated approach. In response, UNICEF has opened sub offices in Helmand and Uruzgan provinces to strategically deliver lifesaving child-focused interventions, which include primary healthcare, nutrition, maternal newborn and child health (MNCH), education and water, hygiene, and sanitation services.
Since March 2020, after polio campaigns were disrupted by COVID-19 pandemic, the programme responded promptly using the existing large network of 4,500 social mobilisers and media networks to engage the communities with COVID-19 prevention messages at national and household levels. At the same time, over 8.2 million bars of handwashing soap were distributed to communities in government and non-government-controlled areas.
Polio Immunization Communication Network (ICN) is composed of social mobilisers based at the community level and Female Mobiliser & Vaccinator (FMVs) positioned at health facilities. The ICN network engages with religious leaders and social influencers, local area representatives, local health partners to address vaccine acceptance and to dispel myths/ rumours around polio vaccination. The objective is to go beyond raising awareness, to make sure communities demand and take ownership of their local polio eradication efforts. Additional efforts are under way to engage influential leaders in Taliban areas including religious leaders and local communities to enlist their support towards encouraging the population to vaccinate their children against polio and other vaccine preventable diseases.
Following the sudden cut of funding for the ICN engagement in early 2020, the programme had to quickly adjust by drastically reducing 2,065 full-time ICN workers and discontinued 2,495 campaign based ICN and 250 community influencers in Central, Western and now Eastern region. The polio programme is focusing on polio problematic areas in the southern region. Mass media has been intensified to disseminate key messages and conduct frequent roundtable discussions through local channels in areas, where ICN was reduced.
The programme will maintain 2,778 ICN in the polio priority areas in the sourth where active circulation of polio virus is combined with high number of refusals, monitoring is possible and high population movement is prevalent.
UNICEF polio programme is also working to maintain a gender balance and to increase the number of female social mobilisers. Culturally, women can access households, while men are not allowed to enter homes without the presence of the family head. In that sense, the polio programme is not only eradicating the disease, but empowering women to contribute much more to the community.
Media engagement and social media
Media engagement remains an instrumental approach to disseminate polio messages that inform, educate and persuade communities to vaccinate their children. An overarching media plan that engages 67 TV and 170 community-based radios with an effective monitoring system is put in place, to ensure dissemination of key polio messages. A comprehensive regional communication plan is developed factoring cultural sensitivities and language dialects and tailored to address communication needs at community level.
With the proliferation of social media in the country, the value of immunization and vaccine safety have sparked an online debate, spread of rumours and misinformation that contribute to vaccine hesitancy. The programme’s social media is still growing with an average reach of 5 million users a month. However, despite significant growth during the peak of COVID 19, it needs to be developed and further strengthened to increase engagement across all platforms, while consistently disseminating polio messages, and utilizing applications to analyze trends, track and counter rumours.
Afghanistan’s 2020 polio results
- The programme achieved 100% of vaccine supply adequacies for all polio activities, which includes campaigns, case responses and Permanent Temporary Teams (PTT).
- Successful introduction of mOPV2, mOPV1 and tOPV for case responses and campaigns through capacity building around vaccine management and accountability.
- Despite COVID-19 pandemic disruption, the polio programme was able to implement 3 National Immunization Days, 2 Sub-National Immunization Days and 3 Case Response Campaign (CRC) across the country.
- Social media engagement and reach went up from an average reach of 2 million users to an average of 5 million users a month. There was an exponential increase in engagement at the height of COVID-19, where Facebook reached 17 million users in April with COVID related messages.
- Media mapping conducted, which resulted in engagement with 170 community radio stations and 67 TV channels. 103 Public Service Announcements (PSAs) aired 54 on polio and 49 on COVID 19 prevention, while additional 50 short videos were disseminated through social media platforms. 56 articles focusing polio were published in local newspapers and over 16 roundtable discussions were carried out both at national and community levels.
- International media polio coverage increased in 2020, where VOA and BBC prepared weekly and monthly polio reports respectively. Radio Free Europe aired 2 to 3 reports a month. Reuters, AP, DW, Aljazeera covered stories on polio & COVID- 19 response. The National Public Radio, National Geography news & Lancet journal did their coverage during world polio day. A breakthrough was reached following discussions with the Taliban, where the programme is enabled to conduct campaigns in some districts in polio high risk areas and provide integrated services.
- Integrated services have been implemented as follows:
- Health and Routine Immunization
- 53 new health facilities established in Kandahar and Helmand BPHs
- ICN referring children for Routine Immunization and supporting vaccination in Health facilities
- 480 FMVs recruited, trained and posted to health facilities to support vaccination for an average of 170,000 children and women per month.
- 45 additional outreach vaccinators supported to increase in EPI coverage in South
- 386,000 hygiene kits distributed to children during routing immunization sessions in the East, West and South to boost immunization coverage.
- Polio banded promotional items:
- 325,000 baby blankets distributed to pregnant women and infants in polio high risk areas.
- 115,000 delivery kits distributed in maternity hospitals in the Southern and Western regions of the country.
- 8.2 million of handwashing bars of soap distributed to both Government and Taliban controlled communities as part of COVID-19 response and campaign support.
- Water, sanitation and hygiene (WASH) polio supported programme:
- 8,039 people gained access to safe drinking water in high risk districts of Helmand. WASH facilities upgraded in 18 schools reaching 52,000 students and 19 health facilities in the south.
- Rural Water Supply started in Uruzgan, Kandahar and Helmand.
- The programme supported procurement of ready to use therapeutic food (RUTF) to decrease and prevent moderate malnutrition with quality and equitable nutrition services
- 392,000 polio branded items were procured, which will be distributed to students in need in South and West.
- Polio supported the establishment of 350 community-based education (CBE) classes in 10 districts of Kandahar and Helmand.
Highlights of key interventions to ensure every child is vaccinated against polio in 2021
Polio programme plans to focus on eradicating wild polio virus, and interrupting the circulation of cVDPV2. Efforts to improve the quality of SIAs and case response to cVDPV2 outbreak will be intensified. Media and community engagement will continue to mobilize communities for vaccine acceptance and trust building, while expanding access to reach children in Taliban controlled areas with integrated services.
Key interventions areas for UNICEF in 2021.
- Strategic shift for communication and community mobilization approaches will be planned and implemented in consideration of three dimensions: Geographical and contextual considerations, prioritizing special initiatives and enabling strategy to support communication efforts.
- Special communication strategy tailored for the South and South East to overcome existing challenges of access and refusal will be developed. Additional, new community engagement approaches (e.g., behavioral insights) will be considered for application to preserve gains achieved in some regions (e.g. East).
- Increase the number of women social mobilizers and influencers to access homes and educate caregivers and refusal families to vaccinate their children and develop & implement a crisis communication strategy to address new vaccines
- Strengthen social media engagement to disseminate messages, track and counter rumours backed by a fully informative polio website.
- Monitor the impact and effectiveness of key interventions in reducing refusals.
- Integrated delivery of services approach is proposed to revamp polio vaccination and subsequently reduce immunity gap in Taliban controlled areas of the three provinces of Helmand, Uruzgan and Kandahar with access challenges through:
- Expanding access to quality basic health services.
- Increasing routine immunization coverage through various strategies.
- Decreasing and preventing moderate malnutrition with quality and equitable nutrition services.
- improving access to safe drinking water in schools and health facilities and hygiene promotion.
- Enhancing community-based education especially for girls and promoting vaccination using education network
- Encouraging polio vaccination by distribution of promotional materials
- Continuing to lead the dialogue on access, programme service implementation and monitoring in Taliban controlled areas.
- Manage and achieve 100% vaccine adequacies, timely deliveries and proper storage, transportation and use of these vaccines. Base on existing and evolving epidemiology, a mixture of new and old vaccines such as tOPV, nOPV, bOPV and mOPV2 may be utilized. Key activities include
- Continuous capacity building on vaccine management and
- institutionalization of vaccine accountability.
- UNICEF will continue to provide hand sanitizers and face masks to all 90,000 front-line workers supporting SIA and all special interventions such as ICNs and FMVs.