Eradication of Poliomyelitis in Countries Affected by Conflict

Large outbreaks of polio have been reported from certain countries affected by conflict, particularly in Africa (Angola and Sudan). Elsewhere, the mobility of refugee populations and internally displaced persons (IDPs) can hamper efforts to organise and follow up both routine immunisation and national immunisation days (NIDs), leaving many children only partially immunised and therefore unprotected. The World Summit for Children emphasised that the provision of basic needs and health care, including immunisation, should not be postponed until conflicts are resolved. The eradication of polio in conflict situations is possible, as has been demonstrated in certain countries of Asia and Central America. However, mass immunisation can be difficult if not impossible in zones of active combat. This article provides an update on the status of polio eradication in 5 countries where, at the time of writing, polio was still endemic and where conflict was taking place.

Country situations:

• Afghanistan - Acute flaccid paralysis (AFP) surveillance was established in this (still-endemic) country in 1997. It relies on trained health workers receiving small monthly incentives who make regular visits to large health facilities and other sites where cases of AFP are likely to occur. Afghanistan was one of the first countries to include data on measles and neonatal tetanus in weekly reports from its 84 AFP surveillance sites.
• Angola - A large outbreak of wild poliovirus type-3 (WPV3) poliomyelitis occurred in the Luanda area between April and June 1999, mainly affecting unimmunised infants and young children of internally displaced families. The outbreak focused attention on the need to accelerate polio eradication and AFP surveillance.
• Democratic Republic of the Congo - Many years of economic decline have compromised the transportation, communication, and health infrastructures. In August 1999, this country became the last with endemic polio to conduct NIDs. More than 8 million children were given oral polio vaccine (OPV) during each of the 3 rounds conducted in 1999. However, access to some districts was impossible because of renewed fighting.
• Somalia - Since 1997, NIDs have been conducted in all parts of Somalia. The implementation of polio eradication strategies has depended on partnerships with local and international non-governmental organisations (NGOs) and on the hiring of Somali nationals in all parts of the country. Discussions on security were held with local community and religious leaders, when partners in each district developed plans of action for NIDs. Active AFP surveillance began at over 80 reporting sites in northern Somalia during 1998 and was then introduced in the south.
• Southern Sudan - In 1998, NIDs covering all parts of southern Sudan were organised for the first time in coordination with NIDs in all government-controlled parts of the country. Local plans of action for NIDs were developed with the help of the network of NGOs operating under Operation Lifeline Sudan and of trained, locally hired Sudanese health workers. Vitamin A supplements were given to children aged 6-59 months during the second of the NID rounds organised in 1998.

As these examples show, the Global Polio Eradication Initiative (GPEI) presents an opportunity to mobilise countries and donors to carry out vaccination and provide basic health services for children, particularly those in areas experiencing current or recent armed conflict. The promise of implementing a health initiative such as polio eradication and of using it to re-establish and strengthen other primary health care services is greatest wherever negotiating and cooperating partners remain. Even in the absence of any recognised central government or force, effective local partnerships have been formed and used effectively, for instance in Somalia.

More specifically, "NIDs provide a rationale for negotiating truces or ceasefires by focusing the attention of warring factions on their children's health. The planning and conducting of NIDs may also open channels of communication for further negotiations between the parties on other issues of common interest. Working together on common goals encourages cooperation and helps to build the trust necessary for permanent solutions....The re-establishment of immunization and other primary care services also promotes peace in the long term by rebuilding health infrastructures for entire populations and thus tackling the inequality that is a root cause of war."

Furthermore, "Critical elements of the polio eradication strategies - political commitment, international partnerships, capacity for surveillance, and integration of preventive services - can be used to strengthen routine services. Vitamin A supplementation has now become part of most NIDs....The experience gained in reaching remote and inaccessible populations during polio NIDs is now being used to develop alternative strategies for the delivery of routine immunization services to hard-to-reach populations in a sustainable way."

In conclusion: "Progress towards polio eradication in countries with civil unrest, insecurity and low routine coverage with OPV is critical for the success of the global polio eradication initiative. It is urgently necessary to optimize coverage in all NID rounds, as well as to achieve rapid development of AFP surveillance of high quality, eventually meeting the criteria for certification of polio eradication."