Shots - Health News
3:03 am
Wed October 30, 2013

Violence, Chaos Let Polio Creep Back Into Syria And Horn Of Africa

Originally published on Thu October 31, 2013 4:27 pm

Update on Thursday, Oct. 31, 6:30 p.m. ET:

A spokesman for the World Health Organization said Thursday that it was mistaken about the polio outbreak in Somalia spreading to South Sudan. The virus has been detected in Kenya and Ethiopia this year. But South Sudan has not recorded a polio case since 2009.

Global efforts to eradicate polio have made impressive progress over the past decade. Last year there were only 223 cases anywhere in the world.

But armed conflict and chaos are making it tough for the world to wipe out the virus completely.

Polio has re-emerged in war-torn Syria after more than a decade, the World Health Organization reported Tuesday. "The original cluster of suspected cases was 22 cases," says the WHO's Oliver Rosenbauer. "Out of those, 10 have now been confirmed as polio. The others are still being processed in the laboratory."

Over in the Horn of Africa, an outbreak has ballooned into more than 190 cases. The outbreak's epicenter is Somalia, where fighting and violence have kept vaccinators from reaching hundreds of thousands of kids in the past few years.

Health officials are concerned that polio could become endemic in Syria and the Horn of Africa. They have launched massive emergency vaccination campaigns in both regions to try to protect millions of children against the crippling virus.

But polio infections in Somalia have already spread to Kenya, South Sudan and Ethiopia. A recent visit to the Somali-Ethiopian border highlights just how easily the virus can move silently around rural areas — and eventually find kids who aren't vaccinated.

So far Ethiopia has reported only six cases of polio compared with 174 in Somalia. But the landlocked country shares a thousand-mile border with Somalia. Most of it's unmarked and uncontrolled. Goat, sheep and camel herders move back and forth across the arid plains between the two countries seeking fresh pastures for their animals.

At the border town of Wajaale, a frayed, knotted rope strung across the road marks the international boundary. The rope is ignored by just about everyone. Young men step over it. Vendors with wheelbarrows full of vegetables scoot under it.

Ethiopian authorities acknowledge that it's impossible to completely control the flow of people between the two countries. But in an effort to limit the importation of polio, Ethiopia has set up 13 vaccination checkpoints at major crossings. The health bureau has also deployed vaccinators to nearly 40 informal points of crossing along the border.

In Wajaale, the vaccination station is a small shack next to the rope on the Ethiopian side. When I visited the station one morning in early October, the vaccinator was absent. The sign announcing mandatory polio vaccination for all children had been tied back so that it was unreadable.

The goal of these border vaccination posts is to immunize every child, under the age of 15, who crosses in either direction, says Abdulahi Mohamed, who is with the government's regional health bureau. "They have their vaccines there," he says pointing to a small ice chest. "They check the children. Everyone under 15, they give one dose of polio [vaccine]."

Abdulahi and other Ethiopian officials say that each border vaccination post is immunizing hundreds of kids every day. But during my visit, only 10 children had been vaccinated by noon.

The vaccinators are poorly paid, Abdulahi says — the equivalent of about $30 a month. He concedes that it's difficult to keep them motivated.

Nevertheless, Ethiopia's Health Ministry says that containing this polio outbreak is a top priority. "If you have a house that's caught fire, you need to extinguish [the flames]," says the country's health minister, Dr. Kebede Worku. "So we take this seriously."

Soon after polio was detected in Somalia this spring, Ethiopia carried out five mass immunization campaigns against the virus along the Somali border. Earlier this month they launched a national campaign to try to reach every child in the country — some 13 million kids. The World Health Organization and UNICEF have helped to fund the drives and stock them with vaccine.

But the vaccination campaigns are organized, run and largely paid for by Ethiopia's Ministry of Health, and the operation has put huge new burdens on an already strained national health system. The Ethiopian government even had to deploy special security details to travel with the vaccination teams in some parts of the country along the Somali border.

"The other side of the border [in Somalia] is totally insecure," Kebede says. "Some of the areas are governed by militants." These militants include al-Shabab, which claimed responsibility last month for the attack on a Nairobi shopping mall that left more than 60 people dead.

Another challenge of running a polio vaccination campaign in remote parts of the Horn of Africa is that the vaccine needs to be kept cold. Most Ethiopian health clinics in the province bordering Somalia don't have electricity. The Health Ministry has to use ice packs and portable, kerosene-fired refrigerators to keep the polio vaccine chilled.

The mass immunization campaigns are also complex and expensive logistical operations, Kebede says. They require hundreds of additional staff, hundreds of thousands of vaccine doses, extra kerosene for the refrigerators, and vehicles to deliver supplies to the targeted area. Each immunization team needs tally sheets and maps.

Plus, polio infects some people without ever making them sick. These so-called asymptomatic carriers appear healthy and can spread the virus to new communities.

"With polio ... the vast majority of the people who are infected and spreading [virus] are not paralyzed," says Dr. Walter Orenstein, a vaccine specialist at Emory University in Atlanta. "So there's a lot of "silent transmission."

"For every case of paralytic polio, we can assume there are at least 100 to 200 — maybe a thousand people," Orenstein says, "who are infected and potentially spreading the virus."

Copyright 2013 NPR. To see more, visit http://www.npr.org/.

Transcript

RENEE MONTAGNE, HOST:

Polio is proving to be an extremely difficult disease to defeat. Global efforts to eradicate polio have made incredible progress. Last year, there were only 223 cases in the entire world.

STEVE INSKEEP, HOST:

But this month, the virus reemerged in Syria. Hamid Jafari of the World Health Organization's Polio Eradication Program in Geneva says the 10 cases in Syria that were confirmed yesterday are probably just the beginning.

HAMID JAFARI: We should brace ourselves to, unfortunately, killing of more paralyzed children. As the reporting gets stronger and active search for patients with acute flaccid paralysis gets going, certainly, we should prepare ourselves for seeing more paralyzed children in this area.

INSKEEP: And Syria is not the only place facing a new outbreak.

MONTAGNE: Polio turned up in Somalia earlier this year. It has now spread to its neighbors: Kenya, Ethiopia and South Sudan. Health officials have launched massive emergency vaccination campaigns to try to protect millions of children in the region against the potentially crippling virus. NPR's Jason Beaubien brings us this report on Ethiopia's attempts to prevent polio from coming in from Somalia.

JASON BEAUBIEN, BYLINE: This is the Wajaale border crossing between Ethiopia and Somalia.

UNIDENTIFIED MAN #1: Here is the post. From here to there, it is Somalia.

BEAUBIEN: The international boundary here is marked by a frayed, knotted rope that's ignored by just about everyone. Young men step over it. Guys with wheelbarrows full of vegetables scoot under it. On the other side of the rope in Somalia, polio has been running rampant in lawless, militant-controlled parts of the country. Ethiopian health officials here on this side have set up a polio vaccination station in a shack next to the border to try to keep the disease out. Abdulahi Mohamed with the Ethiopian government's regional health bureau says the goal here is to immunize every child who crosses the border in either direction.

ABDULAHI MOHAMED: This is the vaccine courier. They have their vaccines there, and they check the children. Then everyone under 15, they give one dose of polio.

BEAUBIEN: But on this morning, the vaccinator is nowhere to be found, and the sign announcing mandatory polio vaccination for all children has been tied back, so that it's unreadable. This rope barrier is one of 13 official transit points between Ethiopia and Somalia. The regional health bureau has set up polio immunization stations at all of them. They've also deployed vaccinators to nearly 40 informal border crossings along the 1,000-mile-long border. Eventually, the vaccinator returns. Abdulahi flips through the vaccinator's daily log.

MOHAMED: This is the tally sheet. This is vaccinated before.

BEAUBIEN: So, that's two that have been vaccinated before.

MOHAMED: Two who are vaccinated before. Below - one below 11 months.

BEAUBIEN: Abdulahi and other Ethiopian officials say that each border vaccination post, like this one, is immunizing hundreds of kids every day. But it's almost noon, and according to the log, only 10 children have been vaccinated here so far on this morning. The vaccinators are government workers from local health clinics. Abdulahi says they don't get any extra pay, and they're still expected to do their regular jobs. He concedes it's been difficult, at times, to keep them motivated. Before the outbreak this spring in Somalia, the world was getting tantalizingly close to wiping polio out completely. A multibillion-dollar effort had practically cornered the virus in three remote parts of Pakistan, Afghanistan and Nigeria. Prior to April, there'd been no reported cases in Somalia since 2007. Now, however, Somalia has more cases than anywhere else in the world. Ethiopia had also eliminated polio, but now it has six cases, all linked to the Somalia outbreak.

KEBEDE WORKU: In any country, you know, wherever you are, an outbreak is priority number one.

BEAUBIEN: Kebede Worku, the Ethiopian state minister for health, says the resurgence of polio is the most significant health challenge currently facing the nation.

WORKU: If you get a house caught fire, you need to extinguish. So we take that seriously.

BEAUBIEN: Kebede says they're now trying to put out the flames of this outbreak. Soon after polio was detected in Somalia this spring, Ethiopia carried out five mass polio immunization campaigns along the Somali border. Earlier this month, they held a national vaccination campaign to try to reach every child in the country, or some 13 million kids. The World Health Organization and UNICEF have been providing the vaccine and helping to fund the drives. But the boots on the ground are staff hired, trained and directed by the Ethiopian Ministry of Health. Kebede says Ethiopia's response to the outbreak has been complicated. In some parts of the Somali border region, they've even had to deploy special security details to travel with the vaccination teams.

WORKU: The other side of the border is totally insecure. Some of the areas are governed by militants.

BEAUBIEN: Militants including al-Shabab, which claimed responsibility last month for the attack on a Nairobi shopping mall that left more than 60 people dead. Back in Jajiga, the capital of the Somali region, Abdulahi Mohamed is in the health ministry's warehouse preparing supplies for an upcoming vaccination trip.

MOHAMED: This is the overall cold room where the vaccine and the other materials, supplies are stored.

BEAUBIEN: The polio vaccine needs to be kept refrigerated. This can be difficult in many remote, undeveloped parts of the world where the virus still flourishes. In much of Ethiopia, even government health clinics don't have electricity. During mass polio immunization campaigns, the Ethiopian health ministry uses portable, kerosene-fired refrigerators and small ice chests to keep the vaccine cool out in the field. But Abdulahi says the fridges are temperamental, and recently there's been a shortage of kerosene to keep them running.

MOHAMED: It happens, sometimes the cold chain breaks, and some of the vaccine becomes unusable. But we try our best to make it useable.

BEAUBIEN: He says a mass polio immunization campaign just in this region requires hundreds of people, thousands of ice packs, hundreds of thousands of doses of vaccine, extra kerosene for the refrigerators, vehicles to deliver supplies to the targeted area. The immunization teams need tally sheets and maps. And then the vaccinators spread out across the vast, arid landscape to search for kids.

MOHAMED: You found some 20 children here. To find the next 20 or 10 children, you should walk not less than 10-15 kilometers by - on foot, because every team cannot have a vehicle.

BEAUBIEN: Fighting this outbreak is expensive. Ethiopia has poured millions of dollars into its emergency response to the Somalia polio outbreak. Similar efforts are now also being organized in Kenya, South Sudan, Uganda. Even though there have been fewer than 200 cases of polio from this current outbreak in the Horn of Africa, health officials fear that if it's not contained quickly, the crippling disease can regain a foothold in this vulnerable region. Jason Beaubien, NPR News. Transcript provided by NPR, Copyright NPR.

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