Executive Summary

The children of Somalia face many overwhelming challenges. However, by working together, we can ensure that no child will ever again by paralysed by polio, and that the existing health system is strengthened in the process.

Somalia was one of the 10 remaining countries in the world with poliovirus transmission in 2001 and the only country in the Horn of Africa with polio to date in 2002. With no central government since 1991, Somalia presents several unique challenges for the global polio eradication initiative. The single greatest challenge is insecurity resulting in inaccessibility to children, particularly in the capital. Mogadishu is the source of all wild poliovirus in Somalia in 2002 and is the most important area of polio transmission in the Horn of Africa.

Despite these constraints, significant progress has been made towards polio eradication since activities started in 1997, due to the unique public-private sector partnership in support of polio eradication. UN agencies, non-governmental organisations, Rotary, and the network of World Health Organisation (WHO) and United Nation's Children's Fund (UNICEF) polio eradication field staff posted through the country have done remarkable work. The program has developed the capacity to access populations throughout Somalia and holds great potential for future health initiatives.

Poliovirus now appears confined to the Mogadishu area. However, international program staff have not had access to the capital since April 2001, and this has had a negative impact on planning and supervision of activities. To successfully interrupt transmission of wild poliovirus in 2002, all children in the Mogadishu area must be reached by the supplemental immunisation activities (SIAs).

To interrupt transmission of polio in 2002 and certify Somalia polio free by 2005 the program has the following goals:

- Ensure quality SIAs that will interrupt wild poliovirus transmission and sustain high population immunity.
- Sustain surveillance capacity to ensure early detection of cases, direct eradication operations and provide data required for certification.
- Maintain polio eradication infrastructure through certification of Somalia as polio free and use it for other health programs.
- Strengthen routine immunisation systems to sustain high immunity against polio and other vaccine preventable diseases.

To succeed in the eradication of polio and to build on the achievements to date, adequate financial support, access to priority areas and security of staff are needed. The partnership can support the program in meeting its goals and overcoming these challenges through the following:

Financial Support: Existing partners are asked to continue or increase support, and actively influence contributions from other partner agencies. Mobilisation of resources remains a constraint and a significant threat to success. To ensure polio's eradication from Somalia and to build on the achievements to date, approximately US $ 12.7 million is needed through 2005.

Advocacy: Partners can actively advocate for increased access, increased political commitment, strengthened inter-agency coordination, and funding.

Background and Overview

At the time of the World Health Assembly resolution for the global eradication of polio in 1988, an estimated 350,000 children in 125 countries were paralysed by polio each year. Today, the global polio eradication initiative is on track to interrupt transmission of wild poliovirus by early 2003 and certify the world as polio free in 2005.

There are four strategies for the eradication of polio:

1) Routine immunisation of infants with oral polio vaccine (OPV) in the first year of life;
2) National immunisation days (NIDs) during which all children under five years of age are vaccinated, regardless of whether they have been vaccinated before;
3) "Mop-up" immunisation campaigns to break the final chains of transmission once transmission is limited to a specific geographic area; and
4) Surveillance for acute flaccid paralysis (AFP) to find and investigate every newly paralysed child to determine if polio is the cause.

As countries implemented the strategies for polio eradication, the incidence and geographic extent of the disease were reduced dramatically. By 2001, only 483 cases were reported in 10 countries. By June 2002, wild poliovirus was reported from only 7 countries. Three of the six WHO regions (Americas, Western Pacific, and Europe) have been certified polio-free.

Somalia is one of seven countries in the world, and the only country in the Horn of Africa, that has detected wild poliovirus to date in 2002. The continuing transmission in Mogadishu not only threatens Somalia's progress towards polio eradication, but that of neighbouring countries as well as the virus does not respect international boundaries. Somalia shares vast and porous borders with its neighbours. The most critical are the nomadic corridors linking Somalia with Kenya and Ethiopia.

Polio eradication activities were first initiated in Somalia in 1997 when WHO and UNICEF coordinated sub-national immunisation days (SNIDs) in the northern parts of the country. This was followed by the first national immunisation day (NID) in 1998. AFP surveillance was initiated in the northern parts of the country in 1998 and was extended to the central and southern areas in 1999.

The program is constrained by extremely low routine immunisation coverage. National coverage is estimated at 37%, but coverage rates are highly variable within the country.

In 1999, eradication activities were accelerated in the face of numerous challenges caused by the war, including lack of a government, inaccessibility and insecurity, risk to staff, and continuous population movement.

To facilitate the intensified activities, WHO and UNICEF established joint leadership of an integrated polio eradication unit, established `hub offices' in different regions,
Wild virus type 1
Wild virus type 3
Importation
Wild Poliovirus*, 13-Aug-2001 to 12-Aug-2002
Data in WHO HQ as of 13 Aug 2002.
Wild virus type 1 and 3
Endemic countries

*Excludes viruses detected from environmental surveillance and v accine derived polio viruses.

Stool Collection and deployed more than 180 full-time national and international staff throughout the country. Polio eradication staff are now present in every district in Somalia.

Immunisation activities were intensified in 1999. Multiple NID rounds have been conducted each year since, and SNIDs have targeted high-risk areas. All SIAs conducted since 1999 have used a house-to-house strategy, which has reached increasing numbers of children.

As the program infrastructure was strengthened, surveillance activities improved greatly. In 2000 the target nonpolio AFP rate was reached. However, difficulties remain in reaching the target of collecting adequate stool specimens from 80% of the cases. Primarily this is result of delayed reporting of cases, particularly those occurring among nomadic populations.

In 2000, the surveillance system detected a large outbreak of polio in Mogadishu that accounted for 92% of all of Somalia's cases. The outbreak was contained in 2001, and circulation of wild poliovirus was restricted to the central regions around Mogadishu.

Subsequently, the program introduced new strategies to successfully access all children. Sweeping house-to-house campaigns were conducted, with teams and supervisors moving from area to area. A "hit and run" strategy was developed for use in conflict-ridden areas. Vaccinators work independently targeting small populations for a short period, allowing staff to cover insecure areas quickly.

The graph shows the impact of the strategies on the extent of polio transmission. A dramatic decrease was seen, from 96 cases in 2000 to 7 in 2001. In 2002, 2 cases have been detected to date - both from the Mogadishu area. Clearly the program has made extraordinary progress in the face of extreme challenges. However, to interrupt transmission of wild poliovirus in 2002, every opportunity must be used to ensure high quality activities in the Mogadishu area where transmission persists. Over-riding challenges are: Security: Security issues continue to hamper program planning, supervision and implementation.

Access: Lack of access to Mogadishu is compromising the program's ability to strengthen and supervise activities. The deployment of national staff has greatly strengthened program activities; however, they can only operate effectively within clan boundaries. International staff has had no access to Mogadishu since April 2001.

Maintaining Infrastructure: The infrastructure that has been put in place for polio eradication is extensive, with staff placed in every district. Lack of adequate funding presents a major threat to this network, which also benefits numerous other health initiatives.

Program Benefits

The benefits of polio eradication are numerous; the most compelling is the benefit to children who might otherwise be crippled by an easily preventable disease. It is estimated that since the initiation of the global programme 5 million cases of paralytic polio have been averted by the eradication initiative.

Eradication activities are strengthening delivery of health services in many countries by increasing surveillance capacity and access to children. Finally, there will be significant savings (up to US $1.5 billion annually) from the polio eradication initiative that can be used to support other health and poverty reduction strategies. Specific benefits to Somalia are numerous:

- Exemplary partnerships have been established. The partnership has successfully developed a mechanism to coordinate a nation-wide health initiative in the absence of a national government.
- Improved capacity to access all children. Somali children have severely limited access to preventative health services. The eradication initiative has established an infrastructure that covers the entire country.
- Strengthened national capacity to tackle other diseases by building disease reporting and surveillance systems that can be utilized to benefit other health programs.
- Increased access to clan-controlled areas. The polio program has successfully developed community acceptance of the program, gaining access to controlled areas. The build-up of community trust, and the increased access it provides, could have enormous benefits to other health initiatives.
- Improved demographic information. Planning for SIAs has increased the availability of demographic data, identifying and mapping all areas where children live. This information is valuable to all health initiatives.
- Increased community awareness and involvement. More than 6,000 vaccinators have been mobilised throughout the country, moving house-tohouse to ensure that all children are vaccinated. This mobilisation has led to a belief in the ability to impact change and demonstrates what other programs can achieve in Somalia.
- Effective utilisation of partner funds. Activities have been managed in such a way that there is no duplication on the part of implementing partners (i.e., a joint staffing plan), thus ensuring effective utilisation of funds.

Future Program Priorities

Mission Statement: Every Child Counts!

To interrupt transmission of wild poliovirus in 2002 and to certify Somalia as a polio free country by 2005, the following goals and objectives must be achieved.

Goal 1: Conduct high quality supplemental immunisation activities to interrupt transmission of wild poliovirus and sustain high population immunity. Objectives:

- Ensure access to all children throughout Somalia, particularly in the Mogadishu area, by utilising local strategies to implement activities on the ground.
- Increase capacity for international supervision and monitoring of campaigns.
- Ensure preparedness for mop-up immunisations if required.
- Sustain SIAs through 2005 - the year global certification is anticipated.

Goal 2: Maintain and strengthen surveillance capacity. AFP surveillance must be sustained to ensure early detection of cases, to provide data required to direct programme operations and to certify the region as polio free. Objectives:
- Sustain and further improve surveillance indicators.
- Maintain a network of field staff in all districts.

Goal 3: Maintain and build on national capacity. The infrastructure developed for polio eradication operations must be sustained for the success of the polio eradication program, and for the benefit of other health programs. Objectives:
- Ensure adequate resources to sustain existing infrastructure through global certification.
- Develop plans to increase the role of polio staff in strengthening routine immunisation and other disease prevention and control activities.
- Develop a plan of action to strengthen other health programs using the foundation created by the polio eradication program.

Goal 4: Strengthen routine immunisation to sustain high immunity against polio and other vaccine preventable diseases. Objectives:
- Build on the polio infrastructure to stimulate routine immunisation activities.
- Implement national plans to strengthen EPI infrastructure including cold chain capacity, vaccine logistics and training of health workers.
- Support strengthening social mobilisation activities to increase awareness of routine immunisations.

Governance: The Partnership in Support of Polio Eradication

The Global Polio Eradication Initiative is spearheaded by the WHO, Rotary International, the US Centers for Disease Control and Prevention (CDC), and UNICEF. It is supported by a large network of partners including governments of countries affected by polio, private foundations, donor governments, humanitarian and non-governmental organisations, corporate partners, and countless health workers and volunteers.

The polio eradication program in Somalia is a unique example of partnership. As there is no central government to lead the eradication initiative in Somalia, WHO and UNICEF jointly lead, coordinate, implement, and promote polio eradication activities, utilizing one another's strengths. The team has developed strong relationships with other UN agencies and NGOs, and coordinates all polio eradication activities closely. Interagency involvement and program activities are coordinated through the Somalia Aid Coordination Body (SACB). External funding for polio activities is channelled through WHO and UNICEF.

The map shown at the right illustrates both the level of coordination and the reach of the polio program. WHO manages areas shown in blue and UNICEF manages areas in yellow. Each symbol represents a polio staff member. The polio program has successfully developed a network of trained personnel that reaches the entire country.

Partnerships at the local level are critical to the program. Activities could not be successfully conducted without community `approval'. Placement of field staff is negotiated with the community. Once in place, staff negotiate program activities to ensure full implementation.

Resource Requirements To meet the challenges outlined above, and conduct polio eradication activities as planned, the programme requires external support.

The partnership successfully mobilised adequate funds for 2002 activities. The tables below show the external funding required for 2003 - 2005. While negotiations are ongoing with partners, to date no firm commitments have been made for 2003 - 2005. Mobilisation of resources is an immediate priority.

                                           Budget Period
Activity 1                      2003          2004         2005            Total
AFP Surveillance         1,637,850   1,617,850 1,617,850   4,873,550
NIDs / SNIDs
OPV                           709,504      709,504     266,064     1,685,072
Operations                  2,271,254   2,260,004  810,783     5,342,041
Total Requirement       2 4,618,608 4,587,358  2,694,697 11,900,663

To achieve its goals, the program needs adequate support, both financial and technical. Without sufficient funding, the extensive system that has been established to access children is at risk - both for polio and for other health care initiatives.

How You Can Help

Somalia is one of the highest priorities of the global polio eradication initiative and the challenges presented are immense. However, the program has demonstrated its capacity to interrupt transmission despite numerous constraints.

There are a number of challenges that must be met to successfully eradicate polio from the country. Partners, old and new, can provide assistance to help the program overcome these, including:

Financial Support: Adequate funding is required to support the extensive polio eradication infrastructure established in Somalia, and to support intensified activities required to interrupt transmission in Mogadishu.

Funding shortfalls continue to threaten the success of the eradication initiative in Somalia. In addition, these shortfalls jeopardise the potential legacy of polio eradication for other health initiatives to improve the lives of Somali children.

Flexible use of partner funds is essential to effectively address a highly dynamic situation. The ability to quickly adapt to new priorities and challenges is required to successfully target end-stage activities. Existing partners are asked to continue or increase their support, and actively influence contributions from other partner agencies.

Advocacy: Partner agencies can be pivotal in advocating for the program, highlighting the numerous benefits that the eradication initiative brings to Somalia. Issues for which partners can advocate in support of the program are: Access to Mogadishu and surrounding areas: Polio eradication must be given highest priority by UN security officials. Increased use of UN security mechanisms can be utilized to allow international staff access to Mogadishu, through UNSECORD, to support SIAs and surveillance activities. Inter-agency collaboration: Several NGOs and agencies have staff working at the grass-roots level in Mogadishu (ICRC, Care, MSF, etc) that could play a larger role in the initiative.

Flexibility: Flexibility of program staff to develop locally appropriate policies must be ensured.

Political commitment and funding: Continue to advocate for additional funding and political commitment from all partners.

The efforts of the polio eradication staff in Somalia have been remarkable. The successful eradication of polio from Somalia is clearly achievable but will require perseverance, commitment, and vision from all involved.

Annex 1

Definition of Terms:
AFP: Acute Flaccid Paralysis
CDC: Centers for Disease Control & Prevention
EMRO: Eastern Mediterranean Regional Office of WHO
EPI: Expanded Programme on Immunisation
HOA: Horn of Africa
ICC: Interagency Coordinating Committee
MSF: Medicins Sans Frontiere
NGO: Non-Governmental Organisation
NIDs: National Immunisation Days
OPV: Oral Polio Vaccine
SIAs: Supplemental Immunisation Activities
SNIDs: Sub-National Immunisation Days
TAG: Technical Advisory Group
UNICEF: United Nations Children's Fund
WHO: World Health Organisation

Program Indicators (as of September 2002) Supplemental Immunisation Activities Surveillance Indicators Year Polio Campaigns Conducted Children Vaccinated,

Round 1 Children Vaccinated, Round 2 AFP Cases Non-polio AFP Rate1 % with 2 Stools Within 14 Days 2 Clinically Confirmed / Compatible Cases Cases with Wild Virus Confirmed by Lab 1997 1 SNID 113,875 340,327 1998 1 NID 1,401,161 1,469,512 32 0.68 28% 12 0 1999 1 NID 1,351,408 1,351,290 40 0.69 35% 17 2 2000 1 NID 1,298,103 1,370,928 Extra Round 1,264,801 161 2.03 50% 50 46 1 NID 1,155,578 1,092,377 1 NID 1,356,109 1,387,364 2001 1 SNID 116,719 129 3.71 59% 10 7 2002 1 NID 1,364,831 1,342,691 1 SNID 756,899 639,173 86 3.52 62% 6 2

1) Certification level is one case of AFP per 100,000 population under 15 years of age
2) Certification level is adequate stool specimens collected from 80% of AFP cases