South Sudan is doing its bit for global polio eradication efforts, but huge gaps in immunization against other diseases remain.
Targeted polio immunization efforts started in the area more than a decade before the country’s independence in 2011 and have remained a top priority. There has not been a single case of polio for more than four years.
Health officials and humanitarian groups are trying to build on this success to improve other immunization efforts, including neonatal tetanus and measles, but more funding and a better health infrastructure are urgently needed.
To combat the re-emergence of polio, Anthony Kirbak, the director of the country’s expanded programme on immunization (EMI), said the Ministry of Health and humanitarian organizations have had to figure out how to circumvent low routine childhood immunization rates.
Every child in the country is supposed to be vaccinated against tuberculosis, polio, diphtheria, tetanus, whooping cough and measles by its first birthday. Kirbak said that only happens for about 65 percent of the country’s children due to a scant health infrastructure, poor roads and cyclical violence in some areas of the country.
To bump up the vaccination rates for polio, the Ministry of Health sends thousands of volunteers out across the country four times a year to immunize every child they can find who is under six. Kirbak said they regularly reach more than 90 percent of the children.
He said South Sudan’s specific focus on polio vaccination stems from the international pressure to completely eradicate the disease.
“The emphasis is because the whole world is supposed to eradicate polio,” Kirbak said. “The only way to do that where there is fragile health system and weak routine immunization, it has to go in the form of campaigns so that many children are reached in a short time.”
The global public health community was originally gunning for full eradication by 2000. They missed the deadline, but according to the World Health Organization (WHO) polio cases worldwide are lower than ever before - there were only 223 in 2012, down from nearly 2,000 a decade before. Kirbak said South Sudan has an international obligation to stay vigilant until well after that number hits zero.
Meanwhile, health officials are rolling out an emergency vaccination campaign next week following polio outbreaks in Kenya’s Dadaab refugee camp in April, and an outbreak in Somalia in May. There are now 110 confirmed polio cases between the two countries.
“Due to our proximity [to Kenya and Somalia] and the low immunization coverage in the country, we actually made an assessment of the risk areas,” Kirbak said. “It was found that we have four states (out of 10) that are at risk of importation, if at all any wild polio outbreak is brought into the country, then we’ll be in danger.”
So vaccines are being distributed to the four states and an additional county in South Sudan where people travelling from Kenya and Somalia are most likely to arrive. For four days next week volunteer vaccinators will immunize every child they can find.
Kirbak credits the country’s efforts to keep polio at bay with strengthening the health system generally. By training volunteer vaccinators and health workers to immunize against polio, they have increased general awareness about the importance of all immunizations.
That does not mean the routine immunizations are always available, even if people want them, either because they are cut off from health centres or because there are no staff to administer the vaccines. Kirbak said there has been improvement - routine immunization rates were up to 65 percent last year from 20 percent in 2007 - but acknowledges that it is still too low, which is why South Sudan will continue to deploy targeted vaccination campaigns until the health system gets stronger.
Officials are borrowing the polio campaign model for an ongoing neonatal tetanus vaccination campaign that has so far reached seven states and a measles immunization outreach that should start next year.
UNICEF provides almost all polio vaccines
Polio eradication efforts are propped up by the UN Children’s Fund (UNICEF) which provides almost all of the vaccines in the country. WHO covers the logistics of transporting them. The government contributes money to cover some of the health workers’ salaries, but Kirbak said the resources simply are not there for the state to do much more. That is why the measles campaign next year is only tentative as EMI waits to see if funding becomes available.
Meanwhile, Daniel Babelwa Ngemera, an immunization specialist with UNICEF, said that as South Sudan searches for funds to launch campaigns or strengthen routine immunization coverage, it is falling further behind other countries in the region, like Kenya. Their basic immunization package includes vaccines against pneumococcal - a strain of pneumonia - and rotavirus, which can cause severe diarrhoea in infants and children.
“Our children in South Sudan, they are not benefiting on that,” Ngemera said. “We are trying our level best to make sure at least the country is able to catch up, to be moving also with the other countries in the region.”
South Sudan will soon submit a proposal to the GAVI Alliance, a public-private partnership that helps countries access vaccines, asking for money to help strengthen the health system. Kirbak would not say how much they were asking for, but said it should boost the health system enough to “avert the issue of campaigns”.
MSF action in refugee camp
In the meantime, state officials ask NGOs and humanitarian organizations to introduce immunization coverage where they can.
Médecins Sans Frontières (MSF) started a three-part pneumococcal vaccination campaign in Yida refugee camp in South Sudan’s Unity State last month. The camp holds more than 75,000 refugees, mostly Sudanese who have fled violence in Sudan’s South Kordofan region.
“They’re living in makeshift structures,” said Christopher Mambula, MSF’s country medical coordinator. “It’s more densely populated. They’re not living under normal conditions in buildings and structures like that, which makes for easier propagation of pneumococcus from one person to another.”
Roughly a quarter of all in-patient treatment in the camp last year was for lower respiratory infections.
Mambula said in the first round of the campaign vaccinators were able to reach about 4,300 children under two. They will go back out this month to administer the second dose and the third will follow in September.
Kirbak said the pneumococcal vaccine is one of many on the list of vaccines he plans to introduce to the country as soon as he can find the money.
Immunization data in South Sudan is patchy. WHO and UNICEF’s “estimates of immunization coverage” for 2012 note that immunization rates “are based on data and information that are of varying, and, in some instances, unknown quality”.