Fighting polio in simmering heat

Sweat trickles down Mohammed Gedi Barre's face as he climbs the steep alleyways of Balbala, one of the poorest neighbourhoods in Djibouti City. He has been on his feet since 6.00 am (03.30 GMT), vaccinating children against polio in one of the hottest regions on the planet. By midday (09.00 GMT) the temperature reaches 45-degrees Celsius, and the humidity makes walking up and down the corridors between the shanties almost unbearable. Mohammed taps his cool box filled with vials of vaccines and explains, "We have to make sure that we leave no one out and provide all children with living polio vaccine." Reaching as many children as possible is only one of his daily concerns, and Djibouti’s climate is as much an adversary to Mohammed as the deadly virus he is trying to prevent. If the temperature of the vials exceeds 10 degrees Celsius, he explains, the vaccine becomes ineffective. Indicators on the capsules show whether the medicine is still active or whether it should be thrown away. Djibouti has undertaken vaccination initiatives against polio since 1988, with great sucess health authorities say. The last polio case was reported in 1999, but recent outbreaks in neighbouring Ethiopia and an epidemic across the Red Sea in nearby Yemen have prompted authorities to act swiftly. "Djibouti is a high-risk area. We might lose all gains if we did not act quickly and cover all people," Jihan Tawilah, a doctor with the UN World Health Organization (WHO) in Djibouti, said. "The danger comes from Yemen, where 220 polio infections were reported so far," she added. "We do not have and do not want to have any cases here." With support from WHO, the Ministry of Health is currently in the second stage of a three-phase countrywide emergency polio-vaccination campaign. The exercise targets children under five, who account for about 14 percent of the total population of 650,000. Each child must swallow two drops of the vaccine three times - the initial dose is repeated after 30 days, and the final dose is administered two months later. The goal of the programme is to minimise the spread of the virus in the community. "We want to erect a transmission barrier," Jihan explained. "But a major problem is that half of Djibouti's population is very mobile." To reach as many people as possible, the health ministry organised radio spots, TV adverts and a week-long information crusade before the start of the vaccination drive. Once the operation was underway, teams conducted follow-up tours of neighbourhoods to make sure every child had been included in the programme. Fatma Mohamed, a health-ministry official, joined local community representatives in a door-to-door information campaign. During her rounds, she looked out for buildings marked with a cross which indicated that children living in them have received their first dose of the vaccine.

Children at a vaccination centre in Djibouti city

CHALLENGES "The most difficult thing is to make sure that all the kids in the poorest neighbourhoods are covered," Fatma said. "Lack of food makes people move around in search for relatives who are better off." In Djibouti's slums, some shanties constructed from discarded paper cartons and scrap metal had no doors or walls, making it difficult to find the markers. It is however the semi-arid desert of Djibouti’s hinterlands - where pastoralists of the Afar and Issa ethnic groups eke out a living by herding camels, goats and sheep – that pose the greatest challenge to polio-eradication campaigners. "Our biggest problem is the heat and drinking water," Fatma said. "People sometimes argue with us and want to know whether the medicine is ‘halal’ and approved by Muslim clergy for consumption. Often they ask for food and khat [a leafy narcotic widely chewed in Djibouti]." While the teams are able to immunise about 80 to 100 children a day in the urban neighbourhoods, they are happy if they reach 50 in the outlying areas. "Sometimes we walk for a whole day just to vaccinate 10 children," Fatma noted. Locating children to vaccinate is also complicated by nomadic pastoralist movements in search of pasture and water. "Sometimes they cross the border to Somalia, Ethiopia or Eritrea. All we can do then is record them for the next campaign," Mohammed said. Despite hardship and logistical constraints, the polio-eradication campaign in Djibouti is considered a success. According to Jihan, the first phase reached about 95 percent of all children in Djibouti City and about 85 percent in the arid countryside. Poliomyelitis (polio) is a highly infectious disease caused by a virus. According to WHO, it invades the nervous system and can cause total paralysis in a matter of hours. The virus enters the body through the mouth and multiplies in the intestine. One in 200 infections leads to irreversible paralysis, usually in the legs. Among those paralysed, five to 10 percent die when their breathing muscles become immobilized. The disease mainly affects children under five years of age. It has no cure and can only be prevented. Polio vaccine, given multiple times, can protect a child for life. According to WHO, reported cases have decreased from an estimated 350,000 cases in 1999 to 1,919 reported cases in 2002 as a result of the global effort to eradicate the disease.