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The legacy of polio in Africa goes far beyond the tragedies of millions of children with permanent paralysis. It has a positive side, which includes the many well-trained polio staff who have vaccinated children, conducted surveillance, tested stool specimens in the laboratories, engaged with communities, and taken care of polio patients. This legacy also includes support for routine immunization services and vaccine introductions and campaigns for other diseases. As polio funding declines, it is time to take stock of the resources made available with polio funding in Africa and begin to find ways to keep some of the talented staff, infrastructure, and systems in place to work on new public health challenges. The partnerships that helped support polio eradication will need to consider funding to maintain and to strengthen routine immunization services and other maternal, neonatal, and child health programs in Africa that have benefitted from the polio eradication infrastructure.

For2 decades, conflicts and recurrent natural disasters have maintained Somalia in a chronic humanitarian crisis. For nearly 5 years, 1 million children10 years have not had access to lifesaving health services, including vaccination, resulting in the accumulation by 2012 of the largest geographically concentrated cohort of unvaccinated children in the world. This article reviews the epidemiology, risk, and program response to what is now known as the 2013 wild poliovirus (WPV) outbreak in Somalia and highlights the challenges that the program will face in making Somalia free of polio once again.A case of acute flaccid paralysis (AFP) was defined as a child15 years of age with sudden onset of fever and paralysis. Polio cases were defined as AFP cases with stool specimens positive for WPV.From 9 May to 31 December 2013, 189 cases of WPV type 1 (WPV1) were reported from 46 districts of Somalia; 42% were from Banadir region (Mogadishu), 60% were males, and 93% were5 years of age. All Somalian polio cases belonged to cluster N5A, which is known to have been circulating in northern Nigeria since 2011. In response to the outbreak, 8 supplementary immunization activities were conducted with oral polio vaccine (OPV; trivalent OPV was used initially, followed subsequently by bivalent OPV) targeting various age groups, including children aged5 years, children aged10 years, and individuals of any age.The current polio outbreak erupted after a polio-free period of6 years (the last case was reported in March 2007). Somalia interrupted indigenous WPV transmission in 2002, was removed from the list of polio-endemic countries a year later, and has since demonstrated its ability to control polio outbreaks resulting from importation. This outbreak reiterates that the threat of large polio outbreaks resulting from WPV importation will remain constant unless polio transmission is interrupted in the remaining polio-endemic countries.

Background After the last case of type 1 wild poliovirus (WPV1) was reported in 2007, Somalia experienced another outbreak of WPV1 (189 cases) in 2013. Methods We conducted a retrospective, matched case-control study to evaluate the vaccine effectiveness (VE) of oral polio vaccine (OPV). We retrieved information from the Somalia Surveillance Database. A case was defined as any case of acute flaccid paralysis (AFP) with virological confirmation of WPV1. We selected two groups of controls for each case: non-polio AFP cases ("NPAFP controls") matched to WPV1 cases by age, date of onset of paralysis and region; and asymptomatic "neighborhood controls," matched by age. Using conditional logistic regression, we estimated the VE of OPV as (1-odds ratio)×100. Result We matched 99 WPV cases with 99 NPAFP controls and 134 WPV1 cases with 268 neighborhood controls. Using NPAFP controls, the overall VE was 70% (95% confidence interval [CI], 37-86), 59% (2-83) among 1-3 dose recipients, 77% (95% CI, 46-91) among ≥4 dose recipients. In neighborhood controls, the overall VE was 95% (95% CI, 84-98), 92% (72-98) among 1-3 dose recipients, and 97% (89-99) among ≥4 dose recipients. When the analysis was limited to cases and controls ≤24 months old, the overall VE in NPAFP and neighborhood controls was 95% (95% CI, 65-99) and 97% (95% CI, 76-100), respectively. Conclusions Among individuals who were fully vaccinated with OPV, vaccination was effective at preventing WPV1 in Somalia.

Background: After two decades of conflict, Somalia remains a fragile state where large scale displacement and inadequate access to functioning health services have left children vulnerable to morbidity and mortality from vaccine preventable disease. Children residing in the autonomous zone of Somaliland are similarly vulnerable to poor access to health care services. Following the conduct of a UNICEF-supported Multiple Indicator Cluster Survey in Somaliland during 2011 which captured information on immunization system performance, a survey was conducted to better understand the reasons for non-vaccination among children in Somaliland. Methods: The Somaliland Routine Immunization Non-Participation Survey (RINPS) was conducted in November 2012 to better understand the reasons for non-participation in both Child Health Days (CHDs) and Routine Immunization Services (RIS). RINPS was a cross-sectional household survey which used a two-stage sample design in order to obtain a representative sample of children 0 - 59 months of age residing in Somaliland. Thirty clusters were randomly selected from the 303 clusters for participation in the 2011 Somaliland MICS. A total of 867 children aged 0 - 59 months were identified and included in the analysis (overall response rate, 96%). Findings: Caregivers lacked motivation to take their children to CHDs and for RIS and lacked information about why children need immunization. Routine vaccination or CHD cards were available for few children at the time of the survey. Almost one-fifth of children aged 0 - 59 months in Somaliland had not received at least one dose of vaccine for DTP, polio or measles vaccine from either CHD or RIS. Conclusion: Child Health Days have a role in at least some area of Somaliland to expand the reach of immunization services. The availability and delivery of sustainable routine immunization services need to be strengthened in Somaliland with a strong social mobilization program to raise awareness about the importance of routine immunization.