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For over 25 years, the Gaza strip has been polio free (UN) and up until 2022 immunization coverage in the Palestinian territories (including Gaza) was 99% (UNICEF) despite tough socioeconomic conditions and intermittent bouts of violence and conflict. In the wake of an unrelenting war that began on October 7, 2023, immunization gains have been reversed. In less than a year of non-stop violence, immunization coverage in Gaza plummeted to 89% (WUENIC) despite vaccination campaigns that attempted to reach as many missed or unimmunized children as possible during the conflict (UNRWA, UNICEF). The Gaza strip became breeding ground for several vaccine preventable diseases, including polio. It was imminent that polio would re-emerge in a context where routine immunization has been disrupted, where people have been living in overcrowded settings under unsanitary and unhygienic conditions, and where risk of transmission was heightened with multiple forced displacement.

On June 23, 2024, six environmental (sewage) samples collected from two locations tested positive for Variant type 2 poliovirus (VDPV2). The virus has been isolated from the environment, and no cases of paralysis associated with it have been reported (GPEI).

A Local AND a Cross-Border Threat to an Unstable Region
The alarm must be sounded. The spread of polio within Gaza has become imminent. At present, the entire Gazan population remains vulnerable because herd immunity, requiring at least 95% vaccination coverage, has not been attained. And Gaza’s non-functioning health system (MSF) will be unable to control the spread of polio.

Gaza’s new public health threat also has trans-boundary ramifications. The highly infectious virus will not be confined to the Gaza strip and could potentially spread beyond borders to affect neighboring areas and countries, especially those with low immunization coverage. Newly released global immunization coverage estimates (WUENIC) alert us to stagnancy, an outcome of the region’s humanitarian and instability situations (UNICEF) which have weakened health systems.

We Need an Immediate Response
To effectively address this inter-boundary and intra-boundary threat, we need an immediate, coordinated, and comprehensive response to be orchestrated by local health authorities and international health organizations. This response must be informed with past experiences in countries with similar contexts in the region.

Beyond environmental surveillance and to get the fuller polio picture in Gaza, we need to strengthen the gold standard for polio detection - acute flaccid paralysis (AFP) surveillance that involves monitoring sudden cases of muscle weakness or paralysis to identify potential polio infections. While surveillance is essential for monitoring the situation, immediate action is also required to respond to the available data. A reactive vaccination campaign should be implemented using monovalent oral polio vaccine type 2 (mOPV2) or novel oral polio vaccine type 2 (nOPV2) to boost immunity against type 2 poliovirus. The choice of vaccine depends on what is approved by health authorities, of course. The implementation of such campaigns must capitalize on innovative and cost-effective approaches considering dwindling resources, health service provider shortages, and inaccessibility issues.

Multi-sectoral collaboration is non-negotiable in this context because polio is an oral-fecal virus that can spread through contaminated water. It is of paramount importance that health stakeholders collaborate with the water, sanitation and hygiene (WASH) sector to enhance sanitation and hygiene practices and ensure access to clean water to reduce virus transmission. More investments are also needed for community empowerment. An effective Risk Communication and Community Engagement (RCCE) can promote preventive measures and inform the public about the steps being taken to control the spread of the virus.

The detection of polio in the Gaza Strip is a grave public health concern that demands action to protect health in Gaza and beyond. Immediacy is key to protecting against polio inside and outside Gaza.


About the Authors
•Dr. Mohannad Al Nsour is a medical doctor and an internationally recognized expert in field epidemiology, operational research, and public health systems, and a fellow through distinction with The Faculty of Public Health at UK (FPH). Dr. Al-Nsour is the Executive Director of the Eastern Mediterranean Public Health Network (EMPHNET).

•Dr. Nada Ahmed is a public health specialist with over twenty years of experience in both national and international areas. Previously she has worked for Sudan Ministry of Health in various lead positions as the Maternal and Child Health Director, the Expanded Program on Immunization (EPI) Manager, and Primary Healthcare Director General. She currently serves as a Senior Technical Specialist at EMPHNET.