As polio strikes more and more people in Chad - 68 cases so far this year - tens of thousands of children are unprotected largely due to flaws in how vaccination campaigns are run.
Recent infections have made Chad the country with the highest number of cases worldwide, according to the World Health Organization (WHO). The government classified more regions as "high risk" in May than in February, despite regional and nationwide immunization drives in February, March and May.
Why are so many children in Chad missing out on the easily administered two drops of oral vaccine, which, given several times at a young age, can protect a child for life?
Weak coordination, supervision and monitoring; a defective cold-chain; and poor communications are some of the "main problems" with polio immunizations, according to a new Chad government plan to improve coverage. Health experts are heartened by the plan but say it must be implemented immediately if a devastating spread of the disease is to be avoided.
"It's encouraging but we need this to be implemented very, very rapidly because we've got quite uncontrolled transmission, particularly of type 1 poliovirus," said Oliver Rosenbauer, spokesperson for WHO's polio eradication group in Geneva.
Chad currently has outbreaks of both wild poliovirus type 1 (WPV1) and WPV3, with at least 65 and three cases respectively this year, according to WHO. WPV3 - centred in Dar Sila District in the east - has been present since 2007 while the WPV1 outbreak (present in Chari Baguirmi, Logones east and west, Wadi Fira, Ouaddai, Salamat, Kanem and Batha, according to the government) began last September when the virus entered from northern Nigeria.
WHO says the presence of polio in Chad is of particular concern with the Hajj (Muslim pilgrimage to Mecca) due in early November.
"Polio has struck close to the border with Sudan, and with Ramadan and the Hajj coming up populations are probably already moving across the area," Rosenbauer said. "It's happened in the past where from there polio spreads into the Horn of Africa, into Yemen [and] all the way into Indonesia."
Polio can strike anyone but those most at risk are children under five, according to WHO.
"What tends to happen in some areas of Chad is that the micro-planning is not sufficient; the map isn't good enough," Rosenbauer told IRIN. "Agents start to go about almost blindly through a neighbourhood. Entire areas are quite easily missed that way."
Mismanagement and corruption have long hindered vaccination coverage in Chad, according to health experts in and outside the country.
"What we really need is ownership at the critical district level which is where the planning takes place. We need district chiefs to get involved and hold their staffs accountable."
The new plan looks to address this, Djabar Hamid, Health Ministry head of immunization, told IRIN. "We are not applying international standards; we are not yet monitoring districts as we should."
If campaigns are run well polio's spread in Chad could be stopped within the year, Rosenbauer told IRIN.
"The good news is Chad is not Nigeria in terms of population numbers and so this is an outbreak that can be very rapidly controlled - even over the next six months. But we've got challenges ahead, including the rainy season, and we've got the lack of ownership at the district level where we urgently need it."
The four polio-endemic countries are Afghanistan, India, Nigeria and Pakistan. Rosenbauer said that Chad - which had once eradicated polio - is currently considered as having "re-established transmission".
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