The challenges in containing a looming polio outbreak in Gaza

Children’s lives in Gaza are riddled with uncertainty. They don’t know when the next bomb will fall, where their next meal will come from or even if their families and friends are still alive.
Now, another variable poses a grave risk to Gaza’s children: polio. The first case was confirmed after a 10-month-old baby tested positive for the virus in mid-August. At least two others are suspected to have been infected.
Poliovirus can be extremely dangerous, affecting nerve function and causing irreversible paralysis. Since the war began last October, inoculations have fallen in Gaza, leaving thousands of children unvaccinated. Doctors and aid workers have been warning for months that the catastrophic humanitarian conditions in the enclave would fuel the spread of disease. Now, 25 years after the virus was eradicated in Palestine, unheeded warnings are proving true.
The World Health Organisation, along with the UN children’s fund, Unicef and other aid groups, has called for a ceasefire or at least a pause in the fighting to be able to administer at least 1.2 million vaccines.
But will it happen?
On Beyond the Headlines this week, host Nada AlTaher discusses the gravity of Gaza’s looming polio outbreak with Dr Zaher Sahloul, president of the medical NGO MedGlobal, and speaks to Unicef’s Jonathan Crickx about vaccine co-ordination efforts.
Below is the full transcript of this episode:
DR ZAHER SAHLOUL: The collapse of the healthcare system does not present itself with only destroyed hospitals and destroyed ventilators and patients who are dying in hospitals. We’ve seen all of that, but it manifests itself by outbreaks.
Host NADA ALTAHER: That was Dr Zaher Sahloul, who witnessed the collapse of the healthcare system in Gaza.
ZS: When you start to see outbreaks, that means the collapse is really, really bad. That means when you see one polio case, that is the tip of the iceberg.
NA: Children’s lives in Gaza are riddled with uncertainty and fear. They don’t know when the next bomb will fall. They don’t know where their next meal will come from. They sometimes don’t even know if their families or friends are still alive. Now, another variable poses a grave risk to children: polio, after a baby as old as the war tested positive for the disease. At least two other children are suspected of having it, and their parents are waiting anxiously for their test results.
But humanitarian groups have been talking about this for weeks, after poliovirus was found in six sewage samples last month. To put this into context, polio was declared eradicated in the occupied Palestinian territories, the same polio that causes nerve damage and can lead to irreversible paralysis.
Doctors, aid workers and Gazans themselves told us they have never seen anything like what’s been going on in the past 10 months, in terms of the scale and depth of trauma, suffering and destruction.
Thousands of tonnes of rubbish continue to pile up. Sewage is collecting in the streets, winding through tents where hundreds of thousands of displaced Palestininans have sought shelter. Let me remind you that at least 90 per cent of Gaza’s population of 2.1 million have been displaced, and the real figures are thought to be even higher. Water and sanitation services are extremely scarce and the healthcare system has collapsed, with not one fully functioning hospital available in the Gaza Strip.
Aid groups have been saying that more people are likely to die from disease in Gaza than in air strikes. Warnings about the spread of disease appear to have fallen on deaf ears. After more than 10 months of war, conditions have made an already vulnerable population more susceptible to all sorts of illnesses, preventable ones, too, with polio the most recent and arguably the most dangerous.
The World Health Organisation, along with Unicef and other aid groups, has called for a ceasefire, or at least a pause in the fighting, just to be able to administer a vaccination campaign to 640,000 children under the age of 10.
But will this happen?
This is Beyond the Headlines and I’m your host Nada AlTaher. In this week’s episode, we consider the gravity of a looming polio outbreak in Gaza and ask, what will it take to stop the disease from spreading before it’s too late?
NA: Dr Zaher is the president of the US-based NGO MedGlobal. I asked him what makes a single case of polio so concerning.
ZS: We’ve seen this movie before in neighbouring Syria, where you had initially one case because of the war. And then after that we had several cases, and we had to have a major vaccination campaign that included eight different countries and millions of children to prevent it from spreading.
One case means that this is the tip of the iceberg. Right now, we have confirmed one case, and the two other cases are being investigated. These three children presented with acute flaccid paralysis, which is the hallmark of polio.
If they are confirmed, that means there are other children who may be harbouring the virus and don’t have symptoms, because only one out of 200 children who contract the virus will have symptoms. And then other children will be prone to have the same condition. And paralysis related to polio is an irreversible condition. It will lead to life-long disability and sometimes death.
That’s why it’s a dangerous disease that the world has been trying to eradicate for the past few decades, with a lot of success. But right now we have only a few hundred polio cases in the world every year in areas with low vaccination rates, or in areas that are in a conflict like Gaza. That’s why one case is too many.
NA: What are the kind of conditions required for polio to re-emerge, especially in Gaza, 25 years after it was declared eradicated?
ZS: Gaza did not have any cases for the past couple of decades because of the successful vaccination campaigns. Gaza is a success story in terms of the healthcare system before this war.
There are two requirements for a disease to re-emerge: the first is the collapse of the healthcare system. That means a decreased vaccination rate and also a lack of personal hygiene, as well as pollution of water, and then introduction of the polio virus from other sources.
There are studies that were done on the virus that were detected in the sewage in Gaza that showed that this virus was introduced from Egypt early in 2023 and that now it’s spreading. That’s why we have these cases of acute paralysis, because of the low vaccination rate. And also because of the displacement, because of the pollution of water, because there is no enough clean water because of the contamination of food. Polio is one of these viruses that can transmit from mouth, from polluted water, from polluted food and then can cause the flaccid paralysis.
NA: I’ve heard other doctors say that, when foreign doctors visit Gaza, some choose to burn their clothes before leaving, for fear of spreading diseases back in their home countries. What is the wider effect of a polio outbreak in Gaza?
ZS: I’ve been in Gaza four times – three times before this war and one time during this war, in January. I spent two weeks there. I stayed in Rafah and I worked in Nasser Hospital in Khan Younis, and also in a clinic in Rafah run by my organisation, MedGlobal.
It’s important to describe daily life in Gaza. When you move from place to place, the first thing that attracts your attention is tents. Tents everywhere. Ninety per cent of Gaza’s population has been displaced, many of them several times. This continuous displacement means you are disconnected from health care.
Then you have the destruction of water supplies, of sewerage systems, of decontamination systems. And it is crowded and there are piles of rubbish around you. That by itself is fertile ground for diseases to spread.
Then you have very limited resources in the hospitals and clinics. And then you have the closure of hospitals because of the destruction and the targeting of the healthcare system in attacks. Only 16 out of 36 hospitals are now functioning, or partially functioning, in Gaza.
Then you have the healthcare workers themselves who are attacked. If you’re a doctor or a nurse, you are displaced like everyone else. Many of the doctors I work with lost several members of their families because they were killed or injured. This is daily life. When you have such conditions, polio virus, like many other viruses, can spread from place to place, from person to person.
It does not only affect the population in Gaza, but it affects the population around Gaza as well. That means people in Egypt, people in Jordan and people in Israel can be affected and the virus can be transmitted. That will lead to an outbreak that is beyond the population in Gaza.
NA: How useful is it to vaccinate people after the first case has been detected? And how useful is it to vaccinate people without fixing the sewerage systems and the infrastructure and to provide people with clean water consistently and continuously?
ZS: Vaccination by itself is not the solution. And for vaccination to happen, there needs to be security.
For example, we have16 medical points in MedGlobal. Two were designated as vaccination centres. For vaccination to happen at these medical points, these are clinics run by local doctors – that means it has to be safe for the population to come to the clinic.
They need to be stable. That means they’re not displaced from place to place. And we need to have supplies: the vaccine in a cold chain. That means the vaccine has to be in the refrigerator so it does not expire or gets ruined. None of these three conditions are available in Gaza right now.
You also need to be able to reach populations that are not reachable right now. They don’t come to the clinic. You need to go to them from tent to tent, house to house. You need to use mobile clinics. You need to have fuel. You need to have transport. You need to have safe conditions so these teams are not bombed. These conditions are not available right now. That’s why we are calling for a humanitarian pause or ceasefire, so we can do the vaccination campaign.
In addition, we need to have clean water. We need to have a sewerage treatment plant. That way, the conditions that lead to the spread of the virus are no longer present.
We need to train staff on how to detect polio, because this is not something that doctors and nurses deal with on a daily basis. We need to have proper surveillance. We need to have clean water, clean facilities, hygiene kits that for some reason are not allowed to be sent into Gaza.
We need all of that so polio does not spread within Gaza and beyond Gaza.
NA: There are children born at the beginning of the war, so they have spent 10 months without being vaccinated. If the war continues, and if there is no humanitarian pause or ceasefire, are we going to have the same conversation a year from now about polio? About other diseases?
ZS: When we’re talking about the vaccination rate dropping from 99 per cent to 90 per cent, that means you have at least 200,000 children who are not vaccinated, 200,000 children who are prone to diseases. That’s why it’s important to understand the scale of the problem.
On top of that, you have malnutrition among children, which causes suppressed immunity. That means your body is less likely to fight against infections. This affects tens of thousands of children in Gaza. Half a million Palestinians in Gaza have the highest level of food insecurity.
NA: Humanitarian agencies have told us about numerous incidents when lorries of medical aid were turned back because one or two items did not meet the requirements of the border police. Has MedGlobal had a similar experience?
ZS: It’s a difficult question. What I know is that we have difficulty getting supplies in and we go through a very extensive clearance process. You have to tell border authorities in advance what you are sending, whether you are sending the supplies through Egypt, before the closure of the Rafah border crossing, or now through Karam Abu Salem or Erez.
We had many incidents when, even with clearance, our supplies were returned. Six months ago we had a shipment of medical supplies from the US – dressing, tubes for patients for different catheters, suture kits, ventilators, hospital beds. It also contained oxygen cylinders.
We sent them the list of supplies more than seven months before and they said, it’s OK. We sent the supplies to Egypt, where they were kept in the warehouse, we moved them to the border and they told us we could not take the supplies into Gaza. We could not take the supplies because of the oxygen cylinders, even though the shipment was approved.
These things, unfortunately, have been happening frequently. Right now, the restrictions on medical supplies and surgical supplies are even worse than a few months ago. It’s more restricted.
NA: Did other doctors, did other NGOs, see the re-emergence of polio coming in Gaza?
ZS: Definitely. This is what we have been warning the world about. And not only MedGlobal, but the WHO, Unicef, UN agencies, other NGOs working in Gaza.
Again, when the healthcare system collapses, you expect viruses, infection and outbreaks to spread. When I was there, I saw many patients with hepatitis A. Hepatitis A is related to contaminated water. It’s actually transmitted the same way as polio.
But if you have a good enough vaccination for polio, that will prevent children from getting polio. In hepatitis A, there’s no vaccine, so it’s easier to spread. We saw the initial signs there’s something going wrong.
We also have seen cases of measles related to the failure of the vaccination system. These two diseases are not as dangerous as polio because they are self-limited – they do not cause death in many, unless they have severe cases. And they do not cause irreversible paralysis, like polio.
But when you see hepatitis A, when you see measles, that means something else will be coming. Everyone knew polio would come because you saw the conditions. It was a matter of time. And now it’s the time, unfortunately.
NA: WHO officials say it’s possible the disease has been circulating in Gaza since last year. Before the war, Gaza had a 99 per cent routine vaccination rate against the virus. But now that number has plummeted to about 86 per cent. This falls well below the coverage rate needed to contain an outbreak.
Unicef’s chief of communication in Palestine, Jonathan Crickx, tells me about the vaccination efforts to deliver at least 1.2 million doses to Gaza in the coming weeks.
JONATHAN CRICKX: It is important to keep in mind that for this vaccination campaign to be a success, we need to have more than 95 per cent of children vaccinated, so the vaccination coverage is sufficient.
The vaccination campaign that Unicef, the WHO and the different partners will do in the coming weeks is very much addressing a specific strain of polio. It’s called the type 2 poliovirus. This strain was eradicated in the 19902 and, since then, the oral polio vaccine was actually targeting the polio type one and polio type three strains.
What was done in terms of routine immunisation in the Gaza Strip was mostly vaccines against type one and type three. Unfortunately, in June, the WHO, the Ministry of Health and Unicef found traces of polio type two. This is the specific type that needs to be addressed and this is why this vaccination campaign is taking place, specifically for polio type 2.
NA: UN agencies, the Palestinian Ministry of Health and other partners are working together to gather 708 teams to administer the vaccines.
JC: It is absolutely critical that we are able to vaccinate 640,000 children below the age of 10 in the coming weeks in the Gaza Strip. The process is that Unicef will bring the cold-chain supplies and the vaccines in the coming days.
They will be stored in a warehouse in Deir Al Balah. And then they will be dispatched to 11 health facilities throughout the Gaza Strip that are equipped with a cold-chain capacity.
People will be able to get vaccinated in those health centres, but there will also be mobile units vaccinating people in co-ordination with the Ministry of Health, with the UN agency for Palestinian refugees, with the WHO and other partners able to vaccinate those children.
The first round of the vaccination campaign will take place at the end of August, or the beginning of September, for one week. Then there will be a second round that will take place at the end of September, or the beginning of October, also for seven days.
NA: The Israeli army stated that its Cogat agency, which co-ordinates civilian matters with Palestinians, will facilitate the entry of more than 43,000 vaccine vials into Gaza in the coming weeks. But under the current conditions of war, safety concerns and a lack of accessibility, aid organisations say it is impossible to conduct a thorough vaccination campaign.
JC: The issue we are facing is that, in the context of war, you have the bombardments, you have insecurity on the ground, you have access restrictions and you have a health system that is only partially functioning.
You have so many hospitals that are not functioning. All of this makes routine immunisation way more complicated. It’s also a big concern that many babies have not yet received the routine vaccines they should get to be protected.
The poliovirus is extremely contagious, especially when it’s carried by a human being. The poliovirus attacks the nervous system and it can create paralysis. And there is very little treatment to address that.
NA: A report released by Oxfam in July found that Israel’s military campaign in Gaza damaged or destroyed five water and sanitation infrastructure sites every three days, and destroyed 70 per cent of all sewerage pumps, and all wastewater treatment plants. In the very first days of the war, Israel also cut off external water supplies, causing extreme water scarcity. This has contributed to more than a quarter of Palestinians in Gaza falling severely ill from easily preventable diseases.
JC: The war in the Gaza Strip has led to many, many challenges and concerns – the lack of water, especially for hygiene, the lack of sanitation, the many times people have been displaced, the fact many people are living in tents where there is absolutely no infrastructure, no toilets, no latrines. There is also the heat, the level of destruction, the fact there is no sewerage system, that there is no waste water treatment system. This has raised concerns when it comes to the spreading of diseases. It is absolutely critical that everything is done to address that.
Ultimately, the only way to address that at scale is a humanitarian ceasefire. That is the only way to put a proper, functioning health system back together, a functioning water distribution system, or any of the things that are absolutely needed to prevent the spread of diseases. That is why, for months now, people have asked for a humanitarian ceasefire in Gaza.