After six sewage samples taken in Gaza in late June tested positive for poliovirus, World Health Organization Director-General Dr. Tedros Adhanom Ghebreyesus warned that it was “just a matter of time” before the disease reached thousands of Palestinian children.
At the time of his warning in late July, cases of acute flaccid paralysis, a symptom of poliovirus infection, had been flagged in the area where the samples were taken. Just week’s later, Gaza’s first polio case in 25 years was confirmed in an unvaccinated 10-month-old.
Now more than 1.2 million oral polio vaccines have arrived in the Gaza Strip, with millions more expected in coming days. The aim is to vaccinate about 640,000 children under the age of 10 with two doses each.
A plan is in place to access the territory and distribute them — all while keeping the vials in the vital temperature range of 2 to 8 degrees Celsius (36 to 46 degrees Fahrenheit).
Still, there are huge challenges ahead to administer the vaccines.
WHO is joined in the vaccination effort by the Palestinian Ministry of Health, the United Nations Children’s Fund, the UN Relief and Works Agency for Palestine Refugees and other partners. Each organization has been assigned a role in the technical and strategic “microplan” to execute the vaccine campaign.
Above all, the organizations have emphasized that a ceasefire — what they are calling a “polio pause”— is crucial. Without one, they say, children in Gaza will continue to become paralyzed, and the deadly disease will spread to the broader region and beyond.
“The Ministry called on international organizations to work and pressure the occupying authorities to stop the continuous aggression against our people in the Gaza Strip so that medical teams can vaccinate children and prevent the spread of the polio virus,” the Ministry of Health in Ramallah said on Sunday.
The cohort and other aid groups have called for seven days to safely administer the vaccines. Hamas said in a statement August 16 that it supports the polio pause.
Israel’s Coordinator of Government Activities in the Territories, which manages the flow of aid into Gaza, previously said that local and international medical teams would administer vaccines to unvaccinated children in Gaza “in the coming days” and would coordinate with the Israeli military to use “humanitarian pauses that will allow the population to reach the medical centers where the vaccinations will be administered.”
Discussions around temporary pauses in fighting are still ongoing. The tentative date to begin vaccinations is August 31 if conditions allow it.
“We are optimistic and getting positive signals that all parties want this campaign done and done well. Everybody agrees that that needs to happen. That’s encouraging, but the details are yet to be worked out,” said Dr. Hamid Jafari, WHO’s polio director for the Eastern Mediterranean Region.
Meanwhile, broader negotiations — mediated by the United States, Qatar and Egypt — are also underway, aiming to end 10 months of conflict after Israel launched a war on Hamas following the group’s October 7 attack. But progress in the talks does not guarantee a final agreement anytime soon.
Clarity and confidence in vaccination
Even with humanitarian pauses, the delivery of vaccines to Gaza is just the start of an obstacle-filled campaign.
The plan begins with each international organization assigned a role, according to Jonathan Crickx, chief of communications at UNICEF Palestine.
WHO is responsible for approving the vaccines, conducting on-the-ground monitoring and testing suspected environmental and human polio cases.
UNICEF is procuring and supplying vaccines and refrigeration materials and leading an awareness campaign for civilians. It will share information on who can get vaccinated, where and why through social media, mass media and printed leaflets.
“Families are making daily decisions whether they go out, risk their lives to get food or water or fuel,” Jafari said. “And we are now going to be asking them to come out to get vaccinations. What do they do? In order to motivate them, we have to make sure that there is clarity of information and enough confidence and trust that it will be safe.”
A ceasefire is the only way to ensure this, he said.
As the awareness campaign progresses, the vaccines will be distributed to 10 UNRWA health facilities and up to 100 mobile medical points across the Gaza Strip.
UNRWA is on the ground to get vaccines into mouths through these health facilities, shelters and mobile units.
“Those mobile teams go from one shelter to another and in the areas where people have taken refuge that are not inside shelters,” UNRWA communications director Juliette Touma said. “People have taken refuge anywhere: in the open, on the streets, by the beach, wherever they can.”
Protecting the cold chain
For WHO and UNICEF, one of the most crucial responsibilities is protecting the cold chain: The vaccines must be kept within a limited temperature range, or they will spoil. This requires ice boxes, mobile fridges, working generators, solar panels and fuel. The necessary equipment to keep the vaccines cold was already delivered to Gaza last week, according to the Health Ministry in Ramallah.
“It’s absolutely critical not only that the vaccine is brought into Gaza but that it’s protected. For them, the chain is a whole operation,” Touma said.
The campaign will enter a region that has experienced “persistent fuel shortages” since October, when Israeli authorities cut off the feeder line supply and shut down the local power plant, the UN said.
The Deir al-Balah warehouse and UNRWA health facilities need this fleeting supply, and each vaccine pack is equipped with temperature-sensitive stickers to indicate whether the cold chain breaks, according to Crickx.
“This is a huge challenge,” he said. “When I’m talking about that warehouse in Deir al-Balah and the UNRWA health facilities, we have to realize that this is not much. It’s only 25% of the cold chain capacity before the war. … The Gaza Strip is exposed to a very serious lack of reliable power supply.”
Aid organizations have tried to supplement the dwindling supply by bringing in fuel. However, a July Oxfam International report said that, on average, only a fifth of what’s required for the functioning of vital services across Gaza has been allowed to cross the border.
“Even before the seventh of October, Gaza was running on only eight hours of electricity a day. … The Israeli government wouldn’t allow specific fuel allocations,” said Bushra Khalidi, the Oxfam policy lead who worked on the report. “As soon as the fuel cut in October, the everything shut.”
“We’ve had goods that are just sitting there in the trucks since May, exposed,” said Edward Carins, emergency response senior operations manager at humanitarian aid organization Mercy Corps. “Access is virtually nonexistent or extremely restricted.”
On average, only 76 humanitarian trucks entered the Gaza Strip each day from August 1 to 12, an 85% drop from an average of 500 trucks before the crisis, according to the UN Office for the Coordination of Humanitarian Affairs.
Israel’s Coordinator of Government Activities in the Territories (COGAT) gave the polio vaccines special permission to access the territory, along with other “cold chain” items that are typically not allowed inside Gaza.
However, the void of existing resources means there is little backup to protect the cold chain if something were to go wrong, according to Carins.
Challenges on the ground
Even with robust plans in place, the vaccine vials have crossed into an “epicenter” of disease.
The collapse of water, sewage and health-care systems combined with shortages of aid, food and sanitation supplies, overcrowding, flooding and the plummeted vaccination rates has turned the region into “an epicenter for various diseases,” said Touma, the UNRWA communications director.
Polio is a highly contagious viral infection spread mainly through contaminated water or food. The virus attacks the nervous system and can cause paralysis, respiratory issues and even death. All the factors that facilitate poliovirus transmission are present in Gaza, according to WHO’s Jafari.
Beyond polio, the conditions have contributed to surging cases of hepatitis, jaundice, diarrheal illnesses and highly contagious skin rashes, among other infectious and gastrointestinal diseases, the UN Office for the Coordination of Humanitarian Affairs reports.
“The whole of Gaza has become one huge refugee camp,” Touma added. “I saw tens of thousands of people just piling up on top of each other … The sewage is overflowing. It was far from clean. I remember a colleague telling us that in community hospitals, after quite a big attack by Israeli forces, he saw staff cleaning the floor with water because they had no disinfectant.”
“Everybody is sick all the time, all the time, all the time, all the time,” Khalidi said. Her own family and friends “are always sick. They were in Rafah, and they were sick. They were in Gaza City, they were sick, and now they are in a refugee camp in Deir al-Balah, and they’re still sick. It’s not related to the area they are. It’s related to the water. My friend has had bloody diarrhea for the last four months and is unable to get medical care for it, and he’s been displaced almost 15 times.”
Since October, nearly 86% of the Gaza Strip has been placed under evacuation orders by the Israeli military, according to the Office for the Coordination of Humanitarian Affairs. As of Wednesday, 1.9 million people – 9 in 10 people across the Gaza Strip – are internally displaced, the UN said.
This constant internal displacement due to mass evacuation orders and “unlivable conditions” will make it challenging to reach the polio vaccination campaign’s goal of at least 90% coverage, according to Jafari.
“We are starting from two positions of disadvantage,” he said. “One is that we detected this outbreak quite late, and the virus is already widespread. We’ve already failed one child who’s been paralyzed by polio now, and more will happen. The second disadvantage is that here we can’t go to houses [because of displacement]. We have to convince families to come to the vaccination sites.”
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UNRWA identified the “notoriously inaccessible” northern territory of Gaza — the first area Israel attacked after October 7 — as a unique challenge amid the already difficult task of reaching families across the strip.
“It’s impossible from to go from Deir al-Balah to the North. It’s too dangerous. The IDF won’t let it. It’s full of unexploded ordnances and full of bandits. Goods and people generally are not passing between the North and middle area, and most aid agencies have very limited presence there,” Carins said.
He said he hopes that when the world sees workers attempt to take the polio vaccines into the North, people will also notice the broader issues at hand.
“We look at the polio vaccinations and are glad that they are going ahead, hopefully under a ceasefire, but are reminded that this campaign is a direct symptom of the fact that this has gone way, way, way too far,” Carins added. “The conditions that are now present in Gaza are totally unacceptable … This week, it’s polio vaccinations. Next week, it will always be something else. These are scars that Gaza is going to have to deal with for decades to come.”
Quelling global spread
Touma highlighted the urgency of the polio vaccine campaign in Gaza.
“Polio is vicious. It can spread very quickly. It doesn’t know any borders or front lines, and it doesn’t need a visa,” Touma said.
To illustrate the virus’ capabilities, Jafari pointed to a 2022 incident in which the same strain spread to London, New York and Israel — places known for having “optimal sanitation and public health infrastructure.”
Before the war, Gaza had near-universal vaccine coverage, but it has since dropped to just over 80%, a number WHO hopes to raise to 90% to 95% by the end of the new campaign.
“If we can’t [reach 90% to 95% vaccine coverage in Gaza], this outbreak will continue. More children will get paralyzed. This outbreak will spread into Israel and into surrounding countries,” Jafari said.
“It is not only a regional threat, it’s a global threat.”