A seven-year-old boy currently undergoing treatment for polio in a Malawian hospital has prompted the nation to initiate a sweeping vaccination campaign aimed at curbing a recent outbreak.

Malawi, despite being one of the world’s most economically challenged nations and suffering from recent aid reductions, has impressively vaccinated 1.3 million children against polio in just four days. This rapid response was made possible after the World Health Organization (WHO) swiftly delivered emergency vaccine supplies by air over a week ago.

The outbreak was officially declared in Malawi following the detection of the virus in environmental samples collected from two sewage plants in Blantyre, the country’s second-largest city, where the sole confirmed case resides.

This development marks a new hurdle in the global mission to eradicate polio, a goal that seemed within reach 28 years ago when the number of cases had dwindled to 2,880 across 20 countries, largely due to an oral vaccine. Nonetheless, the virus has persistently lingered in some of the most isolated areas worldwide.

Earlier this year, Dr. Jamal Ahmed, the WHO’s polio chief, issued a poignant reminder: “Remember that eradication is all or nothing. You’re either done with it, or it comes back in full force.”

Dr Jamal Ahmed, the WHO’s polio chief, issued a stark warning earlier this year: “Remember that eradication is all or nothing. You’re either done with it, or it comes back in full force.”

Those pushing to finally stamp out a disease that has killed and paralysed millions globally are fighting a battle on two fronts – against the virus itself, and for the trust of the communities where it is making its last stand.

In Malawi, as community health workers visited nursery, primary schools and homes in Ndirande township, Blantyre, the Guardian spoke to six young mothers aged between 21 and 31. Half knew nothing about the disease, while the other three were wary of allowing their child to receive the vaccine.

“My child is four years old but I don’t know much about the vaccine. I am also not interested in getting the child vaccinated. I feel my child has had enough vaccines in her life,” says 21-year-old Frida Seva.

At Chisime primary school, dozens of children lined up to receive the drop. Health workers had contacted the teachers in advance in order for the pupils to get consent for the vaccination from their parents. About one in 10 of them, whose parents had not given permission, remained seated at their desks.

“There are some reasons including religion but to some parents it is just a choice,” says one teacher, Georgina Donasi.

Malawi’s communities have stepped up in this campaign, with social mobilisers, health workers, religious leaders and traditional authorities all giving advice and working to correct misinformation and reassure families.

Their efforts worked: in Ndirande, a township on the outskirts of Blantyre,of 84 households that were initially reluctant, 45 then acceptedthanks to this targeted engagement.

It is a common experience for polio workers in its remaining strongholds, especially in the border areas of Afghanistan and Pakistan, where the wild virus remains endemic, that local communities prove essential in building the trust needed for successful vaccination drives.

Sheeba Afghani has sat with mothers adamant that their child will not be vaccinated against polio. “You can give her any argument,” says Afghani, a senior manager with Unicef’s polio eradication programme. “It doesn’t matter. And then you have a local influencer walk in, and he says ‘vaccinate’, and she just hands you the child.”

“I’m thinking ‘woah’: we gave her so much logical, scientific [argument]. Every information possible.”

Social media also inflames misinformation, says Afghani. Once, if a death was incorrectly linked to vaccination, “we would have the community influencers, the doctor on duty etc, arrive in that particular family and address it locally,” she says.

“Now, even before we’ve had the opportunity to arrive in the community, it’ll be on social media,” she says.

Many places where polio has a foothold are also regions struggling with insecurity and poor health infrastructure, so people might have little faith in the state, helping to make mistrust deeply seated, says Afghani.

Malawi’s outbreak is the newest threat: a sporadic outbreak of variant poliovirus, also known as circulating vaccine-derived poliovirus, which occurs when the weakened virus used in the oral polio vaccine is excreted in someone’s faeces.

In places with poor sanitation, it begins to spread from person to person. This is initially helpful, spreading protection. But in places where vaccination rates are low, the virus can mutate into a form that can cause paralysis. There were 225 cases reported last year.

Misinformation and disinformation are rated as two of the biggest threats globally over the next few years, and vaccination campaigns are particularly vulnerable.

“The same misinformation can land in different places and play out very differently,” says Prof Heidi Larson, director of the Vaccine Confidence Project at the London School of Hygiene & Tropical Medicine. “In some cases, it’ll roll like water off a duck’s back, and then in another, it can disrupt a whole programme and cause major problems.”

With polio, the very phrase “vaccine-derived”, she says, “lends itself to very innocent misinformation because it makes it sound like you get the vaccine and you can get polio, which is not the case.”

US leaders – including Robert F Kennedy Jr, Donald Trump’s health secretary – casting doubt on vaccinations have harmful potential, Larson says. “There were suggestions that polio wasn’t important any more.

“And even though that was highly challenged, one of our challenges with the internet and social media is people hear one piece of the story,” she says. “A lot of the misguided things coming out of the US right now are really causing confusion. And when there’s uncertainty, it’s fertile ground for rumours.”

In 2019, staged videos of children collapsing after polio vaccinations forced a programme in Pakistan to be suspended. The videos led to panic, with health clinics set on fire, thousands of children rushed to hospital by parents and the deaths of a health worker and two police officers.

In Afghanistan, where half last year’s recorded cases of wild polio virus occurred, there are unique challenges with the population fearing its own government’s directives. The Taliban have stopped women working, mothers are behind closed doors, and girls are not in school, all locked away from vaccination teams who are unable go on outreach drives and can only lobby the government for a change in policy.

Money is also an issue. The Global Polio Eradication Initiative saw funding fall last year, as leading donors including the US and Britain cut aid spending. With its 2022-29 strategy facing a $1.7bn ($1.3bn) funding shortfall, the initiative said it would no longer be able to respond “at scale” to all outbreaks as it did in Malawi this month.

Dr Mike Chisema, Malawi’s Ministry of Health immunisation programme manager, says: “The funding space has really shrunk, and this has affected a lot of services that we offer concurrently on the emergencies that we face time and time again, beyond the emergency funding that could always be there.

“We would like to mount a coordinated and organised response to make sure that we protect our children and not have a disability cohort of children in future, which can also affect productivity of the country,” he says.

The polio outbreak comes at a time when Malawi, with 55% of its total health expenditure funded by donors, is also suffering the impact of the massive aid funding cuts.

“While the funds may not be adequate, there is always something to push the countries to respond, including the procurement of the vaccinations, delivering the service, the actual vaccination, making sure the logistics of the vaccines are well catered for so that we have the vaccine even at the very last mile,” says Chisema.

“Every time we have a case, we tend to mount a huge response because we don’t want to see it any more. So we want to control it from the source. We do testing every week in some places, and we also do testing fortnightly in some places.

“And we continue to look for these cases in the communities and we promote reporting of any of such cases because we want to make sure that it is no longer there,” he adds.

If Malawi’s effort seem to be breaking through to people, Unicef teams have found that agreement to vaccinate in some regions can be conditional, either on the go-ahead from a local leader or on the family also receiving something else – food, for example, or other types of healthcare.

Polio vaccination boycotts are often led by people who actually support the programme, Afghani says. “And they’re pretty conflicted, but their first loyalty is to their community. And they have bigger challenges there.”

Her team has recruited “microinfluencers” charged with challenging misinformation online, and havea dashboard on the wall of their New York headquarters with the output of software scouring social media for mentions of polio or vaccination. Any spike, potentially showing false rumours are spreading, ahead of a planned campaign, can be responded to swiftly.

As Malawi continues with its vaccination efforts, the country is hopeful that it is protecting its children. “It’s very important that we work very well with our stakeholders, the communities who are the beneficiaries of this important response,” adds Chisema. “[Otherwise] people will die, because polio can get hold of the respiratory muscles. We have a huge history of polio in Malawi.”

At Malabada health centre in Ndirande, Ruth Kutaombe is holding her eight-month-old boy. She is firmly pro-vaccination. “It will protect him from contracting the disease,” she says.

“I visited the hospital for the routine under-five clinic but after hearing they are giving the vaccine, I made a choice to have him vaccinated.”