Sisay G. Tegegne

The Role of the Polio Program Infrastructure in Response to Ebola Virus Disease Outbreak in Nigeria 2014

Background. The current West African outbreak of the Ebola virus disease (EVD) began in Guinea in December 2013 and rapidly spread to Liberia and Sierra Leone. On 20 July 2014, a sick individual flew into Lagos, Nigeria, from Monrovia, Liberia, setting off an outbreak in Lagos and later in Port Harcourt city. The government of Nigeria, supported by the World Health Organization and other partners, mounted a response to the outbreak relying on the polio program experiences and infrastructure. On 20 October 2014, the country was declared free of EVD. Methods. We examined the organization and operations of the response to the 2014 EVD outbreak in Nigeria and how experiences and support from the countrys polio program infrastructure accelerated the outbreak response. Results. The deputy incident manager of the National Polio Emergency Operations Centre was appointed the incident manager of the Ebola Emergency Operations Centre (EEOC), the body that coordinated and directed the response to the EVD outbreak in the country. A total of 892 contacts were followed up, and blood specimens were collected from 61 persons with suspected EVD and tested in designated laboratories. Of these, 19 (31%) were positive for Ebola, and 11 (58%) of the case patients were healthcare workers. The overall case-fatality rate was 40%. EVD sensitization and training were conducted during the outbreak and for 2 months after the outbreak ended. The World Health Organization deployed its surveillance and logistics personnel from non–Ebola-infected states to support response activities in Lagos and Rivers states. Conclusions. The support from the polio program infrastructure, particularly the coordination mechanism adopted (the EEOC), the availability of skilled personnel in the polio program, and lessons learned from managing the polio eradication program greatly contributed to the speedy containment of the 2014 EVD outbreak in Nigeria.

Role of Serial Polio Seroprevalence Studies in Guiding Implementation of the Polio Eradication Initiative in Kano, Nigeria: 2011–2014

Background. Nigeria was one of 3 polio-endemic countries before it was de-listed in September 2015 by the World Health Organization, following interruption of transmission of the poliovirus. During 2011–2014, Nigeria conducted serial polio seroprevalence surveys (SPS) in Kano Metropolitan Area, comprising 8 local government areas (LGAs) in Kano that is considered very high risk (VHR) for polio, to monitor performance of the polio eradication program and guide the program in the adoption of innovative strategies. Methods. Study subjects who resided in any of the 8 local government areas of Kano Metropolitan Area and satisfied age criteria were recruited from patients at Murtala Mohammed Specialist Hospital (Kano) for 3 seroprevalence surveys. The same methods were used to conduct each survey. Results. The 2011 study showed seroprevalence values of 81%, 75%, and 73% for poliovirus types 1, 2, and 3, respectively, among infants aged 6–9 months age. Among children aged 36–47 months, seroprevalence values were greater (91%, 87%, and 85% for poliovirus types 1, 2, and 3, respectively). In 2013, the results showed that the seroprevalence was unexpectedly low among infants aged 6–9 months, remained high among children aged 36–47 months, and increased minimally among children aged 5–9 years and those aged 10–14 years. The baseline seroprevalence among infants aged 6–9 months in 2014 was better than that in 2013. Conclusions. The results from the polio seroprevalence surveys conducted in Kano Metropolitan Area in 2011, 2013, and 2014 served to assess the trends in immunity and program performance, as well as to guide the program, leading to various interventions being implemented with good effect, as evidenced by the reduction of poliovirus circulation in Kano.

Contribution of Environmental Surveillance Toward Interruption of Poliovirus Transmission in Nigeria, 2012–2015

Background. Cases of paralysis caused by poliovirus have decreased by >99% since the 1988 World Health Assemblys resolution to eradicate polio. The World Health Organization identified environmental surveillance (ES) of poliovirus in the poliomyelitis eradication strategic plan as an activity that can complement acute flaccid paralysis (AFP) surveillance. This article summarizes key public health interventions that followed the isolation of polioviruses from ES between 2012 and 2015. Methods. The grap method was used to collect 1.75 L of raw flowing sewage every 2–4 weeks. Once collected, samples were shipped at 4°C to a polio laboratory for concentration. ES data were then used to guide program implementation. Results. From 2012 to 2015, ES reported 97 circulating vaccine-derived polioviruses (cVDPV2) and 14 wild polioviruses. In 2014 alone, 54 cVDPV type 2 cases and 1 WPV type 1 case were reported. In Sokoto State, 58 cases of AFP were found from a search of 9426 households. A total of 2 252 059 inactivated polio vaccine and 2 460 124 oral polio vaccine doses were administered to children aged <5 year in Borno and Yobe states. Conclusions. This article is among the first from Africa that relates ES findings to key public health interventions (mass immunization campaigns, inactivated polio vaccine introduction, and strengthening of AFP surveillance) that have contributed to the interruption of poliovirus transmission in Nigeria.

Strategies for Improving Polio Surveillance Performance in the Security-Challenged Nigerian States of Adamawa, Borno, and Yobe During 2009–2014

Background. The security-challenged states of Adamawa, Borno, and Yobe bear most of the brunt of the Boko Haram insurgency in Nigeria. The security challenge has led to the killing of health workers, destruction of health facilities, and displacement of huge populations. To identify areas of polio transmission and promptly detect possible cases of importation in these states, polio surveillance must be very sensitive. Methods. We conducted a retrospective review of acute flaccid paralysis surveillance in the security-compromised states between 2009 and 2014, using the acute flaccid paralysis database at the World Health Organization Nigeria Country Office. We also reviewed the reports of surveillance activities conducted in these security-challenged states, to identify strategies that were implemented to improve polio surveillance. Results. Environmental surveillance was implemented in Borno in 2013 and in Yobe in 2014. All disease surveillance and notification officers in the 3 security-challenged states now receive annual training, and the number of community informants in these states has dramatically increased. Media-based messaging (via radio and television) is now used to sensitize the public to the importance of surveillance, and contact samples have been regularly collected in both states since 2014. Conclusions. The strategies implemented in the security-challenged states improved the quality of polio surveillance during the review period.

Strengthening Routine Immunization in Areas of Northern Nigeria at High Risk for Polio Transmission During 2012–2014

Background. Following the 2012 declaration by World Health Organization (WHO) Regional Director for Africa and the WHO Executive Board to ramp up routine immunization (RI) activities, began to intensify activities to strengthen RI. This study assessed how the intensification of RI helped strengthen service delivery in local government areas (LGAs) of northern Nigeria at high risk for polio transmission. Methods. A retrospective study was performed by analyzing RI administrative data and findings from supportive supervisory visits in 107 high-risk LGAs. Results. Our study revealed that administrative coverage with 3rd dose of diphtheria-pertussis-tetanus vaccine in the 107 high-risk LGAs improved from a maximum average coverage of 33% during the preintensification period of 2009–2011 to 74% during the postintensification period of 2012–2014. Conclusions. Routine immunization could be strengthened in areas where coverage is low, and RI has been identified to be weak when certain key routine activities are intensified.

Implementation of a Systematic Accountability Framework in 2014 to Improve the Performance of the Nigerian Polio Program

Background. An accountability framework is a central feature of managing human and financial resources. One of its primary goals is to improve program performance through close monitoring of selected priority activities. The principal objective of this study was to determine the contribution of a systematic accountability framework to improving the performance of the World Health Organization (WHO)–Nigeria polio program staff, as well as the program itself. Methods. The effect of implementation of the accountability framework was evaluated using data on administrative actions and select process indicators associated with acute flaccid paralysis (AFP) surveillance, routine immunization, and polio supplemental immunization activities. Data were collected in 2014 during supportive supervision, using Magpi software (a company that provides service to collect data using mobile phones). A total of 2500 staff were studied. Results. Data on administrative actions and process indicators from quarters 2–4 in 2014 were compared. With respect to administrative actions, 1631 personnel (74%) received positive feedback (written or verbal commendation) in quarter 4 through the accountability framework, compared with 1569 (73%) and 1152 (61%) during quarters 3 and 2, respectively. These findings accorded with data on process indicators associated with AFP surveillance and routine immunization, showing statistically significant improvements in staff performance at the end of quarter 4, compared with other quarters. Conclusions. Improvements in staff performance and process indicators were observed for the WHO-Nigeria polio program after implementation of a systematic accountability framework.

The Journalists Initiatives on Immunisation Against Polio and Improved Acceptance of the Polio Vaccine in Northern Nigeria 2007–2015

Background. The polio eradication initiative had major setbacks in 2003 and 2007 due to media campaigns in which renowned scholars and Islamic clerics criticized polio vaccines. The World Health Organization (WHO) partnered with journalists in 2007 to form the Journalists Initiatives on Immunisation Against Polio (JAP), to develop communication initiatives aimed at highlighting polio eradication activities and the importance of immunization in northern Nigeria. Methods. We evaluated the impact of JAP activities in Kaduna State by determining the total number of media materials produced and the number of newspaper clips and bulletins published in support of polio eradication. We also determined the number of households in noncompliant communities that became compliant with vaccination during 2015 supplementary immunization activities (SIAs) after JAP interventions and compared caregivers’ sources of information about SIAs in 2007 before and after the JAP was formed. Results. Since creation of the JAP, >500 reports have been published and aired, with most portraying polio vaccine positively. During June 2015 SIAs in high-risk wards of Kaduna STATE, JAP interventions resulted in vaccination of 5122 of 5991 children (85.5%) from noncompliant households. During early 2007, the number of caregivers who had heard about SIA rounds from the media increased from 26% in January, before the JAP was formed, to 33% in March, after the initiation of JAP activities. Conclusions. The formation of the JAP resulted in measurable improvement in the acceptance of polio vaccine in northern Nigeria.

Revised Household-Based Microplanning in Polio Supplemental Immunization Activities in Kano State, Nigeria. 2013–2014

Background. Remarkable progress had been made since the launch of the Global Polio Eradication Initiative in 1988. However endemic wild poliovirus transmission in Nigeria, Pakistan, and Afghanistan remains an issue of international concern. Poor microplanning has been identified as a major contributor to the high numbers of chronically missed children. Methods. We assessed the contribution of the revised household-based microplanning process implemented in Kano State from September 2013 to April 2014 to the outcomes of subsequent polio supplemental immunization activities using used preselected planning and outcome indicators. Results. There was a 38% increase in the number of settlements enumerated, a 30% reduction in the number of target households, and a 54% reduction in target children. The reported number of children vaccinated and the doses of oral polio vaccine used during subsequent polio supplemental immunization activities showed a decline. Postvaccination lot quality assurance sampling and chronically missed settlement reports also showed a progressive reduction in the number of children and settlements missed. Conclusions. We observed improvement in Kano States performance based on the selected postcampaign performance evaluation indicators and reliability of baseline demographic estimates after the revised household-based microplanning exercise.

Sensitivity of Acute Flaccid Paralysis Surveillance in Nigeria (2006-2015)

Background: Nigeria has made tremendous progress towards polio eradication. The country was removed from the list of polio endemic countries by the World Health Organization (WHO) in September 2015. The last cases of wild poliovirus (WPV) and circulating vaccine derived poliovirus (cVDPV) from acute flaccid paralysis (AFP) cases had onset of paralysis in July 2014 and May 2015 respectively. The country has completed the phase I of laboratory containment of poliovirus activities, has achieved and maintained certification standard surveillance and is now in the process of ensuring adequate documentation preparatory to certification in 2017. Methods: We conducted a retrospective review of AFP surveillance performance in Nigeria between 2006 and 2015 from the AFP database at the WHO Country Office. We also reviewed rapid surveillance assessment reports conducted in various states of the country within the reporting period to identify surveillance strengths and gaps as well as recommendations put forward to improve polio surveillance performance. Results: The sensitivity of AFP surveillance in Nigeria increased consistently over the past 10 years. The number of confirmed and polio compatible cases has reduced significantly during the reporting period. AFP reporting sites have been prioritized for active surveillance and community informants have been engaged and cut across several key stakeholders in community health care delivery system. Conclusion: The AFP surveillance performance in Nigeria during the reporting period demonstrated high level of sensitivity that can be relied upon to timely detect polio outbreak. Residual surveillance gaps at sub national levels however exist and must be closed to be able to identify remaining areas of poliovirus transmission should such exist as well as promptly detect possible cases of importation. Quality surveillance is also required for certification.

The global switch from trivalent oral polio vaccine (tOPV) to bivalent oral polio vaccine (bOPV): facts, experiences and lessons learned from the south-south zone; Nigeria, April 2016

BackgroundThe globally synchronized switch from trivalent Oral Polio Vaccine (tOPV) to bivalent Oral Polio Vaccine (bOPV) took place in Nigeria on April 18th 2016. The country is divided into six geopolitical zones. This study reports the experiences and lessons learned from the switch process in the six states that make up Nigeria’s south-south geopolitical zone.MethodsThis was a descriptive retrospective review of Nigeria’s switch plan and structures used for implementing the tOPV-bOPV switch in the south-south zone. Nigeria’s National Polio Emergency Operation Centre (NPEOC) protocols, global guidelines and reports from switch supervisors during the switch were used to provide background information for this study. Quantitative data were derived from reviewing switch monitoring and validation documents as submitted to the NPEOCResultsThe switch process took place in all 3078 Health Facilities (HFs) and 123 Local Government Areas (LGAs) that make up the six states in the zone. A total of