A health worker prepares to administer a vaccine in northern Nigeria. WHO/L.Dore
A mass vaccination campaign to protect more than 4 million children from a measles outbreak in conflict-affected states in north-eastern Nigeria started on 13 January. The polio eradication infrastructure has been on hand to help with this feat of logistics. GPEI partners WHO, UNICEF and US Centres for Disease Control have been working with nongovernmental organizations to support the campaign in a range of areas including data management, training, social mobilization, monitoring and evaluation, supportive supervision and waste management.
“Nigeria’s well-established polio vaccination programme provides a strong underpinning for the campaign,” says Dr Wondimagegnehu Alemu, WHO Representative in Nigeria. “Population data from the polio programme has been essential to guide planning for the measles campaign. We are also able to make use of staff that have vast experience in providing health services in very difficult and risky areas.”
One third of more than 700 health facilities in Borno State, north-eastern Nigeria, have been completely destroyed, according to a report released in December by WHO. Of those facilities remaining, one third are not functioning at all. This is leaving the health of communities vulnerable.
WHO has a strong presence in the community in these areas thanks to a well-established polio programme which includes teams of health workers trained to work in areas of high insecurity and reach communities that no other partner can reach.
With levels of malnutrition as high as 20% in some populations in Borno State, children are particularly vulnerable to diseases like measles, malaria, respiratory infections and diarrhoea.
Planning for the future
This measles campaign in northern Nigeria is by no means the only example of polio funded functions and infrastructure contributing to other critical functions. On average, polio-funded staff spend more than 50% of their time on non-polio activities, such as routine immunization, measles campaigns, maternal and child health initiatives, humanitarian emergencies and disease outbreak, sanitation and hygiene programmes and strengthening health systems. In Nigeria in 2015, the Emergency Operations Centres set up to tackle polio were repurposed instantly in response to the spread of Ebola to the country, which enabled the outbreak to be ended almost as soon as it began.
Polio is closer to eradication than it has ever been; and while we keep all efforts on rooting out the virus in its final hiding places, the Global Polio Eradication Initiative is also beginning to plan for the future. The 16 priority countries, including Nigeria, where 95% of the programmes assets are based are planning now so that some polio funded functions and infrastructure can continue to contribute to other critical health and development goals, as polio funding gradually decreases
Read more about the measles vaccination campaign in Nigeria.
A child in northern Nigeria receives a dose of the oral polio vaccine. Vaccination teams are going to great lengths to protect every last child against polio. UNICEF/T.Moran
Experts from across the Global Polio Eradication Initiative (GPEI) partnership convened an emergency meeting in Abuja, Nigeria, from 3 – 5 November. Led by senior epidemiologists from the governments of Nigeria and neighbouring countries, the group examined a detailed review of the current impact of the outbreak response, and identified area-specific challenges and prioritized operational plans accordingly.
The detection of new wild poliovirus type 1 (WPV1) cases in Borno, Nigeria, in August – the first detected on the African continent in more than two years – has prompted an unprecedented response. The outbreak was immediately declared by both the Government of Nigeria and governments of surrounding countries to be national and regional public health emergency. This opened the way for a regional outbreak response, mobilizing emergency resources from across the public and civil society sectors.
Thousands of health workers across the region have been mobilized and trained, and in Borno alone more than 1.7 million children have been vaccinated. But many more continue to be un- or under-immunized, either due to operational deficits in outbreak response implementation, hampered access due to insecurity or large-scale population movements within countries.
Unless these missed children are rapidly reached, the risk remains that the current outbreak could spread further, including internationally, and cause more preventable, incurable paralysis.
Access and reaching populations everywhere
Insecurity, geographical challenges and difficulties with communication in some of the hardest to reach areas are providing barriers to reaching all children. Internally displaced persons (IDPs), refugees and nomads are particularly vulnerable groups, with insecurity blocking transit routes and the ability to accurately predict population size ahead of vaccination campaigns reduced. Due to population displacement, detailed micro-plans are frequently disrupted.
Children across northern Nigeria and other countries in the Lake Chad region must be protected rapidly against polio to end the outbreak. UNICEF/T.Moran
Cross-border coordination, embedding the response within the broader humanitarian emergency context, and innovating rapidly to adapt strategies to local challenges is what has stopped similar outbreaks with similar challenges elsewhere in the world.
Yet despite these challenges, the GPEI can draw on a vast array of experience from running outbreak responses in similar settings, most recently in the Middle East, Central Africa and the Horn of Africa from 2013-2015. These existing, proven strategies are rapidly adapted to the evolving environment. Permanent vaccination teams are now in place, as and when an area becomes accessible, to rapidly implement ‘mini’ vaccination campaigns in between larger-planned activities. Such teams are also critical to reach populations as they leave inaccessible areas. Children in both formal and informal IDP camps are a particular focus for the delivery of the polio vaccine alongside other humanitarian and basic health needs.
Assuming that many children living in conflict-affected areas will not have been vaccinated for several years, the target age group has been raised to protect children over 5 years of age.
The Volunteer Communication Network of vaccination advocates within communities has been expanded to cover Internally Displaced Populations living in camps and host populations, while Koranic School teachers have been engaged to address non-compliance and the mobilization of women and youth to ensure local protection for vaccination teams.
Volunteer community mobilizers wearing distinctive blue hijabs are working in IDP camps and host communities to identify unvaccinated children, pregnant women and those with severe acute malnutrition. UNICEF/T.Moran
Coordinating across borders
While cases of polio have only been found in Borno, extensive population movement, insecurity and previous cross border population movements require the outbreak response to cover the entire Lake Chad region. Cameroon, the Central African Republic (CAR), Chad, Nigeria and Niger are working together to track population movements and addressing the challenges inherent in accessing some hard-to-reach areas in each country, including sourcing communication equipment to operate where there is a lack of telecommunication network, closed borders in some places and language barriers. Efforts are being intensified to map out the seasonal movement of nomads, identifying resting places and water points with the support of nomadic community leaders in order to improve micro-planning to inform the response. In Chad, vaccination campaigns are providing livestock vaccines alongside polio vaccines to children in order to increase uptake in nomadic communities.
It is not insecurity alone that leads to hampered access. Sometimes it is simply a more natural phenomenon: the rains! The rainy season in the region typically runs from June to mid-October. Some areas are completely cut off from roads and other transport networks as a result of the associated flooding. With the rainy season now over, many areas and populations will be able to be reached with polio vaccine and other urgent health services.
Stopping outbreaks in such challenges settings is possible
There is no doubt that running an outbreak response with such challenges is far more complex, dangerous, costly and slower than under normal circumstances. However, what is equally clear is that the plans being intensified and implemented across the region are having an impact, and will continue to have an impact. Cross-border coordination, embedding the response within the broader humanitarian emergency context, and innovating rapidly to adapt strategies to local challenges is what has stopped similar outbreaks with similar challenges elsewhere in the world.
The groundwork set by this first phase of the outbreak response has set for reaching previously missed children in late 2016 and throughout 2017.
With continued leadership of political, health and community leaders at the local, national and regional levels alongside the international development community, this outbreak will be stopped and children across Africa protected against polio.
Nigeria has been experiencing insurgency in the north-eastern part of the country since 2009 which led the Nigerian President to declare the state of emergency in the 3 worst affected states of Borno, Yobe and Adamawa states in May 2014.
The Global Polio Eradication Initiative (GPEI) aims to deliver polio vaccine alongside broader life-saving health interventions to some of the most marginalized populations globally in order to fulfil the goals of the Endgame plan. As part of the humanitarian response to the current crisis in Nigeria, a holistic approach to tackling polio underpins the current outbreak response efforts.
A deteriorating humanitarian situation
Against a backdrop of long-term crisis, the humanitarian situation in northern Nigeria has worsened substantially in recent weeks. Over seven million people are in urgent need of humanitarian assistance across the country, with limited access to basic health and other essential services, with the main areas impacted by the crisis situated in the north-east. Access to health services has been drastically compromised, with half of the population not having access to any basic health services. As a result on-going public health risks are very high, with low baseline vaccination coverage rates, populations housed in overcrowded and unsanitary camps and severe food insecurity. The crisis also has broader regional implications, with approximately 155 000 refugees in Chad, Cameroon and Niger.
Challenges to polio eradication
This difficult situation was made more complicated by the detection in August in Borno of two new cases of polio – the first cases detected in Africa since 2014. As many as 600,000 children across north eastern Nigeria remain inaccessible to polio vaccinators, presenting a very real obstacle to polio eradication efforts. Concrete strategies are in place to tackle such obstacles, including through close collaboration with key community stakeholders. Similar approaches have been used by the GPEI in other parts of the world beset by complex humanitarian emergencies or insecurity. Most recently in the Middle East, the polio outbreak response was conducted within the broader humanitarian response effort, to ensure that as communities are reached, they are not just reached with polio vaccine but with a host of other lifesaving health interventions.
An effective outbreak response
Following the recent cases of polio in Nigeria, a major vaccination campaign in Nigeria and the surrounding region has been launched in collaboration with the Ministry of Health and UNICEF, with subsequent rounds to follow. Vaccination efforts form part of the broader response to the current humanitarian crisis in Borno and the surrounding states, and across the Lake Chad basin countries. The focus is on coordinating the delivery of basic health services including vaccinations, enhancing surveillance for epidemic-prone diseases, providing life-saving interventions to manage common ailments among children, adult and the elderly, improving maternal and child health services at the community and facility level including mentoring of health workers, conducting ongoing evaluations of the evolving situation, and improving readiness response for any new disease outbreaks. The GPEI is committed to integrating within a broader humanitarian framework in order to secure a polio-free world.
Following the recent detection of wild poliovirus in Nigeria, Ministers of Health from Cameroon, Central African Republic, Chad, Niger and Nigeria have declared the polio outbreak in Nigeria as a public health emergency for countries of the Lake Chad basin. The declaration, coming out of the 66th session of the World Health Organization Regional Committee for the African Region, demonstrates commitment from governments across the region to bolster momentum in the fight against the virus.
A regional response to a regional risk
The declaration requests that Nigeria and all countries of the Lake Chad Basin, as a matter of the utmost urgency, fully implement coordinated outbreak responses in order to quickly interrupt this outbreak before the end of 2016 and prevent international spread. It calls on all Member States of countries of the Lake Chad Basin to extend all possible support, including political advocacy and engagement at all levels, for successful coordination and implementation of synchronized polio vaccination activities across the countries of the Lake Chad sub-region. The declaration builds on the sustained commitment of member states across the region in the path towards polio eradication, highlighted at the African Union summit in June 2015 where African heads of state gathered to declare polio eradication a “historical legacy for future generations”.
Immediate action, challenging terrain
An immediate response was mounted by the Nigerian government following the outbreak by quickly declaring it as a public health emergency and mobilizing the needed resources, with a large-scale vaccination campaign implemented and further rounds planned across the Lake Chad sub-region.
While challenging terrain lies ahead in beating the poliovirus for good, in Nigeria, and in Africa – not least because of the grave humanitarian situation in many of the countries around Lake Chad – the declaration of a regional emergency provides an important foundation for action, including the mobilization of necessary financial, political and technical support from partners of the Global Polio Eradication Initiative and governments across the region.
Geneva 11 August 2016 – After more than two years without polio in Nigeria, the Government reported today, that two children have been paralyzed by the disease in the northern Borno state.
As an immediate priority, the Government of Nigeria is collaborating with the World Health Organization (WHO) and other partners of the Global Polio Eradication Initiative to respond urgently and prevent more children from being paralyzed. These steps include conducting large-scale immunization campaigns and strengthening surveillance systems that help catch the virus early. These activities are also being strengthened in neighbouring countries. In response to confirmation of these cases, the Government of Nigeria declared this outbreak as a national public health emergency.
Genetic sequencing of the viruses suggests that the new cases are most closely linked to a wild poliovirus strain last detected in Borno in 2011. Low-level transmission of the poliovirus is not unexpected, particularly in areas where it is difficult to reach children with the vaccine. Subnational surveillance gaps persist in some areas of Borno, as well as in areas of neighbouring countries.
“We are confident that with a swift response and strong collaboration with the Nigerian Government, we can soon rid the country of polio once and for all. This is an important reminder that the world cannot afford to be complacent as we are on the brink of polio eradication – we will only be done when the entire world has been certified polio-free,” said Mr Michel Zaffran, Director of polio eradication at WHO Headquarters.
As recently as 2012, Nigeria accounted for more than half of all polio cases worldwide, but the country has made significant strides, recently marking 2 years without a case on 24 July 2016. This progress has been the result of a concerted effort by all levels of government, civil society, religious leaders and tens of thousands of dedicated health workers. Recent steps including increased community involvement and the establishment of Emergency Operations Centers at the national and state level have been pivotal to Nigeria’s capacity to respond to outbreaks.
Last week, global political commitment to eradicating polio was affirmed at the World Health Assembly (WHA) in Geneva. During the polio agenda item, member states discussed progress made in the last year and the remaining hurdles that stand in the way of polio eradication.
In her opening address to the WHA, Dr Margaret Chan, Director General of WHO, said polio eradication has never been so close to the finish line. “During the short span of 2 weeks in April, 155 countries successfully switched from trivalent to bivalent oral polio vaccine, marking the largest coordinated vaccine withdrawal in history. I thank you and your country teams for this marvellous feat,” she said.
Member states reviewed the latest global epidemiology, noting the strong progress made across Africa with no case of wild poliovirus in approaching two years. Delegates from Afghanistan and Pakistan, the final remaining polio endemic countries, outlined the steps they are taking to ensure that transmission is interrupted as a matter of urgency. With fewer missed children than ever before and just 74 cases across the two in 2015, achieving eradication has never appeared to be such an achievable target.
Many member states spoke to reaffirm their commitments to fulfilling the objectives of the resolution passed at the last WHA to commit to ending polio once and for all. Michel Zaffran, Director of Polio Eradication at WHO, stated that strong progress had been made against all four objectives of the Polio Eradication and Endgame Strategic Plan.
Delegates also commended the historic achievement of the switch, warning that shortages of the inactivated polio vaccine and potential outbreaks of type 2 vaccine-derived polioviruses would be some of the major challenges of the coming year. They also expressed appreciation for the global contingency plans put in place to adequately manage the risks associated with the supply shortage, notably the availability of the stockpile of monovalent oral polio vaccine type 2.
Gavi, the Vaccine Alliance, supported the interjections of several member states highlighting the importance of ramping up transition planning in countries to prepare for the end of the polio infrastructure after eradication. “To be sustainable, the decision on which polio assets to sustain must be fully led and driven by countries themselves, based on national ownership, national plans and investments,” said the Gavi spokesperson.
Rotary international spoke to affirm that their 1.2 million volunteers worldwide remain fully committed to polio eradication. “We have three key challenges remaining,” said the Rotarian speaker. “First, we have to interrupt polio in Pakistan and Afghanistan. Second, we must avoid complacency. An additional US $1.5 billion is needed through 2019 to sustain high levels of immunity, repeatedly reaching more than 400,000,000 children in up to 60 countries and carrying out high quality surveillance to protect progress. Finally we must fully leverage the physical and intellectual assets of polio eradication so that they can benefit broader public health priorities.”
