2016 Nigeria Polio Eradication Emergency Plan

"The entire communication network coupled with other demand creation initiatives such as the scaling up of health camps and attractive pluses have shown results in reducing missed children, including non-compliance. Additional social data showed overall high levels of acceptance for both polio vaccines and routine immunization. There remain however some gaps in knowledge and understanding..."

From Nigeria's National Primary Health Care Development Agency (NPHCDA), this report reviews progress made to date to meet the 2015 National Polio Eradication Emergency Plan (NPEEP) and sets forth intentions for 2016 with regard to Nigeria's polio eradication programme. The effort is spearheaded by the Government of Nigeria, which oversees the National Emergency Operations Centre (EOC) - providing technical leadership and coordinating Government and partner efforts at the central level - and the State EOCs or their equivalents coordinating implementation at the state level. Under their leadership, on September 25 2015, Nigeria was officially removed from the list of polio-endemic countries by the World Health Organization (WHO) following "historical progress" in interruption of wild poliovirus (WPV) transmission for over 12 months. In 2015, there were no reported WPV cases, compared to 6 cases in 2 states (Kano and Yobe) in 2014. A significant reduction in circulating Vaccine Derived Poliovirus (cVDPV) cases was recorded, with only 1 confirmed cVDPV type 2 from the Federal Capital Territory (FCT) in May 2015, compared to 30 cases across 5 states (Borno, Kano, Katsina, Yobe, and Jigawa) in 2014.

In addition to "focused leadership and unprecedented political commitment", the NPHCDA attributes the 2015 achievements mostly to the improved quality of supplemental immunisation activities (SIAs). The proportion of Local Government Areas (LGAs) achieving an estimated coverage of least 80% coverage, as verified by lot quality assurance sampling (LQAs), was 97% in 2015. Quality improved as the a result of continued implementation of interventions and innovations to reach missed children in 2015. These included: timely use of data to identify and reach vulnerable populations; scale up of Directly Observed Polio Vaccination (dOPV) to address team performance and non-compliance; scale up of health camps and demand creation interventions to address felt needs of communities; increased focus on hard-to-reach populations during and in between campaigns, including internally displaced populations (IDPs) from security-compromised areas; and precision focus on high- risk LGAs. Additionally, inactivated polio vaccine (IPV) introduction was scaled up in all states in 2015.

The 2016 NPEEP outlines key strategic priorities to ensure that interruption of polioviruses is sustained: (i) building resilience toward certification; (ii) enhancing SIA quality in prioritised vulnerable areas; (3) carrying out special approaches for insecurity-impacted areas; (iv) mounting timely and adequate poliovirus outbreak responses; (v) enhancing routine immunisation (RI); (vi) intensifying surveillance and tracking documentation deliverables toward certification; (vi) withdrawal of trivalent oral polio vaccine (tOPV); and (viii) polio legacy planning. For each of these 8 areas of focus, the report describes the present situation and future plans, outlining specific activities to be pursued.

As in the achievements to date, the report points to the role that communication strategies have played and encourages strengthened attention to this dimension of the programme looking into 2016. For example, with regard to (i), above, the NPHCDA states that, "[w]orking closely with the data team, there will be more rigorous attention to delving deeper into the reasons for missed children, including through special investigations in areas with chronically missed children. In 2016, more emphasis will be placed on social and community mobilization through a wide range of stakeholders to highlight risk and reiterate the need for all immunization. Additional social data will be collected to identify key gaps, including special investigations in areas with chronically missed children and through periodic polling in communities. Experience has shown that significant impact can be achieved by developing locally appropriate communications plans that include targeted household and community engagement approaches during and in-between polio campaigns."

More specifically: "In 2016, VCMs [Volunteer Community Mobilizers] will continue to work at the household level supported by...community engagement approaches which will include a strong focus on the engagement of religious and traditional leaders for routine and SIAs. The integrated training package which includes IPC [interpersonal communication], routine immunization and key household practices will be fully rolled out across the VCM network to ensure mobilizers are fully equipped to engage with communities on issues beyond polio. Social data shows that children are missed during polio campaigns due to participation in local ceremonies. VCMs will track and immunize newborns and all under five children during and in-between campaigns, also taking advantage of traditional naming ceremonies as an additional opportunity to immunize missed children. VCMs will continue to support defaulter tracing and health education for routine immunization in their settlements. The network of Daawa members [a network of religious leaders and institutions] will be further engaged to ensure the full engagement of local religious leaders, particularly Jummat mosque imams in all wards within high risk LGAs for SIAs and routine immunization together with the Northern Traditional Leaders Committee and other religious institutions. With increased focus at the community level, community-based organizations (CBOs), including youth groups will be identified to expand the network of community partners even further in the prioritized LGAs. Emphasis will be placed on motivating communities for all immunization."

It is noted that positive immunisation messages engaging key influencers and using popular entertainment feature prominently in the 2016 approach through community influencers, viewing centres, and new technologies (Bluetooth pairing and sharing) putting polio within a broader health context of child survival. Efforts in 2016 will also focus on broader entertainment-education activities for all components of immunisation guided by social data. Entertainment-education packages for Hausa media platforms that reflect the revised programme narrative and include RI will be scaled up further in 2016, supported by proactive media engagement. This also includes strong community engagement and mobilisation through local channels in order to motivate and inspire communities. The new message framework will guide programming across these platforms to create a positive environment for immunisation at the community level and to work closely with community gatekeepers in order to mobilise the citizenry to embrace immunisation. On a related note, emphasis in 2016 will also be placed on motivating the front lineworkers. A more systematic approach to appreciating good performance will be implemented through public recognition initiated by the national EOC. Trainings and evening review meetings will be institutionalised as opportunities for recognition and motivation.

The report notes that traditional leaders play a very important role in the Polio Eradication Initiative (PEI) programme. They have been incorporated in all task forces, from presidential to the LGA task force. In addition, the traditional authorities in northern Nigeria have an organisation called the Northern Traditional Leaders committee on PHC (NTLC-PHC), whose mandate is in part to lead the process of achieving PEI and RI goals through the systematic involvement in activities for polio eradication. They have established committees at Emirate and District levels that coordinate activities in the LGAs, wards, and settlements. These committees are involved in micro planning, vaccinator team selection, supervision of Immunization Plus Days (IPDs) activities, resolution of non-compliance, and promotion of community demand for vaccination services. NTLC-PHC as well as the religious leaders though established structures such as the Nigeria Inter-Faith Action Alliance (NIFAA) will be included in national coordination committees and thereby support planning, implementation, and evaluation of priority activities in the 2016 NPEEP.

It is hoped that strategies such as these, outlined in more detail in the report, will help the programme to address the outstanding 2015 challenges, including immunity gaps among the most vulnerable populations, inaccessibility in security-compromised areas, non-compliance, and surveillance gaps at ward level. Furthermore: "The program will have to be protected from financial risk associated with national and global funding-reprioritization following Nigeria's removal from the list of polio endemic countries, until certification [of polio eradication by the Global Polio Eradication Initiative] is attained."