2019 Nigeria Polio Eradication Emergency Plan

"Achieving the gains in 2018 were a result of carefully planned and implemented mobilization and engagement meetings, which resulted in strong political support and collaborative implementing of innovative strategies across the county."

From Nigeria's National Primary Health Care Development Agency (NPHCDA), this report presents the context and status of polio eradication efforts in the country - outlining remaining challenges for focus in 2019, as well as goals, targets, milestones, and strategic priorities. The below summary focuses on the communication elements of the 2019 Nigeria Polio Eradication Emergency Plan (NPEEP).

In short, Nigeria faced 2 separate outbreaks of circulating vaccine-derived poliovirus type 2 (cVDPV2) in 2018. That said, the Nigeria polio eradication initiative (PEI) made progress in 2018, marking 27 months with no case of wild poliovirus (WPV) reported. This progress was due to increased vaccination and surveillance reach in inaccessible areas in the northeast: Reaching Every Settlement (RES) and Reaching Inaccessible Children (RIC) strategies were employed in Borno and Yobe states, and the programme also continued to implement in-between round special interventions intended to vaccinate more children potentially missed through house-to-house (H2H) campaigns. These strategies resulted in more settlements being accessed and thus more children vaccinated in security-compromised areas than the previous years; a combination of H2H, RES, and RIC improved vaccination reach from 7,926 settlements in December 2016 to 12,296 settlements by December 2018.

One of the prevailing risks to the polio programme in 2018 was the emergence of community or group refusal of vaccination to protest perceived inequitable distribution of insecticide-treated nets (ITNs) in some high-risk states. This resulted in high rate of missed children, especially in Jigawa and Katsina states. Other states also experienced cases of group refusals, where provision of community felt needs such as boreholes, schools and roads, etc. was given as a condition for accepting vaccination for children.

As reported here, the Presidential Task Force for Polio Eradication and Routine Immunization, which provides overall stewardship and leadership to the programme, met 3 times in 2018. The National and State emergency operation centres (EOCs) continued to drive the programme, ensuring strong coordination of government and partner efforts at all levels and strategic technical support to the programme, including close monitoring of performance. However, the PEI saw waning political support and commitment at the state and local government area (LGA) levels; in particular, the involvement of political leaders in polio activities waned during the course of the year in the build-up to the national elections in quarter 1 (Q1) 2019.

The plan for 2019 involves developing and implementing rapid, robust, and effective communication plans at all levels to strengthen community awareness of persisting risks of polio, particularly for children under 5, and the benefits of vaccination. The overarching roadmap for 2019 communication, social mobilisation, and advocacy efforts will be the Expanded Programme on Immunization (EPI) communication strategy for Nigeria, developed in 2018. Dissemination of the strategy to polio and routine immunisation (RI) communication actors at all levels through cascaded workshops will be prioritised in early 2019 to ensure standardisation in interventions and messaging. Roll-out of full implementation of the strategy will entail development of new information, education, and communication (IEC) materials with integrated messaging for both PEI and RI, guided by social data and fine-tuning of relevant standard operating procedures (SOPs).

The use of popular entertainment will feature prominently in the 2019 approach, and use of community influencers and of new technologies will aid in putting polio within the broader health context of child survival. A new and nuanced messaging framework will be developed for key audiences - political leaders, donors, community influencers such as religious and traditional leaders, programme officers, frontline workers, and communities themselves - taking into consideration the government's position that the country will not claim to have stopped WPV transmission until every part of the country is accessible for immunisation and surveillance activities. The new message framework will guide programming across all immunisation platforms to create a positive environment for immunisation at the community level.

The programme plans to evolve a strategic approach to communicating the presence of VDPV without jeopardising the gains that have been made in trust-building for the programme among stakeholders, especially at the community and household levels. Intensive capacity-building of communication and social mobilisation actors at all levels will be undertaken to ensure that standardised messaging on VDPV and the need for outbreak response is clearly understood.

In terms of advocacy, the NPHCDA calls 2019 a particularly a crucial year for polio and RI to be on the agenda of political leaders, given the national election scheduled for February 2019. Aggressive advocacy efforts will continue post-election with the newly elected political leaders (president, governors, national and state legislators, LGA chairmen, etc.) to ensure that child health is strategically placed in national and state plans. The PEI will develop and implement a strategic plan for re-engagement of political leaders using existing platforms such as the Nigerian Governors' Forum (NGF) and Association of Local Governments of Nigeria. Also, the Health Committees of National and State Houses of Assembly will be sensitised on the need for oversight and adequate funding to finish the job of polio eradication. More specifically: "Donors and Partners will be sensitized to be true polio ambassadors by integrating polio issues during every advocacy opportunity with political leaders at all levels. Concerted effort will be made to address donor fatigue through a synthesis of interventions including sensitization meetings, social events, field visits and media visibility such as sponsored editorials and commentaries."

In addition, the programme will leverage every opportunity to send the message that the job of polio eradication is not done yet. To that end, media engagement will complement advocacy, using targeted messaging to create positive opinions toward vaccination. The media also serve a critical role in controlling rumours and false information, as a key molder of public opinion. The programme will continue to promote intensive media engagement at the state level and media advocacy at the national level.

Lessons learned from the Jigawa experience in October 2018 (see above) indicate that intensive and proactive engagement of community gatekeepers can reduce non-compliance due to community felt needs. Consequently, the programme will make such engagements mandatory prior to implementation activities. Concerted effort will be made to amplify the linkage between the social amenities donated to communities by polio partners (United Nations Children's Fund (UNICEF) efforts on water, sanitation, and hygiene (WASH), Rotary boreholes, etc.) to the polio programme to underscore the additional benefits of the polio programme to the community. In addition, the national EOC will initiate intersectoral collaboration with relevant programmes so that various sectors of development will work together to respond to the diverse needs of communities, including regular interface between the malaria programme and the polio programme at the national and state levels.

Intensive H2H mobilisation by the volunteer community mobiliser (VCM) network will continue to be the backbone of social and community mobilisation. In 2018, over 21,000 VCMs were deployed in 14 polio high-risk states, and they have continued to be pivotal in ensuring intensive household mobilisation for polio, RI, and non-polio supplementary immunisation activities (SIAs). Training and mentoring will be provided to VCMs to keep them up to date, to ensure data accuracy, and to strengthen their capacity as they provide messaging beyond polio. The programme will conduct periodic evaluation of the VCMs to ensure sustained quality and redistribute them within states in line with 2019 high-risk analysis.

According to the NPHCDA, the engagement of traditional and religious leaders has remained critical in addressing non-compliance and building trust for the polio programme. This engagement will be sustained and further improved through capacity-building of Northern Traditional Leaders Committee on Polio & PHC (NTLC) and National Emergency Routine Immunization Coordination Centre (NERICC) community engagement focal persons. Also, Da'awah Coordination Council of Nigeria (DCCN) members will be empowered to provide oversight on religion-related issues during immunisation plus days (IPDs). The NTLC Secretariat will be reinvigorated to produce quarterly reports on the NTLC and DCCN partnership.

In addition, the capacity of health educators will be strengthened to facilitate their role as key actors at state and LGA levels to positively influence acceptance of both polio and RI initiatives. Cascaded interpersonal communication (IPC) training for communication actors and service providers will be conducted to further hone their skills.

The programme will also ensure cross-border coordination and synchronisation, communication, notification, and implementation of activities at local border LGA/district levels in the Lake Chad Basin countries. Activities will be guided by an integrated communication plan and assessment tools that will be developed to inform the behaviour and social change component of the mobile population in 15 priority LGAs. For example, it is anticipated that there will be IPC skills training and production of IEC materials for acute flaccid paralysis (AFP) active case search during IPDs by H2H vaccination teams in all priority LGAs. Also planned: advocacy visits and sensitisation meetings with nomadic leaders, as well as identification of potential VCMs among nomads, among other activities detailed in the NPEEP.

Biannual review of the country's EPI communication landscape will be undertaken in collaboration with NERICC to holistically identify and address emerging challenges. Evidence-based communication and advocacy will be supported by timely data collection and analysis. In addition to the social data aggregated within and in-between rounds, a knowledge, attitudes, and practice (KAP) survey will be conducted in select high-risk states to guide interventions. Also, a behavioural surveillance survey (BSS) will be conducted to better understand the risk behaviours that predispose children to VDPV, especially in areas where most cVDPV2 cases are among healthy children. Special investigation will be undertaken for a more in-depth understanding of missed children in settlements with persistently missed children.

Finally, concerted effort will be made to formally document all programme strategies, innovations, SOPs, events, and any other documentations that may be required by the national polio EOC.