Polio Outbreak Response Assessment - Lao People's Democratic Republic

From January 23 to February 1 2016, independent consultant Ellen A. Coates participated in the initial external evaluation of the Lao People's Democratic Republic steps taken to interrupt poliovirus circulation and end the outbreak since the first case was confirmed on October 6 2015. As the emerging report indicates, Coates focused in particular on the communications aspects of the response - both in central-level meetings with the Ministry of Health (MOH), the United Nations Children's Fund (UNICEF), and the World Health Organization (WHO) in Vientiane City, and meetings and site visits conducted in the Bolikhan District, Bolikhamxay Province. This report includes findings of the first official Outbreak Response Assessment (OBRA), intended to determine whether or not the outbreak response is on track to end within the WHO-recommended goal of 120 days (see Related Summaries, below) and provide recommendations for strengthening the response to the Lao government and partners.

As Coates reports in the background section, laboratory confirmation of circulating Vaccine Derived Poliovirus 1 (cVDPV1) in an 8-year-old Hmong boy from Phamyeung village in Bolikhan District, Bolikhamxay Province was received on October 6 2015. Since then, 6 additional cVDPV1 cases have been confirmed and, as of January 27, 50 acute flacid paralysis (AFP) cases had been reported from Bolikhamxay, Vientiane Capitol, Vientiane Province, Xaysamboun and Xiengkhuang provinces. A Supplementary Immunisation Activity (SIA) intended to reach different age groups in different locations took place in Lao during the week of the OBRA. Since Bolikhamxay province, where the first 3 cases occurred, was the only province visited by the communication for development (C4D) team member, the report includes findings shared by other team members and by members of several rapid convenience monitoring (RCM) teams that visited health centres and vaccination posts in other provinces during the January round (their findings gathered by phone and during a UNICEF meeting on January 30 2016).

One contribution to consistently very low immunisation coverage, Coates explains, is language/ethnicity issues (the government recognises 49 "non-Lao ethnic groups" (NLEG) divided into 4 main ethno-linguistic groups and 6 language groups) and geographic challenges that impact delivery and utilisation of health services. "Long-standing tensions with and distrust of the government among some ethnic groups, particularly the Hmong, are also playing a role in campaign participation, as are fears that the vaccine is being distributed for free because it's poor quality, or it will make children sick, which will force parents to stay home from rice fields or their other means of supporting their families." Also, weaknesses in the AFP surveillance system that are common among polio-free countries opened the doors to undetected circulation and possibly cases of vaccine-derived polio.

Coates describes several strengths in the response to date, noting that the national government responded very quickly to the outbreak and has exhibited openness and willingness to work with and accept recommendations from UNICEF and WHO. The Emergency Operations Centre (EOC) has been meeting regularly at national and provincial levels and situation reports are produced weekly. "[I]t is clear that the national level leadership and staff are committed to reaching not just the Lao, and now Hmong populations but other vulnerable populations." For example, the prime minister as well as a senior member of parliament, a Hmong woman herself, each posed for posters showing them giving a child oral polio vaccine (OPV) drops. National-level leaders have visited villages in Bolikhamxay, where village leaders and Sing Sao (Hmong clan leaders) have played an important role in overcoming hesitancy and increasing campaign coverage. Multi-sectoral participation in the response, including in the OBRA process, has been recorded. In addition to this evidence of achievements in the areas of advocacy and social mobilisation, Coates points to other communication activities, such as recordings of the key polio messages in Lao and 4 other local languages. These have been made available on USB flash drives that can be used by local radio stations and through the public announcement (village loudspeaker) system in communities. "Clearly the efforts made by national staff to support local staff in reaching and convincing Hmong families to vaccinate their children (and themselves in campaigns targeting adults) have been intensive and seem to be having an impact, at least in Bolikhamxay."

Coates cautions that, although Lao's effort to end the outbreak "is clearly on the right track, a number of significant gaps remain. If no more AFP cases are confirmed as polio (making the December 18th case the last one) then Lao PDR will have contained the outbreak and interrupted transmission within the 120 day WHO goal, but this seems unlikely given continued low immunization coverage in some districts and continued zero AFP reporting in some areas of the country." She points to several specific concerns, which raise the need to, for example, offer increased training/refresher sessions in interpersonal communication (IPC) and ensure that campaign posters are reaching health centres and village vaccination posts and are posted in other public locations such as marketplaces, teahouses, etc. as recommended in the national strategy guidelines.

Coates specifically assesses the current status of social mobilisation and communications activities as gauged by the strategy elements as outlined in the "Lao PDR Polio Communication Strategy and cVDPV Outbreak Response Action Plan 2015-16" and the "Polio Outbreak Response Plan", both published in November 2015. [See Related Summaries, below.] A chart illustrates these elements and includes Coates' comments, such as her observation that, in some villages, more families are participating in the polio vaccination campaigns thanks to efforts to mobilise community leadership to take the lead in face-to-face communication for raising awareness, acceptability, and participation, especially in high-risk districts. For instance, "central level MOH health education senior staff held public evening meetings that extended late into the night, and continued the following night. Some hesitating families were convinced then, and the Sing Sao and village leaders have become very engaged in convincing remaining hesitating families to immunize their children, and promoting immunization as a community health responsibility. In one Bolikhan District village the village chief was registering participating families during the campaign. The MOH also recognizes that successes with the Hmong population and villages in Bolikhan must be continued and expanded to other vulnerable ethnic groups, districts and provinces. The use of photos and minimal text for the campaign posters, and consistent use of color and logo on other print materials, as well as pre-testing of the messages is a good strategy."

There are, however, concerns and areas for improvement, informing a list of communication recommendations:

• "Ensure that the national level polio communications strategy and guidelines are supported at the provincial level and implemented at the district, village and health service delivery site levels. Where necessary provide specific guidelines for local level use...
• Integrate communications and social mobilization activities, and timelines into campaign plans and microplans, especially at local levels. Include specific actions to be taken, by whom, when and where.
• ...[B]egin [social mobilisation activities to support campaign participation] at least one week before the campaign begins. Planning should take place early enough to allow time to ensure that instructions and guidelines as well as communications materials (posters, usb's, etc.) will reach communities and health centers in time...
• Increase the number of trained social mobilizers; consider including other respected community members such as elders or retired school teachers.
• Conduct interpersonal communications on polio and routine immunization with people waiting for vaccination at campaign sites.
• Continue to build on opportunities to use cultural events such as concerts, short dramas, children's events, and other creative ways of reaching audiences from different high risk groups.
• Explore new, creative ways of promoting campaign and RI [routine immunisation] participation through child-to-parent communications and consider locally appropriate children's activities just prior to or at the launch of each campaign to generate energy and awareness.
• When using social indicators and other data to inform communications planning and materials examine the data at a sub-national level...
• Develop a 'ready-to-go' set of messages in all local languages in response to AEFI [adverse events following immunisation] and a detailed plan for delivering them to all sub-national levels...
• Reintroduce AFP poster/job aid in health facilities.
• Consider developing a very simple illustrated poster/job aid reminding health workers to talk about polio prevention and routine immunization during all contacts with parents and children.
• Consider using formative research (focus groups, key informant interviews, etc.) especially in the high risk and under-reached districts or populations to identify underlying factors limiting participation in campaigns, and potentially to strengthen communications/social mobilization and potentially AFP case identification and reporting..."

Click here for the 9-page trip report in Word format.