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

To identify areas of polio transmission in Adamawa, Borno, and Yobe (3 of the states in the northeast geopolitical zone of Nigeria), polio surveillance must be very sensitive, according to this report. These states, which also have international borders with Cameroon, Chad, and Niger, bear most of the brunt of challenges to security as a result of the Boko Haram insurgency. The compromised security has resulted in the killing of health workers, the destruction of health facilities, and the displacement of large numbers of individuals, all of which have negatively affected polio eradication activities, including acute flaccid paralysis (AFP) surveillance. The possibility of cross-border importations further makes it paramount that polio surveillance be enhanced.

The researchers conducted a retrospective review of AFP surveillance in the security-compromised states between 2009 and 2014, using the AFP database at the World Health Organization (WHO) Nigeria Country Office to assess the non–polio-associated AFP rate and the percentage of AFP cases with adequate stool specimen collection. They also reviewed the reports of surveillance activities conducted in these security-challenged states to identify strategies that were implemented to improve polio surveillance.

Strategies included:

• Environmental surveillance (testing sewage samples for the presence of poliovirus) was implemented in Borno in 2013 and in Yobe in 2014. Collection of stool specimens from 3 contacts of every individual with AFP was initiated in Borno and Yobe in 2014 with the aim of further improving the sensitivity of surveillance. All disease surveillance and notification officers (DSNOs) in the 3 security-challenged states now receive annual training in addition to on-the-job training during supervision and during the monthly DSNO review meetings.
• Informants are people who own or manage places in the nonformal health sector where parents with AFP may most likely seek assistance or consult. Examples are patent medicine vendors, traditional and spiritual healers, traditional bonesetters, and traditional birth attendants. All 3 states were able to engage and sensitise more community informants on surveillance. The state team engaged informants after meetings with different associations of nonformal healthcare providers, such as the patent medicine vendor association. The sensitisation emphasised the AFP case definition and the roles informants could play in AFP case identification and reporting. At the end of sensitisation, AFP picture posters and case definitions were distributed to all informants.
• To sensitise the public, radio broadcasts, phone-in programmes, and jingles were aired at prime times. The discussions and jingles broadcast on radio and television focused on importance of immunisation, the description of AFP cases, and the need to report. Myths and fears about immunisation were allayed during phone-in programmes.
• Select community-based organisations (CBOs) in these states were also sensitised on polio surveillance. The Federation of Muslim Women Association of Nigeria was selected because it is a popular and influential group in these states. The association has an influence on mothers through its preaching platforms, as well as its house-to-house sensitisation activities. The association of commercial motorcycle riders is another influential group whose membership is extensive, reaching even the most remote areas. Sensitisation of these groups was focused on their role in supporting polio eradication initiative activities including surveillance.

Amongst the study's findings: The highest level of AFP surveillance sensitivity during the study period in all 3 states occurred during 2014. The main sources of AFP reporting in 2014 in the security-challenged states were health workers, focal persons, community informants, and vaccination teams. The proportion of DSNOs trained in all the security-challenged states in 2013 was <90%. In 2014, however, the proportion rose to 100% in all security-challenged states. The number of community informants in these states has dramatically increased since 2011. All 3 security-challenged states conducted sensitisation of CBOs and airing of jingles.

In reflecting on these findings, the researchers attribute the consistent improvement in the quality of polio surveillance in the security-challenged states of Adamawa, Borno, and Yobe from 2009 to 2014 to the implementation of key surveillance activities as described above. They also stress that "traditional strategies of improving polio surveillance can be effective even in times of conflict. Such measures as community involvement have sustained a high level of surveillance in other countries affected by conflict, such as Afghanistan and Pakistan, and have even led to interruption of polio transmission during active conflicts in Cambodia, Peru, and Columbia....However, intervention measures to enhance polio surveillance in security-challenged areas need to be country specific if success is to be assured. For instance, while some countries used negotiation of cease-fire agreements, truces, and conflict-free days, others, such as Nigeria, have concentrated on such measures as community engagement and training of surveillance personnel..."

They conclude that "[o]ne of the key public health implications of our findings is that compromised security by itself is not an absolute barrier to achieving quality surveillance. We found that political commitment, adequate resources, and determined and persistent efforts are required for optimal surveillance in the face of security challenges." They recommend that continuous community and clinician sensitisation be enhanced. "Documentation of all surveillance activities and archiving of information should be given priority, along with active case searching and timely provision of feedback to all stakeholders. Finally, surveillance field staff, including the DSNOs, field volunteers, and environmental surveillance sample collectors, should receive commendation and encouragement for working in this extremely challenging security situation."