Successful Polio Supplementary Immunisation Activities in a Security Compromised Zone - Experiences from the Southwest Region of Cameroon

"Proper sensitisation of communities remains a key element in immunisation."

Supplementary immunisation activities (SIAs) play a central role in polio eradication efforts, yet poor communication, inadequate resource mobilisation, mistrust in the health care system, and lack of adequate security to both the vaccinators and those seeking to be vaccinated are among the factors that can lead to suboptimal SIAs. The Boko Haram insurgency has been prevailing since 2010 in the northern regions of Nigeria, with encroachments into Cameroon. In addition, Cameroon faces a new threat in its Northwest and Southwest regions, with armed conflict leading some health facilities to be completely shut down - halting the provision of routine immunisation activities. It is in this context that the 2018 national polio SIA coupled with the Mother and Child Health Action Week were carried out in the Southwest region of Cameroon. This paper presents experiences from that endeavour and reports that dedication of health staff and the population's understanding and acceptance of polio SIAs are key to the eradication of polio in conflict zones.

The polio SIA was organised and coordinated by the Central Technical Group for the Expanded Programme on Immunisation (CTG-EPI), which led extensive planning prior to the SIA. Planning included security assessment, advocacy, and social mobilisation. For example, the United Nations Children's Fund (UNICEF) specifically gave sponsorship to carry out communication activities, such as training of supervisors, vaccinators, and social mobilisers, using a cascade approach. Staff of the RTG-EPI trained the district teams (district medical officers, chief nurses and district focal points for communication), who then trained the health area (HA) teams (chief medical officers of the HA and HA focal points for communication). The HA teams then trained the vaccinators and social mobilisers. Training topics included: rationale for the SIA, organisational methods to achieve a high quality SIA, data management, and finance. Importantly, training on the management and strategies to ensure safety of the vaccination teams was provided.

Materials including communication flyers and aprons for communicators were distributed to the HDs upon collection of vaccines. Equipped with such materials, advocacy and social mobilisation teams carried out several activities to ensure the communities were aware of the SIA implementation. The activities included: closed meetings with the administrative authorities, traditional, and opinion leaders; briefing of media houses; radio and television interviews; and dissemination of messages in churches and mosques. In addition, door-to-door sensitisation, which began 2 days before the SIA, entailed communicating the importance of getting children vaccinated, the type of vaccine to be administered, and the vaccination dates. Though vaccine hesitancy in the Southwest region is low (based on reports from previous SIAs), the mobilisers emphasised to the communities that the health sector was not involved with the socio-political crisis. The advocacy and social mobilisation team reiterated the key messages about the SIA, counted the number of children eligible for vaccination in each household, and marked the house.

Despite the fact that reports from the district teams determined that only 4 (22.2%) out of the 18 health districts (HD) were considered safe, vaccination teams worked in all HDs. The SIA took place from March 2-4 2018 and sought to reach 307,920 children aged 0-59 months. The vaccinators administered 2 drops of bivalent oral polio vaccine (bOPV) alongside vitamin A capsules and Mebendazole. The SIA achieved a coverage of 89.9%. Most (76%) children were vaccinated using the door-to-door strategy. The main reason given for non-vaccination was absence from the house during the visits by the vaccination team (52%). There was no incident of vaccination refusal reported during the polio SIA.

At the end of each vaccination day, review meetings were held at all levels to discuss the experiences and challenges faced during the day and to agree on the measures to be taken to overcome the challenges. Vaccination data were forwarded daily by the vaccination teams through the district team to the regional data management team for compilation, analysis, dissemination, and archiving.

The main sources of information were town criers who made announcements in the streets (38.5%), social mobilisers (32.7%), and churches/mosques (17.2%). To expand upon one of those sources: A total of 1,292 social mobilisers were deployed across the region; they visited 421,116 households and sensitised 1,160,423 people. The mobilisers advised guardians of the vaccinated children to take their children to the nearest health facility in case of any adverse event following immunisation (AEFI); no AEFIs were reported.

According to the authors, several factors could be attributed to the successful 2018 polio SIA. These factors include: political will, optimal planning and co-ordination, support from partners, widespread sensitisation and mobilisation of the members of the community before and during the SIA, and dedication by the teams involved. Notwithstanding, several challenges were faced that were either resolved or circumvented.  For example, misunderstanding of the objectives of immunisation and fear that vaccines might transmit diseases or be used as a weapon by the authorities during times of conflict may lead to vaccine hesitancy. To prevent such mistrust, the administrative authorities involved in the planning of the SIA were not put at the forefront, as is routinely done. Rather, the World Health Organization (WHO) and UNICEF were portrayed as the main organisers. This strategy permitted vaccination in certain districts where the population was suspicious of the government.

In conclusion, the authors reflect on the fact to achieve polio eradication, SIAs will have to be conducted in all areas, including security-compromised settings. Due to the approach adoped in Cameroon, as described in the article, community members were very receptive to the SIA; the authors suggest that this may be due to the communication that was adopted. Strong dedication by vaccination teams and community members' understanding and acceptance of polio SIAs are key factors to the eradication of polio in conflict zones.