WHO-UNICEF Joint Strategic Action Plan for the Polio Outbreak Response in the Horn of Africa

"[S]pecific communication challenges make it difficult for the public to perceive the risks of polio among other priorities, and hinder adequate support from governments, social and religious institutions, the media, community leaders and other stakeholders."

From the World Health Organization (WHO) and the United Nations Children's Fund (UNICEF), this outbreak plan was developed in response to the fact that the Horn of Africa (HoA) region began experiencing an outbreak of wild poliovirus (WPV) type 1 in April 2013 after a WPV importation from West Africa to the Banadir region of Somalia. "Inaccessibility, mainly due to security concerns in south and central Somalia and in border areas of north-eastern Kenya, makes it difficult for vaccinators to reach all children during campaigns, resulting in suboptimal population immunity. Large population movements help the virus spread and lead to large pools of unvaccinated children in some areas."

The phases of the outbreak plan are outlined. For instance, communication-related activities included:

• In Phase 1, the Global Polio Eradication Initiative (GPEI) worked with governments to design and implement the HoA emergency outbreak response plan. There was reportedly strong commitment by the Presidency in Kenya, the chairing of the polio command post by the Minister of Health in Ethiopia, the declaration of the outbreak as a public health emergency by all countries in the East African Community in August 2013, cross-border coordination and communication efforts among affected and at-risk countries. Selected communication strategies from Phase 1:
  • "[R]ecent HoA regional planning discussions identified multiple areas within each country and across the region where evidence-based polio eradication communication strategies could be improved and enhanced. Although these needs have been identified, further resources are needed to effectively implement strategic communication initiatives that help extinguish the outbreak in the HoA and prevent further transmission inside the area and outside to other world regions."
  • "In the HoA, cross-border coordination is of historic importance, as is cross-agency coordination in a setting where multiple UN regions intersect. Within each country, programmes that achieve successful coordination are those that use existing mechanisms, such as interagency coordination committees and national immunization technical advisory groups, but these existing mechanisms can be further strengthened. Coordination must be efficient between the epidemiology and the laboratory, and adequate resources must be in place in the laboratory system to effectively and carefully manage the increased influx and capacity needed to respond to the outbreak."
  • Expanded partnerships are vital within each country and across the region for success. This ranges from local partnerships at the lowest levels to highest level advocacy and management functions, and the strengthening of cross-regional partnerships combined with strong national programme ownership."
• In Phase 2, November 2013 to April 2014: "innovative and adaptive strategies will be used to maximize opportunities for immunization in inaccessible areas as well as in accessible areas bearing in mind population travel trends. Renewed efforts are needed to maintain an enabling communication environment and positive public perception for the repeated polio vaccination campaigns across the HoA. Once the outbreak has been stopped, improving routine immunization, carrying out preventive campaigns and maintaining a high-quality surveillance system will be crucial to maintain a polio-free HoA." Sample insights: "Effective communication during an outbreak is critical. Two overarching communication outcomes create an enabling environment for polio campaigns: (a) the public must perceive the risks of polio and see vaccination as a solution; and (b) governments, social and religious institutions, the media, community leaders and other stakeholders must support the campaigns. Abruptly elevating a health issue such as polio to the top of public and personal agendas is in itself a paramount task. While polio unquestionably is a dangerous disease that paralyses children for life, people face numerous other competing security, public health and social risks every day in the HoA. The communication challenges associated with the response to this outbreak include:
  • aggressive campaign schedules with short-interval additional doses and repeated campaigns that may create distress and fatigue, especially in the absence of other health services;
  • staggered campaigns and spot selection of geographic areas for vaccination that make messaging difficult especially when mass communication channels are engaged;
  • special communication strategies to extend the age group to 15 years or even to the whole population...;
  • inadequate communication capacity and infrastructure....The intensity of the response in the HoA is comparable to that of eradication activities in the endemic countries; however available communication and financial resources are grossly incomparable...; and
  • the lack of social data and its inadequate use for evidence-based communication planning....[T]here is poor empirical knowledge of the behavioural or social barriers that are linked to polio vaccination in the HoA. While health seeking behaviour and vaccination intent are generally high (few refusals), a thorough understanding of community sentiment is critical for sustained demand and ownership."

For example, in terms of regional communication activities, all infected countries have developed and are implementing communication for development (C4D) outbreak response plans. To improve the use of empirical evidence for communication planning in the region, WHO and UNICEF held a joint workshop in August 2013 on evidence-based communication and social data for polio campaign planning that drew national Expanded Programme on Immunization (EPI) managers and UNICEF and WHO specialists from Ethiopia, Kenya, Somalia, South Sudan, Uganda and Yemen. As a result of regional capacity-building, social data are being collected and used for campaign planning.

Radio is one particular medium highlighted in the report: "The HoA features prominent radio platforms that are very popular among the Somali population residing in the outbreak area (Central South Zone of Somalia, Somali region of Ethiopia and North-Eastern Province of Kenya). To leverage this opportunity in the region, platforms such as the BBC Somali service and the Voice of America Somali service are coming on board through BBC Media Action and the Broadcasting Board of Governors, respectively, the development agencies associated with these two stations. Polio issues will be integrated into ongoing Somali programmes in the HoA." These programmes include convergence of polio eradication and water, sanitation, and hygiene (WASH) initiatives, including community-led total sanitation (CLTS), such that polio messages and polio outreach workers have promoted CLTS and reinforced messages around the risks of open defaecation.

Amongst the suggestions included here for going forward in terms of communication - which will employ advocacy, mass media/promotion, social mobilisation/community engagement, and behaviour change/participatory communication and capacity building strategies: working to create an enabling communication environment and positive public perception for the repeated polio vaccination campaigns across the HoA in response to the outbreak by: engaging media and the public to create awareness, amplify risk perception of polio, and build public momentum and supportive attitude towards vaccination and repeated campaigns; mobilise communities through relevant socio-cultural channels to support local ownership and generate wide community support and vaccine acceptance; sensitise decisionmakers and influencers to treat polio outbreak response as priority; involve public and private sectors of the society to support polio campaigns; and continue joint work with integration of nutrition, water, sanitation, and hygiene messages into polio outbreak response awareness communication messages.