Strategic Plan for Polio Outbreak Response in the Middle East

"In October 2013, wild poliovirus was detected in north-eastern Syrian Arab Republic. A robust coordinated multipartner plan is needed to interrupt virus transmission to protect the children in the region from paralytic polio."

Jointly finalised by the World Health Organization (WHO) and the United Nations Children's Fund (UNICEF) in collaboration with the ministries of health and other humanitarian aid and United Nations (UN) partners, this strategic plan outlines the specific actions that need to be implemented across the Syrian Arab Republic, Iraq, Jordan, Lebanon, Turkey, Egypt, and the West Bank and Gaza Strip in response to the circulation of wild poliovirus (WPV) in October 2013 after a 15-year absence.

As described here, the critical challenge is accessing all children, including those living in areas difficult to reach due to conflict or insecurity. The suggestion, then, is that the outbreak response should be conducted within the broader humanitarian response effort to the Syrian crisis. It is urged that, in order to ensure that oral polio vaccine (OPV) is urgently delivered into all communities, effective coordination with international humanitarian organisations, United Nations (UN) agencies, national Red Crescent societies, non-governmental organisations (NGOs), and broader civil society forms a critical aspect of the plan.

The report details specific steps and strategies to follow as part of this effort to address what is called "a public health emergency". In brief, the approach involves: (i) large-scale and repeated supplementary immunisation activities (SIAs); (ii) efforts to enhance the reporting and investigation of acute flaccid paralysis; and (iii) actions to improve routine immunisation (RI) coverage to provide protection in the longer term and to sustain the polio-free status.

Communication elements and challenges of this path forward are outlined in the report. With WHO and other partners, UNICEF indicates that it will support the affected countries to raise awareness on the risks and impact of WPV, the rationale for the vaccines used, and the delivery strategies, as well as to generate community demand for vaccination each time OPV is offered. Aside from the challenge of elevating and sustaining the risk perception of the virus among a population who has not seen polio in over a decade, "[a]mid conflict, distrust among various population groups about the safety of the vaccine is likely to emerge - particularly after the initial wave of response and media attention has waned." Between the publication of this report and the goal (end of March 2014) by which the activities were hoped to be achieved, here is an excerpt from the report outlined what was planned:

"The communications plan will identify trusted influencers in the Syrian Arab Republic and the region to promote the safety of the vaccine and the need for multiple doses.

A rumour tracking and response system will be established and linked to Polio Control Teams (PCTs) to promptly identify false rumours or urgent community concerns about the vaccination programme.

Vaccination campaigns will be promoted through multiple channels before each activity takes place. Diverse mediums will be utilized to promote campaigns and vaccination messages in conflict-affected areas, IDP [internally displaced persons] host communities and accessible areas. Mass media and social media will be an important platform to reach inaccessible areas in particular, with multiple spokespeople identified and trained to promote OPV who can relate to - and be trusted by - diverse segments of the population.

Local health workers will be an important source of information at transit points, health centres and doorsteps. The communications programme will ensure the health workers are equipped with interpersonal communications skills and materials that allow them to explain the importance of vaccination and respond to caregiver questions.

Building trust for immunization will be a cornerstone of the communications strategy, and the programme will need to demonstrate its genuine concern for the well-being of children's health in general, beyond polio. Where feasible, immunization will aim to be promoted with other health or humanitarian services to maximize vaccination coverage.

Independent monitoring data will be analysed to measure the proportion of children missed due to refusals or other social reasons, and this data will be incorporated into local communications plans....Communication related indicators (missed children due to refusals, and campaign awareness) will be integrated to ensure the monitoring of family vaccination acceptance throughout the campaigns."

Part of what was planned is the short interval additional dose strategy, which is designed to quickly boost population immunity by delivering two to three doses of vaccine in a short period of time when access to an area may be limited. For this reason, it is often used in conflict settings when periods of peace can be negotiated. Communication-related elements of success of this strategy in conflict-affected areas include: (i) mobilisation of community resources to ensure every child is reached with vaccine; (ii) coordination between campaign planning and communications to trigger information to the community; (iii) ready-to-use communication messages about the importance of multiple doses once access is gained; (iv) a "whole-of-society approach" to vaccination campaigns, which often entails the movement of vaccine beyond normal health infrastructure and service in partnership with local and international NGOs who can demonstrate their capacity to reach children and have the necessary infrastructure and training; and (v) negotiated access to hard-to-reach children.