Polio Outbreak Response Plan: Lao People's Democratic Republic

This document provides a plan - including a communication plan - to respond to an outbreak of polio in 2015 in Lao People's Democratic Republic (Lao PDR), a country that had been polio-free since 2000. In it, the Ministry of Health (MoH), the World Health Organization (WHO), and the United Nations Children's Fund (UNICEF) describe the index case: an 8-year old boy from the Hmong community in Phamueng Village of Bolikhan District, Bolikhamxay Province (where the reported oral polio vaccine (OPV)-3 coverage was only 37% in 2010, rising to (a still low) 66% in 2014). This Acute Flaccid Paralysis (AFP) case tested positive for type 1 vaccine-derived poliovirus (VDPV1) on October 6 2015. The outcome of the outbreak response would be to attain a coverage of more than 90% in every district of the targeted province, thereby interrupting the circulation of poliovirus in Lao PDR.

Analysis of the Lao Social Indicator Survey, 2011/12 demonstrates that the national average conceals the high levels of disparities in immunisation coverage across socio-economic groups, by ethnicity, provinces, and educational level of mothers. Various charts and figures detail vaccination coverage in Lao PDR in general and in different ethnic groups - in Bolikhan district in particular, which is identified as a difficult district in terms of vaccination reach due to difficult geo-topography and vaccine hesitancy in identified communities. It is presumed by the National Immunization Programme and the provincial epidemiology officers that vaccine-preventable disease outbreaks in Bolikhamxay tend to occur amongst the Hmong communities. The risk of spread of this disease to other parts of the country is perceived to be low to moderate due to the fact that the movement of people from this village to other provinces and districts seems to be limited because the Hmong community in the country socialise mostly with other Hmong families. In rural areas, they do not socialise much with other communities due to difference in language and cultural practices.

The document outlines the overall response strategy, which consists of 4 sub-national trivalent OPV (tOPV) immunisation rounds, including 2 national tOPV supplementary immunisation activities (SIAs) to be conducted from October 2015 to March 2016. The geographical coverage in each of the rounds is provided, with charts indicating specifics. "In villages with vaccine hesitancy, the visits to households and revisits to influence the parents should be made along with the local community leaders. This will be conducted with support from traditional leaders and village authorities including the Village Health Committees wherever it exist....As Hmong community is vulnerable to vaccine preventable diseases evidenced by the occurrence of measles, diphtheria and VDPV cases, it is imperative that special mobilization strategies will be required to address the vaccine hesitancy and other access and utilization issues. This would involve organizing village level meeting with traditional leaders, village head man and social mobilization activities including radio and village level announcements in local vernacular to name a few."

Micro-plans are described as well. They will include a special section for social mobilisation of each block / village as well as information such as name of the village head, other key influencers in this community, activities that will be undertaken by those key groups prior to the campaign, names and roles of the community outreach networks and their role and schedule of community mobilisation before the campaign, and activities that will be undertaken between the different campaigns.

Detailed advocacy, communication, and social mobilisation activities are outlined in section 8. The communication response is divided into two phases: Immediate and Adaptive phases, which are based on the global polio communication strategy as well as the communication for development (C4D) polio guidelines. Within the immediate response phase, communication has to be clear, and elicit an urgent response from parents and the community at large. The primary goal is to raise awareness of the outbreak, the disease, the vaccine, vaccination dates, and the response to a threshold of at least 90% awareness as quickly as possible. In the adaptive phase, communication shifts to reach the chronically missed children, who, in this case, are predominantly found among the Hmong ethnic group. Communication in this phase is about understanding social barriers and opportunities for promoting vaccination, and addressing and leveraging these, respectively, through communications and engagement approach. This phase will continue until the outbreak is concluded and the lessons learnt from this campaign will be carried forward to routine immunisation (RI) communication activities. A number of strategies will be pursued to achieve these targets, such as utilisation of media, research, capacity building of frontline workers, and development of simple educational materials to reach high-risk communities. (It has to be noted that written material in Hmong language cannot be printed in Lao PDR, but spoken media as TV, radio, loudspeakers and theatre can be used.)

A community rapid assessment conducted by the National Immunization Programme found that a common misunderstanding among the Hmong ethnic community is that, as the vaccine is offered free by the government in Lao PDR (unlike other curative treatment they must pay for), it must be of poor quality. It was also learnt that the mothers, even if they are convinced of the benefits of immunisation, won't take children to be immunised without an explicit authorization from their husbands. Also mentioned by the communities was the perception that health workers were often from outside the community and could not, literally, speak their language and pronounce the names of the mothers/children correctly during outreach activities. Thus, understanding the social structure of the Hmong communities will be key to reaching influencers and rejecters.

The Minister of Health, who is the official spokesman to the media for this activity, conducted a press conference on the third day of the detection of the positive VDPV to inform the community of the planned campaigns. Going forward, the Provincial and District Mother and Child Commission which is chaired by the Governors and Vice-Governors will lead the advocacy and communication activities. At the community level, the channels for SIA communication and social mobilisation will be through local community mobilisers/influencers, health workers, village health volunteers, village leader, Unit chiefs, and schoolteachers, as well as community organisations such as the Lao Front for National Construction, which has a specific mandate to engage with ethnic groups. Also involved will be the Lao Women's Union, which has volunteers in most villages. In areas with predominant Hmong population, the local Hmong community radio will be used to share the information on the importance of the campaign and about the dates of vaccination sessions. Hmong very important persons (VIPs) will also be asked to pass on key messages.

Subsequent sections of the document explore human resource issues as well as coordination and partnership. (The central coordination role at the National level is being managed through the activation of the National Emergency Operational Centre (EOC), which is headed by the Minister of Health. The activation of the EOC provides a platform for consolidating the synergies between different units to support the implementation.) AFP surveillance is also part of the outbreak plan, as is outbreak assessment (conducted in January 2016 and May 2016).

Click here for the 25-page report in PDF format.