Polio Outbreak Simulation Exercise IV Report

"The exercise highlighted the importance of effective pre-prepared communications strategies, the importance of monitoring and that effective risk communications requires a dedicated budget."

This report describes the fourth Polio Outbreak Simulation Exercise (POSE IV), conducted November 17-19 2015 in Almaty, Kazakhstan to critically review and update national plans for responding to the detection of wild polioviruses and vaccine-derived polioviruses in national and cross-regional contexts. After previous POSEs held in Bosnia and Herzegovina (2011), Ukraine (2013), and the United Kingdom, the European Regional Certification Commission for Poliomyelitis Eradication (RCC) stated that "the utility and advantages of conducting POSE have now been demonstrated." Designed and delivered in conjunction with Public Health England (PHE), the bi-regional table-top exercise included 42 participants from both the World Health Organization (WHO) European Region and the WHO Western Pacific Region. The exercise challenged participants in preparedness, response, risk assessment, reporting (including International Health Regulations, or IHR), government engagement, budgetary constraints, communication in response to a polio outbreak, and maintaining polio-free status.

The 3-day POSE IV was combined with a half-day communications workshop on November 19 and a half-day IHR workshop on the following morning. During the exercise, participants were grouped according to country. The true-to-life scenario began with participants being asked to review their plans in light of ongoing polio transmission in neighbouring countries Afghanistan and Pakistan. The scenario then developed fictionally with a "hot" case of wild poliovirus type 1 (WPV1) identified in Kyrgyzstan. This case was a young child whose father was a lorry driver operating from Naryn (Kyrgyzstan) north to Bishkek (Kyrgyzstan) and Almaty (Kazakhstan) and south to Kashgar (China). In Kashgar, the father regularly spent time with other drivers who operate from Pakistan through the Karakoram Highway to Kashgar, Urumqi (China) and onward to Ulaanbaatar (Mongolia). One further case was identified in a school child in Almaty, Kazakhstan. An exercise teleconference chaired by WHO was held to practice the logistics around key people speaking different languages dialling in from neighbouring countries. The national media reported these outbreaks in a way that caused anxiety in the population and alarmed visitors to the regions. Anti-vaccination pressure-group social media reports were damaging to the response by publishing inaccurate facts about the dangers of vaccination. In order to examine the recovery and longer term issues, the exercise scenario concluded with a time jump to >120 days after the detection of WPV1 in Kyrgyzstan and Kazakhstan during which time there had been no further cases. The scenario was spread over 3 sessions.

This exercise allowed direct personal interaction and communications between participant groups and subject matter experts. There were also frequent plenary sessions throughout to share learning and issues encountered. In addition, representatives from each country were interviewed by a "mock media" film crew on their response to the outbreak. The exercise was delivered in English and Russian, including all documents, presentations, and plenary sessions. Two experienced translators enabled simultaneous translation into either English or Russian. Discussions and feedback after each session during POSE IV were led by a bilingual facilitator from the Regional Office.

Each country delegation critically reviewed their national action plan and noted areas for improvement highlighted by the exercise. The main issues identified during POSE IV for each participant country to concentrate on subsequently were to:

• revise the national plan of action, in line with the current Global Polio Eradication Initiative (GPEI) standard operating procedure (SOP) for responding to an outbreak;
• develop national risk communication plans in preparation for the management of a polio outbreak;
• perform a current assessment to understand who and where the high-risk/marginalised population groups (including travellers, nomads) are;
• identify strategies to reach these high-risk groups with polio eradication interventions;
• advance collaboration between the Ministry of Health and other ministries on information sharing about cross-border population movement; and
• sustain quality of acute flaccid paralysis (AFP) surveillance and environmental surveillance.

"Communications was explored thoroughly during the workshop and the exercise, and streamlining the existing national plan of action with the GPEI SOP to include a crisis communications plan was identified as a requirement. Participants felt it would be helpful for WHO to include a polio communications Q&A on the WHO website to aid countries to write their own communications plans....During the exercise the country groups were asked to prepare a briefing to their Health Minister and later on to deliver a press release. The official briefings were thorough, accurate and appropriate; the press releases were less successful as they were almost identical to the briefings. During the communications workshop participants realized the importance of a single over-riding communication objective and keeping messages to the media and public short and understandable, avoiding any scientific jargon. Participants also explored communication to the public through traditional media (television, radio, newspapers) and discussed the importance of working with journalists to ensure the correct messages are disseminated. Social networks were not routinely monitored but are an important aspect of social mobilization in order to gauge public mood and when necessary mitigate anti-vaccination rumours. During the Tajikistan outbreak, Kazakhstan had experience of divisive stories being circulated that the serious outbreak was a malicious fabrication. There was discussion around the ethics of using material showing paralysed children to get the message across."

The report concludes with a detailed discussion of the recommendations that emerged from the exercise, as well as an evaluation of POSEIV and suggested improvements for future WHO POSEs.