Standard Operating Procedures: Responding to a Poliovirus Event and Outbreak - Version 3

This Global Polio Eradication Initiative (GPEI) guide is for national governments and public health decision-makers who coordinate responses to poliovirus events and outbreaks, and their global, regional, and country-level partners. The purpose of these standard operating procedures (SOPs) is to offer policy guidance and to provide performance standards on how to respond to any type of poliovirus outbreak or event in a timely and effective manner and, specifically, to stop an outbreak within 120 days. This version of the SOPs incorporates lessons learned from previous outbreak response efforts since the trivalent oral polio vaccine (tOPV) to bivalent OPV (bOPV) switch in April and May of 2016.

As of July 2018, 3 countries remained endemic for type 1 wild poliovirus (WPV1): Afghanistan, Nigeria, and Pakistan. While efforts to eradicate WPV1 continue in these countries, GPEI stresses that the world needs to be prepared for the international spread of WPV and for vaccine-derived poliovirus (VDPV) of serotypes 1, 2, or 3, which can also still emerge in different contexts due to a number of possible factors, including low population immunity, importation of virus, or a containment breach from laboratory or vaccine manufacturing facilities.

This framework guides national responses to poliovirus events or outbreaks, providing the basis for coordination and collaboration among partners, to ensure that national polio response activities are fully supported. The essential elements to a successful response to a polio event or outbreak as outlined in the SOPs are:

1. Fully engaged national and subnational governments;
2. Rapid detection, notification, investigation, and risk assessment;
3. Strong advocacy, communication, and social mobilisation;
4. A robust immunisation response, where indicated; and
5. High-quality and enhanced surveillance.

Version 3 of the SOPs (see Related Summaries, below, for earlier versions) offers technical updates, focuses on practical guidance, and guides response for all poliovirus types in a single document. Guidance covers all aspects of outbreak response: investigation, risk assessment and grading, coordination and management, vaccination, surveillance enhancement, communication for development (C4D) and social mobilisation, monitoring and evaluation (M&E) of response, and other elements.

Number 3, above, corresponds to chapter 9 in the SOPs. Here, the GPEI explains that the polio C4D outbreak response approach is designed to redress perceptions and social norms that deter caregivers from vaccinating their children and to rebuild commitment to vaccination, including routine immunisation (RI). Critical C4D steps include:

• raising awareness of campaign dates;
• strengthening community perception of vaccination through building trust in health worker capacity and vaccine safety and efficacy;
• elevating perception of polio risk; and
• addressing bottlenecks in the decision to vaccinate.

Specifically:

• Immediately creating or reinvigorating a national communication or social mobilisation committee is necessary to help initiate C4D outbreak response communication as soon as an outbreak is declared. At this phase, the focus is on building (or rebuilding) caregivers' awareness about polio, OPV, and the fact that there is an outbreak. Communication approaches should be straightforward and clear and should elicit an urgent response from parents and the community at large. C4D activities should be shaped by a review of existing data sources for knowledge, attitudes, practices, and behaviour or, if not available, by a rapid social assessment of norms that may affect vaccination. Gender issues should be integrated into data analysis.
• Plans for subsequent campaigns, including supplementary immunisation activities (SIAs) and a mop-up round, should include C4D interventions to reach missed children and reduce refusals. For campaigns using the short interval additional dose (SIAD) approach, locally appropriate messaging is important so that families understand the process. After each campaign, independent monitoring (IM)/lot quality assurance sampling (LQAS) data and/or other sources should be analysed in a timely way, especially regarding the core indicators for C4D (outlined in the SOPs), in order to amend communication strategies as required.
• Where an outbreak is ongoing for more than 4 months, there may be one or more underlying communication barriers. As the intended audience may include acceptors, vulnerable acceptors, transient groups, or even rejecters, a root cause analysis should be conducted to identify such barriers, whether social or related to access or quality of the service. Reasons for missed children should be well investigated and analysed to adjust strategies for issues such as fatigue of repeated campaigns or mistrust in vaccine or frontline workers.
• Regardless of how the outbreak evolves, the focus of C4D strategies should shift towards supporting RI as soon as possible. The final outbreak response assessment (OBRA) reviews country improvement plans for RI and longer-term preparedness. Achievements and lessons learned from social mobilisation, advocacy, and media and partnership activities at the national, provincial, and district levels should be documented.

GPEI notes that deploying a variety of strategies ensures that communities and decision-makers at local, national, and regional levels are engaged in promoting vaccination. Engagement with religious and community leaders, health providers, parliamentarians, women's and youth groups, or other influencers in the social network is an important strategy to build strong public consensus about the urgency of the outbreak and the need to take collectively the decision to vaccinate. Mass and social media play a critical role for reaching a large audience very quickly, especially where interpersonal communication networks are less strong. In conflict areas, radios can serve as a channelling tool.

Special populations that are hard-to-reach or in conflict areas can be particularly vulnerable to polio outbreaks. Community mobilisers should be selected from the communities, and efforts should be made to include women. To build community trust, (s)he should be trained on key messages and be part of the vaccination team. Global training standards are available for training of vaccinators and other volunteers. Furthermore, community influencers/groups should be consulted and engaged in the planning phase of the campaign, with continuation through to the end of the outbreak. Geographic, security, or demographic challenges could limit access. The use of non-traditional means, such as mobile texting, awareness around water points, days when a population moves from one place to the other, printed messages about polio on food bags, or messages in bread packages and other innovations, may augment standard communication strategies.