Finding inhabited settlements and tracking vaccination progress: the application of satellite imagery analysis to guide the immunization response to confirmation of previously-undetected, ongoing endemic wild poliovirus transmission in Borno State, Nigeria.

BACKGROUND: Four wild polio-virus cases were reported in Borno State, Nigeria 2016, 1 year after Nigeria had been removed from the list of polio endemic countries by the World Health Organization. Resulting from Nigeria's decade long conflict with Boko Haram, health officials had been unable to access as much as 60% of the settlements in Borno, hindering vaccination and surveillance efforts. This lack of accessibility made it difficult for the government to assess the current population distribution within Borno. This study aimed to use high resolution, visible band satellite imagery to assess the habitation of inaccessible villages in Borno State. METHODS: Using high resolution (31-50 cm) imagery from DigitalGlobe, analysts evaluated the habitation status of settlements in Borno State identified by Nigeria's Vaccination Tracking System. The analysts looked at imagery of each settlement and, using vegetation (overgrowth vs. cleared) as a proxy for human habitation, classified settlements into three categories: inhabited, partially abandoned, and abandoned. Analysts also classified the intact percentage of each settlement starting at 0% (totally destroyed since last assessment) and increasing in 25% intervals through 100% (completely intact but not expanded) up to 200+% (more than doubled in size) by looking for destroyed buildings. These assessments were then used to adjust previously established population estimates for each settlement. These new population distributions were compared to vaccination efforts to determine the number of children under 5 unreached by vaccination teams. RESULTS: Of the 11,927 settlements assessed 3203 were assessed as abandoned (1892 of those completely destroyed), 662 as partially abandoned, and 8062 as fully inhabited as of December of 2017. Comparing the derived population estimates from the new assessments to previous assessment and the activities of vaccination teams shows that an estimated 180,155 of the 337,411 under five children who were unreached in 2016 were reached in 2017 (70.5% through vaccination efforts in previously inaccessible areas, 29.5% through displacement to accessible areas). CONCLUSIONS: This study's methodology provides important planning and situation awareness information to health workers in Borno, Nigeria, and may serve as a model for future data gathering efforts in inaccessible regions.

Evaluation of the integrated disease surveillance and response system for infectious diseases control in northern Ghana.

BACKGROUND: Well-functioning surveillance systems are crucial for effective disease control programs. The Integrated Disease Surveillance and Response (IDSR) strategy was developed and adopted in 1998 for Africa as a comprehensive public health approach and subsequently, Ghana adopted the IDSR technical guidelines in 2002. Since 2012, the IDSR data is reported through the new District Health Information Management System II (DHIMS2) network. The objective was to evaluate the Integrated Disease Surveillance and Response (IDSR) system in northern Ghana. METHODS: This was an observational study using mixed methods. Weekly and monthly IDSR data on selected infectious diseases were downloaded and analyzed for 2011, 2012 and 2013 (the years before, of and after DHIMS2 implementation) from the DHIMS2 databank for the Upper East Region (UER) and for two districts of UER. In addition, key informant interviews were conducted among local and regional health officers on the functioning of the IDSR. RESULTS: Clinically diagnosed malaria was the most prevalent disease in UER, with an annual incidence rate close to 1. Around 500 suspected HIV/AIDS cases were reported each year. The highest incidence of cholera and meningitis was reported in 2012 (257 and 392 cases respectively). Three suspected cases of polio and one suspected case of guinea worm were reported in 2013. None of the polio and guinea worm cases and only a fraction of the reported cases of the other diseases were confirmed. A major observation was the large and inconclusive difference in reported cases when comparing weekly and monthly reports. This can be explained by the different reporting practice for the sub-systems. Other challenges were low priority for surveillance, ill-equipped laboratories, rare supervision and missing feedback. CONCLUSIONS: The DHIMS2 has improved the availability of IDSR reports, but the quality of data reported is not sufficient. Particularly the inconsistencies between weekly and monthly data need to be addressed. Moreover, support for and communication within the IDSR system is inadequate and calls for attention.

Improving polio vaccination coverage in Nigeria through the use of geographic information system technology.

BACKGROUND: Historically, microplanning for polio vaccination campaigns in Nigeria relied on inaccurate and incomplete hand-drawn maps, resulting in the exclusion of entire settlements and missed children. The goal of this work was to create accurate, coordinate-based maps for 8 polio-endemic states in northern Nigeria to improve microplanning and support tracking of vaccination teams, thereby enhancing coverage, supervision, and accountability. METHODS: Settlement features were identified in the target states, using high-resolution satellite imagery. Field teams collected names and geocoordinates for each settlement feature, with the help of local guides. Global position system (GPS) tracking of vaccination teams was conducted in selected areas and daily feedback provided to supervisors. RESULTS: Geographic information system (GIS)-based maps were created for 2238 wards in the 8 target states. The resulting microplans included all settlements and more-efficient team assignments, owing to the improved spatial reference. GPS tracking was conducted in 111 high-risk local government areas, resulting in improved team performance and the identification of missed/poorly covered settlements. CONCLUSIONS: Accurate and complete maps are a necessary part of an effective polio microplan, and tracking vaccinators gives supervisors a tool to ensure that all settlements are visited.

Sparking, supporting and steering change: grounding an accountability framework with viewpoints from Nigerian routine immunization and primary health care government officials.

Existing accountability efforts in Nigeria primarily serve as retrospective policing. To enable accountability to guide change prospectively and preemptively, we drew from a literature review to develop a framework that highlights mutually reinforcing dimensions of accountability in health systems along three counterbalancing axes. The axis of power sparks change by wielding 'sticks' that curb the potential abuse of power, but also by offering 'carrots' that motivate constructive agency. The axis of ability supports change by enabling service delivery actors with formal rules that appropriately expand their authority to act, but also the informal norms and inputs for improved performance. Last, the axis of justice orients the strategic direction of change, balancing political representation, community ownership and social equity, so that accountability measures are progressive, rather than being captured by self-interests. We consulted Nigerian government officials to understand their viewpoints on accountability and mapped their responses to our evolving framework. All government officials (n = 36) participating in three zonal workshops on routine immunization filled out questionnaires that listed the top three opportunities and challenges to strengthening accountability. Thematically coded responses highlighted dimensions of accountability within the axes of ability and power: clarifying formal roles and responsibilities; transparency, data and monitoring systems; availability of skilled health personnel that are motivated and supervised; addressing informal norms and behaviours; and availability of inputs regarding funding and supplies. Other dimensions of accountability were mentioned but were not as critical from their viewpoints: managerial discretion; sanctions and enforcements; political influence and community engagement. Strikingly, almost no respondents mentioned social equity as being an important aspect of accountability, although a few mentioned broad development concerns that reflected community perspectives. Reframing accountability as a means of sparking, supporting and steering change can highlight different dimensions of health systems that need reform, particularly depending on the positionality of the viewpoints consulted.