Routine immunization community surveys as a tool for guiding program implementation in Kaduna state, Nigeria 2015-2016.

BACKGROUND: Routine childhood immunization remains an important strategy for achieving polio eradication and maintaining a polio-free world. To address gaps in reported administrative coverage data, community surveys were conducted to verify coverage, and guide strategic interventions for improved coverage. METHODS: We reviewed the conduct of community surveys by World Health Organization (WHO) field volunteers deployed as part of the surge capacity to Kaduna state and the use of survey results between July 2015 and June 2016. Monthly and quarterly collation and use of these data to guide the deployment of various interventions aimed at strengthening routine immunization in the state. RESULTS: Over 97,000 children aged 0-11 months were surveyed by 138 field volunteers across 237 of the 255 wards in Kaduna state. Fully or appropriately immunized children increased from 67% in the fourth quarter of 2015 to 76% by the end of the second quarter of 2016. Within the period reviewed, the number of local government areas with < 80% coverage reduced from eight to zero. CONCLUSIONS: The routine conduct of community surveys by volunteers to inform interventions has shown an improvement in the vaccination status of children 0-11 months in Kaduna state and remains a useful tool in addressing administrative data quality issues.

The role of supportive supervision using mobile technology in monitoring and guiding program performance: a case study in Nigeria, 2015-2016.

BACKGROUND: Supportive supervision is one of the interventions that fosters program improvement by way of imparting knowledge and skills to health workers. The basic challenge in supportive supervision is the availability of data in real time for timely and effective feedback. Thus, the main objective of this study was to determine the contribution of real-time data collection during supportive supervision for timely feedback and generation of evidence for health intervention planning. METHODS: We analyzed supportive supervision records collected through handheld devices employing the open data kit (ODK) platform from July 2015 to June 2016. Supervision was conducted across the country by 592 World Health Organization (WHO) officers. The availability of real-time data and the distance of health facilities to the community were analyzed. RESULTS: During the study period, 90,396 health facilities were supervised. The average time spent during supervision varied from 1.53 to 3.78 h across the six geopolitical zones of the country. The average interval between completion of the supervisory checklist and synchronization with the server varied from 3.9 h to 7.5 h. The average distance between the health facility and a ward varied from 5 to 24 km. CONCLUSION: The use of handheld devices for supportive supervision provided real-time data from health facilities to state and zonal levels for analysis and feedback. Program officers used the findings to rectify process indicators in time for a better outcome.

Environmental, economic and socio-cultural risk factors of recurrent seasonal epidemics of cerebrospinal meningitis in Kebbi state, northwestern Nigeria: a qualitative approach.

BACKGROUND: Kebbi State remains the epicentre of the seasonal epidemic meningitis in northwestern Nigeria despite interventions. In this setting, no previous study has been conducted to understand the risk factors of the recurrent meningitis epidemics using qualitative approach. Consequently, this study intends to explore and better understand the environmental, economic and socio-cultural factors of recurrent seasonal epidemic meninigitis using a qualitative approach. METHODS: We conducted in-depth interview (40 IDIs) and focus group discussions (6 FGDs) in two local government areas (LGAs) in Kebbi State, Northwestern Nigeria to understand the environmental, economic and socio-cultural factors of recurrent meningitis outbreaks. Routine surveillance data were used to guide the selection of settlements, wards and local government areas based on the frequency of re-occurrences and magnitude of the outbreaks. RESULTS: The discussions revealed certain elements capable of potentiating the recurrence of seasonal meningitis epidemics. These are environmental issues, such as poorly-designed built environment, crowded sleeping and poorly ventilated rooms, dry and dusty weather condition. Other elements were economic challenges, such as poor household living conditions, neighbourhood deprivation, and socio-cultural elements, such as poor healthcare seeking behaviour, social mixing patterns, inadequate vaccination and vaccine hesitancy. CONCLUSION: As suggested by participants, there are potential environmental, socio-cultural and economic factors in the study area that might have been driving recurrent epidemics of cerebrospinal meningitis. In a bid to addressing this perennial challenge, governments at various levels supported by health development partners such as the World Health Organisation (WHO), United Nation Habitat, and United National Development Programme can use the findings of this study to design policies and programmes targeting these factors towards complementing other preventive and control strategies.

Profile of polio-compatible cases in Nigeria, 2006-2016.

BACKGROUND: The tremendous progress made by Nigeria towards polio eradication has recently suffered a setback with the isolation of circulating vaccine-derived poliovirus (cVDPV) type 2 from environmental samples and confirmation of four wild poliovirus (WPV) cases from acute flaccid paralysis (AFP) cases, with dates of onset of paralysis in July and August 2016. All these viruses were confirmed from the security-challenged northeastern state of Borno. Polio-compatible cases exist in Nigeria, and they indicate surveillance failure. Surveillance, therefore, has to be strengthened for the country to achieve certification. The objective of this paper is to highlight the epidemiological profile and magnitude of polio-compatible cases in Nigeria during the reporting period, as well as immunization and surveillance response activities conducted to close immunity and surveillance gaps. METHODS: We conducted a retrospective review of AFP surveillance performance and polio-compatible cases in Nigeria between 2006 and 2016 from the AFP database at the World Health Organization Country Office. We also reviewed and compared key epidemiological features of polio-compatible cases with those of wild poliovirus cases during the reporting period. RESULTS: The non-polio AFP rate improved from 6.5 in 2006 to 19.5 in 2016. The corresponding figures for stool adequacy rates were 88 and 98%. The total number of polio-compatible cases reported during the reporting period was 888, with the highest number (194) of cases reported in 2006 and the least (24) in 2016. Clusters of polio-compatible cases were reported every year during the reporting period except in 2015. The highest number (65) of polio-compatible cases in clusters was reported in 2006. The key epidemiological features of polio-compatible and wild poliovirus cases were similar. CONCLUSION: AFP surveillance performance has improved significantly during the reporting period. Surveillance gaps still existed as shown by the presence of orphan viruses and polio-compatible cases, and these gaps need to be identified and closed to achieve certification.

Polio eradication in Nigeria: evaluation of the quality of acute flaccid paralysis surveillance documentation in Bauchi state, 2016.

BACKGROUND: Nigeria is the only country in Africa that is yet to be certified as polio free. Surveillance for acute flaccid paralysis (AFP) is the foundation of the polio eradication initiative since it provides information to alert both health managers and clinician that timely actions should be initiated to interrupt transmission of the polio virus. The strategy also provides evidence for the absence of wild poliovirus. This evaluation was performed to assess key quality indicators defined by the polio eradication program and thus to identify gaps to allow planning for corrective measures to achieve a polio-free situation in Bauchi state and in Nigeria at large. We conducted a cross-sectional descriptive study which involved a desk review of documents to authenticate the correctness and completeness of data, and a review of documented evidence for the quality of AFP surveillance. We interviewed Local Government Authority (LGA) surveillance officers and clinicians from focal and non-focal sites, along with caregivers of children with AFP and community leaders. The data were entered and analyzed in a Microsoft Excel spreadsheet. METHODS: We conducted a cross-sectional study of the AFP surveillance and documentation in eighteen of the twenty Local Government Areas (LGAs) of Bauchi State. We assessed the knowledge of the clinician at focal and non-focal sites on case definition of AFP, the number and method of stool specimen collection to investigate a case and types of training received for AFP surveillance. We verified AFP case investigations for the last three years: The caregivers (mothers) were interviewed to authenticate the reported information of AFP cases, the method used for stool specimen collection and feedbacks. Community leaders' knowledge on AFP surveillance was also assessed. Data was entered and analyzed in excel spread sheet. RESULTS: Of the 18 LGA Disease Surveillance and Notification Officers (DSNOs), only 2 (11%) and 5 (28%) had reports of polio outbreak investigations and supervisory visits at the lower levels, respectively. Furthermore, only 6 (33%) and 7 (39%) of the DSNOs had minutes of meetings and surveillance work plans, respectively. Of the 31 AFP cases investigated, only 39, 26, 23, and 23% had correct and complete information for the birth day, birth month, date of onset of paralysis, and date of investigation, respectively. Seventy-one percent of the clinicians at the AFP focal sites knew the correct definition for AFP compared with only 30% at the non-focal sites. Of the 38 caregivers (mothers), 16 (42%) did not remember the day or month the AFP investigation was conducted. However, 95% gave a correct number of stool samples collected and 40% mentioned that the samples were collected 24 h apart. Feedback was not given to 26 (68%) of the caregivers. The majority (79%) of the community leaders knew how to recognize a case of AFP and knew that the stool was the specimen required for the investigation, but 21% did not know to whom they should report a case of AFP in their community. CONCLUSION: This study revealed a gap in the quality indicators for polio eradication in the state, especially regarding knowledge and documentation for AFP surveillance at the operational level. Regular training of the DSNOs and focal persons, regular sensitization of clinicians, community education, supplies of reporting tools, and ensuring their judicious use will improve AFP surveillance in the state.

Mobilizing political support proved critical to a successful switch from tOPV to bOPV in Kano, Nigeria 2016.

BACKGROUND: Kano is one of the high-risk states for polio transmission in Northern Nigeria. The state reported more cases of wild polioviruses (WPVs) than any other state in the country. The Nigeria Demographic and Health Survey of 2013 indicated that OPV3 coverage in the routine immunization (RI) programmewas 57.9%. Additionally, serial polio seroprevalence studies conducted from 2011 to 2015 in the eightmetropolitan LGAs indicated low immunity levels against all three polio serotypes in children below one year. Areas with sub-optimal RI coverage such as Kanothat fail to remove all tOPV during the tOPV-bOPV switchwill be at increased risk of VDPV2 circulation. METHODS: We assessed the impact of political leadership engagement in mobilizing other stakeholders on the outcomes of the bOPV-tOPV switch in Kano State from February to May 2016 using nationally-selected planning and outcome indicators. RESULTS: A total of 670 health facilities that provide RI services were assessed during the pre-switch activities. Health workers were aware of the switch exercise in 520 (95.1%) of the public health facilities assessed. It was found that health workers knew what to do should tOPV be found in any of the 521 (95.2%)public health facilities assessed. However, there was a wide disparity between the public and private health practitioners' knowledge on basic concepts of the switch. There was 100% withdrawal of tOPV from the state and the seven zonal cold stores. Unmarked tOPVwas found in the cold chain system in 2 (4.5%) LGAs. Only one health facility (0.8%) had tOPV in the cold chain. No tOPVwas identified outside the cold chain without the "Do not use" sticker in any of the health facilities. CONCLUSION: The engagement of the political leadership to mobilize other key stakeholders facilitated successful implementation of the tOPV-bOPVswitch exercise and provided opportunity to strengthen partnerships with the private health sector in Kano State.

Stopping circulatory vaccine-derived poliovirus in Kaduna state by scaling up special interventions in local government areas along rivers of interest- kamacha basin experience, 2013-2015.

BACKGROUND: The Kamacha river is one of the five polio environmental surveillance sites in Kaduna State where 13 circulating vaccine-derived polioviruses (cVDPDs) were isolated between 2014 and 2015. Kamacha river accounted for 5 of all reported cVDPVs in Kaduna State between 2014 and 2015. Poor quality Supplemental Immunization Activities (SIAs) and low population immunity have been reported in the 10 LGAs with tributaries that flow into the river. We described the processes of implementing the various health interventions in these targeted LGAs along the Kamacha River and assessed the effectiveness of the interventions in stopping cVDPV in Kaduna, state, Nigeria. METHODS: Special interventions that had been proven to be functional and effective in reaching unreached children with potent vaccines in the state were scaled up in these targeted 10 LGAs along the Kamacha River. These interventions included revision of house based microplans, scaling up of transit vaccination, scaling up of youth engagement, intensified supportive supervision, scaling up of Directly Observed Polio Vaccination (DOPV) and in-between rounds vaccination activities. We analyzed immunization plus days (IPDs) administrative tally sheet and monitoring data from 10 rounds before and 10 rounds after the special interventions. RESULTS: The number of children immunized increased from 1,862,958 in December 2014 before the intervention to 1,922,940 in March 2016 after the intervention. Lot Quality Assurance Sampling (LQAS) results showed an increase in the proportion of LGAs accepted at coverage > 90% after the interventions, from 67% before intervention to 84% after intervention. The proportion of non-polio AFP children with > 4 doses of oral polio vaccine increased from 2 to 8% before to 93-98% after the interventions.. No new environmental cVDPV has been isolated since the introduction of the interventions in April 2015 until July 2016. CONCLUSION: Scaling up known working interventions in the 10 LGAs with tributaries that drain to Kamacha River environmental sample site may have contributed to improved immunity and interruption of cVDPV in Kaduna state. These interventions should be replicated in LGAs and states with persistent poliovirus isolation.

Impact of engaging security personnel on access and polio immunization outcomes in security-inaccessible areas in Borno state, Nigeria.

BACKGROUND: Nigeria was polio free for almost 2 years but, with the recent liberation of areas under the captivity of insurgents, there has been a resurgence of polio cases. For several years, these inaccessible areas did not have access to vaccination due to activities of Bokoharam, resulting in a concentration of a cohort of unvaccinated children that served as a polio sanctuary. This article describes the processes of engagement of security personnel to access security-compromised areas and the impact on immunization outcomes. METHODS: We assessed routine program data from January 2016 to July 2016 in security-inaccessible areas and we evaluated the effectiveness of engaging security personnel to improve access to settlements in security-compromised Local Government Areas (LGAs) of Borno state. We thereafter evaluated the effects of this engagement on postcampaign evaluation indicators. RESULTS: From 15 LGAs accessible to vaccination teams in January 2016, there was a 47% increase in July 2016. The number of wards increased from 131 in January to 162 in July 2016, while the settlement numbers increased from 6050 in January to 6548 in July 2016. The average percentage of missed children decreased from 8% in January to 3% in July 2016, while the number of LGAs with ≥ 80% coverage increased from 85% in January to 100% in July 2016. CONCLUSION: The engagement of security personnel in immunization activities led to an improved access and improvement in postcampaign evaluation indicators in security-compromised areas of a Nigerian state. This approach promises to be an impactful innovation in reaching settlements in security-compromised areas.

Assessment of unmet needs to address noncompliant households during polio supplemental immunization activities in Kaduna state, 2014-2016.

BACKGROUND: Despite concerted global efforts being made to eradicate poliomyelitis, the wild poliovirus still circulates in three countries, including Nigeria. In addition, Nigeria experiences occasional outbreaks of the circulating vaccine-derived poliovirus type 2 (cVDPV2). Vaccine rejection by caregivers persists in some parts of northern Nigeria, which compromises the quality of supplemental immunization activities (SIAs). In 2013, the Expert Review Committee (ERC) on polio recommended innovative interventions in all high-risk northern states to improve the quality of SIA rounds through innovative interventions. The study assessed the impact of using unmet needs data to develop effective strategies to address noncompliant households in 13 high-risk Local government areas (LGAs) in Kaduna state, Nigeria. METHODS: A retrospective study was conducted in noncompliant communities using unmet needs data collated from 2014 to 2016. Household-based noncompliance data collated from tally sheets between 2013 and 2016 was also analyzed to assess the impact of unmet needs data in addressing noncompliance households in high-risk communities in Kaduna state. A structured interview was used to interview caregivers by the application of an unmet needs questionnaire, a quantitative study that assesses caregiver perception on immunization and other unmet needs which, if the gaps were addressed, would allow them to accept immunization services. Interventions include siting of temporary health camps in noncompliant communities to provide free medical consultations, treatment of minor ailments, provision of free antimalaria drugs and other essential drugs, and also referral of serious cases; intervention of religious and traditional leaders, youth against polio intervention, and the use of attractive bonuses (sweets, balloons, milk) during SIAs were all innovations applied to reduce noncompliance in households in affected communities as the need for eradication of polio was declared as a state of emergency. Outcomes from the analyses of unmet needs data were used to direct specific interventions to certain areas where they will be more effective in reducing the number of noncompliant households recorded on the tally sheet in each SIA round. Hence, seven immunization parameters were assessed from the unmet needs data. RESULTS: Overall, 54% of the noncompliant caregivers interviewed were ready to support immunization services in their communities. The majority of caregivers were also willing to vaccinate their children publicly following unmet needs interventions that were conducted in noncompliant communities. The trend of noncompliant households decreased by 79% from 16,331 in September 2013 to 3394 in May 2016. CONCLUSIONS: Unmet needs interventions were effective in reducing the number of noncompliant households recorded during SIA rounds in Kaduna State. Hence, unmet needs intervention could be adapted at all levels to address challenges faced in other primary healthcare programs in Nigeria.

Transboundary nomadic population movement: a potential for import-export of poliovirus.

BACKGROUND: Nomadic populations have a considerably higher risk of contracting a number of diseases but, despite the magnitude of the public health risks involved, they are mostly underserved with few health policies or plans to target them. Nomadic population movements are shown to be a niche for the transmission of diseases, including poliomyelitis. The nomadic routes traverse the northern states of Nigeria to other countries in the Lake Chad subregion. As part of the February 2016 polio supplemental immunization activity (SIA) plans in Bauchi state, a review of nomadic routes and populations identified a nomadic population who originated from outside the international borders of Nigeria. This study describes the engagement process for a transboundary nomadic population and the interventions provided to improve population immunity among them while traversing through Nigeria. METHODS: This was an intervention study which involved a cross-sectional mixed-method (quantitative and qualitative) survey. Information was collected on the nomadic pastoralists entry and exit points, resting points, and health-seeking behavior using key informant interviews and semistructured questionnaire. Transit vaccination teams targeted the groups with oral polio vaccines (OPVs) and other routine antigens along identified routes during the months of February to April 2016. Mobile health teams provided immunization and other child and maternal health survival interventions. RESULTS: A total of 2015 children aged under 5 years were vaccinated with OPV, of which 264 (13.1%) were zero-dose during the February 2016 SIAs while, in the March immunization plus days (IPDs), 1864 were immunized of which 211 (11.0%) were zero-dose. A total of 296 children aged under 1 year old were given the first dose of pentavalent vaccine (penta 1), while 119 received the third dose (penta 3), giving a dropout rate of 59.8%. CONCLUSIONS: Nomadic pastoralists move across international borders and there is a need for transboundary policies among the countries in the Lake Chad region to improve population immunity and disease surveillance through a holistic approach using the One-health concept.

Acute flaccid paralysis (AFP) surveillance intensification for polio certification in Kaduna state, Nigeria: lessons learnt, 2015-2016.

BACKGROUND: Nigeria has made remarkable progress in its current efforts to interrupt wild poliovirus transmission despite the re-emergence of wild poliovirus in 2016. The gains made in Nigeria have been achieved through concerted efforts by governments at all levels, traditional leaders, health workers, caregivers, and development partners. The efforts have involved an elaborate plan, coordination, and effective implementation of routine immunization services, supplemental immunization activities, and acute flaccid paralysis (AFP) surveillance. METHODS: We conducted the following activities to strengthen AFP surveillance in Kaduna state: a monetary reward for all AFP cases reported by health workers or community informants and verified as "true" AFP by a World Health Organization (WHO) cluster coordinator; training and sensitization of surveillance officers, clinicians, and community informants; recruitment of more personnel and expansion of the surveillance network; and the involvement of special populations (nomadic, hard-to-reach, and border communities) and caregivers in stool sample collection. The paired t test was used to evaluate the impact of the different initiatives implemented in Kaduna state to intensify AFP surveillance in 2016. RESULTS: There was increased annualized non-polio AFP rate (ANPAFPR) in 21 out of 23 Local Government Areas (LGAs) of Kaduna state 6 months after implementation of different initiatives to intensify AFP surveillance. The AFP reported by the special population increased in 15 out of 23 LGAs. Statistical analyses of mean scores of ANPAFPR before and after the interventions using the paired t test revealed a significant difference in mean scores: mean = 19.7 (standard deviation (SD) = 16.1) per 100,000 < 15 years old in July-December 2015, compared with 38.0 (SD = 21.6) per 100,000 < 15 years old in January-June 2016 (p < 0.05). Likewise, analysis of silent wards using the paired t test showed a significant difference in mean scores: mean = 4.0 (SD = 2.1) in July-December 2015 compared with 2.4 (SD = 1.8) in January-June 2016 (p < 0.05). CONCLUSION: The different initiatives implemented in 23 LGAs of Kaduna state to intensify AFP surveillance may be responsible for the significant improvement in the AFP surveillance performance indicators in 2016.

Targeting the last polio sanctuaries with Directly Observed Oral Polio Vaccination (DOPV) in northern Nigeria, (2014-2016).

BACKGROUND: The declaration of poliomyelitis eradication as a programmatic emergency for global public health by the 65th World Health Assembly in 2012 necessitated innovations and strategies to achieve results. Review of the confirmed polio cases in 2013 showed that most of the cases were from non-compliant households, where parents connived with vaccinators to finger mark the children without actually vaccinating the children with oral polio vaccine or children were absent from home at the time of the visit of vaccinators. METHODS: We used pre-post design to quantify the outcomes of directly observed vaccination in 90 local government areas from 12 northern Nigeria states at very high risk of polio transmission. The strategy is an intervention, vaccinating children under the direct supervision of an independent supervisor to ensure compliance. Attractive incentives (pluses) were used to make parents willingly submit their children for vaccination or directly attract children to the vaccination teams or post as part of this strategy. RESULTS: There was a steady increase in population immunity in all the 90 DOPV implementing LGAs since the introduction of DOPV in 2013. The number of states in which > 90% of children received > 4 OPV doses increased from 7 in 2013 to 11 states by July 2016. Yobe state reported the highest proportional increase from 75 to 99% by July 2016 (22% increase), while Kano state reported 17% increase, from 82 to 99% by July 2016. CONCLUSION: Directly observed polio vaccination strategy improved uptake of polio vaccines and population immunity in high-risk areas for polio transmission.

Conduct of vaccination in hard-to-reach areas to address potential polio reservoir areas, 2014-2015.

BACKGROUND: The Global Vaccine Action Plan (GVAP) seeks to achieve the total realization of its vision through equitable access to immunization as well as utilizing the immunization systems for delivery of other primary healthcare programs. The inequities in accessing hard-to-reach areas have very serious implications for the prevention and control of vaccine-preventable diseases, especially the polio eradication initiative. The Government of Nigeria implemented vaccination in hard-to-reach communities with support from the World Health Organization (WHO) to address the issues of health inequities in the hard-to-reach communities. This paper documents the process of conducting integrated mobile vaccination in these hard-to-reach areas and the impact on immunization outcomes. METHODS: We conducted vaccination using mobile health teams in 2311 hard-to-reach settlements in four states at risk of sustaining polio transmission in Nigeria from July 2014 to September 2015. RESULTS: The oral polio vaccine (OPV)3 coverage among children under 1 year of age improved from 23% at baseline to 61% and OPV coverage among children aged 1-5 years increased from 60 to 90%, while pentavalent vaccine (penta3) coverage increased from 22 to 55%. Vitamin A was administered to 78% of the target population and 9% of children that attended the session were provided with treatment for malaria. CONCLUSIONS: The hard-to-reach project has improved population immunity against polio, as well as other routine vaccinations and delivery of child health survival interventions in the hard-to-reach and underserved communities.

Towards an effective poliovirus laboratory containment strategy in Nigeria.

BACKGROUND: The Global Commission for the Certification of the Eradication of Poliomyelitis will declare the world free of wild poliovirus transmission when no wild virus has been found in at least 3 consecutive years, and all laboratories possessing wild poliovirus materials have adopted appropriate measures of containment. Nigeria has made progress towards poliomyelitis eradication with the latest reported WPV type 1 on 21 Aug 2016 after 2 years without any case. This milestone achievement was followed by an inventory of biomedical laboratories completed in November 2015 with the destruction of all identified infectious materials. This paper seeks to describe the poliovirus laboratory containment process in Nigeria on which an effective containment system has been built to minimize the risk of virus re-introduction into the population from the laboratories. METHODS: A national survey of all biomedical facilities, as well as an inventory of laboratories from various sectors, was conducted from June-November 2015. National Task Force (NTF) members and staff working on polio administered an on-site questionnaire in each facility. Laboratory personnel were sensitized with all un-needed materials destroyed by autoclaving and incineration. All stakeholders were also sensitized to continue the destruction of such materials as a requirement for phase one activities. RESULTS: A total of 20,638 biomedical facilities were surveyed with 9575 having laboratories. Thirty laboratories were found to contain poliovirus or potentially infectious materials. The 30 laboratories belonged to the ministries of health, education, defence and private organizations. CONCLUSIONS: This article is amongst the first in Africa that relates poliovirus laboratory containment in the context of the tOPV-bOPV switch in alignment with the Global Action Plan III. All identified infectious materials were destroyed and personnel trained to continue to destroy subsequent materials, a process that needs meticulous monitoring to mitigate the risk of poliovirus re-introduction to the population.

The Role of the Polio Program Infrastructure in Response to Ebola Virus Disease Outbreak in Nigeria 2014.

BACKGROUND: The current West African outbreak of the Ebola virus disease (EVD) began in Guinea in December 2013 and rapidly spread to Liberia and Sierra Leone. On 20 July 2014, a sick individual flew into Lagos, Nigeria, from Monrovia, Liberia, setting off an outbreak in Lagos and later in Port Harcourt city. The government of Nigeria, supported by the World Health Organization and other partners, mounted a response to the outbreak relying on the polio program experiences and infrastructure. On 20 October 2014, the country was declared free of EVD. METHODS: We examined the organization and operations of the response to the 2014 EVD outbreak in Nigeria and how experiences and support from the country's polio program infrastructure accelerated the outbreak response. RESULTS: The deputy incident manager of the National Polio Emergency Operations Centre was appointed the incident manager of the Ebola Emergency Operations Centre (EEOC), the body that coordinated and directed the response to the EVD outbreak in the country. A total of 892 contacts were followed up, and blood specimens were collected from 61 persons with suspected EVD and tested in designated laboratories. Of these, 19 (31%) were positive for Ebola, and 11 (58%) of the case patients were healthcare workers. The overall case-fatality rate was 40%. EVD sensitization and training were conducted during the outbreak and for 2 months after the outbreak ended. The World Health Organization deployed its surveillance and logistics personnel from non-Ebola-infected states to support response activities in Lagos and Rivers states. CONCLUSIONS: The support from the polio program infrastructure, particularly the coordination mechanism adopted (the EEOC), the availability of skilled personnel in the polio program, and lessons learned from managing the polio eradication program greatly contributed to the speedy containment of the 2014 EVD outbreak in Nigeria.

Implementation of a Systematic Accountability Framework in 2014 to Improve the Performance of the Nigerian Polio Program.

BACKGROUND: An accountability framework is a central feature of managing human and financial resources. One of its primary goals is to improve program performance through close monitoring of selected priority activities. The principal objective of this study was to determine the contribution of a systematic accountability framework to improving the performance of the World Health Organization (WHO)-Nigeria polio program staff, as well as the program itself. METHODS: The effect of implementation of the accountability framework was evaluated using data on administrative actions and select process indicators associated with acute flaccid paralysis (AFP) surveillance, routine immunization, and polio supplemental immunization activities. Data were collected in 2014 during supportive supervision, using Magpi software (a company that provides service to collect data using mobile phones). A total of 2500 staff were studied. RESULTS: Data on administrative actions and process indicators from quarters 2-4 in 2014 were compared. With respect to administrative actions, 1631 personnel (74%) received positive feedback (written or verbal commendation) in quarter 4 through the accountability framework, compared with 1569 (73%) and 1152 (61%) during quarters 3 and 2, respectively. These findings accorded with data on process indicators associated with AFP surveillance and routine immunization, showing statistically significant improvements in staff performance at the end of quarter 4, compared with other quarters. CONCLUSIONS: Improvements in staff performance and process indicators were observed for the WHO-Nigeria polio program after implementation of a systematic accountability framework.

The Journalists Initiatives on Immunisation Against Polio and Improved Acceptance of the Polio Vaccine in Northern Nigeria 2007-2015.

BACKGROUND: The polio eradication initiative had major setbacks in 2003 and 2007 due to media campaigns in which renowned scholars and Islamic clerics criticized polio vaccines. The World Health Organization (WHO) partnered with journalists in 2007 to form the Journalists Initiatives on Immunisation Against Polio (JAP), to develop communication initiatives aimed at highlighting polio eradication activities and the importance of immunization in northern Nigeria. METHODS: We evaluated the impact of JAP activities in Kaduna State by determining the total number of media materials produced and the number of newspaper clips and bulletins published in support of polio eradication. We also determined the number of households in noncompliant communities that became compliant with vaccination during 2015 supplementary immunization activities (SIAs) after JAP interventions and compared caregivers' sources of information about SIAs in 2007 before and after the JAP was formed. RESULTS: Since creation of the JAP, >500 reports have been published and aired, with most portraying polio vaccine positively. During June 2015 SIAs in high-risk wards of Kaduna STATE, JAP interventions resulted in vaccination of 5122 of 5991 children (85.5%) from noncompliant households. During early 2007, the number of caregivers who had heard about SIA rounds from the media increased from 26% in January, before the JAP was formed, to 33% in March, after the initiation of JAP activities. CONCLUSIONS: The formation of the JAP resulted in measurable improvement in the acceptance of polio vaccine in northern Nigeria.

Strategies for Improving Polio Surveillance Performance in the Security-Challenged Nigerian States of Adamawa, Borno, and Yobe During 2009-2014.

BACKGROUND: The security-challenged states of Adamawa, Borno, and Yobe bear most of the brunt of the Boko Haram insurgency in Nigeria. The security challenge has led to the killing of health workers, destruction of health facilities, and displacement of huge populations. To identify areas of polio transmission and promptly detect possible cases of importation in these states, polio surveillance must be very sensitive. METHODS: We conducted a retrospective review of acute flaccid paralysis surveillance in the security-compromised states between 2009 and 2014, using the acute flaccid paralysis database at the World Health Organization Nigeria Country Office. We also reviewed the reports of surveillance activities conducted in these security-challenged states, to identify strategies that were implemented to improve polio surveillance. RESULTS: Environmental surveillance was implemented in Borno in 2013 and in Yobe in 2014. All disease surveillance and notification officers in the 3 security-challenged states now receive annual training, and the number of community informants in these states has dramatically increased. Media-based messaging (via radio and television) is now used to sensitize the public to the importance of surveillance, and contact samples have been regularly collected in both states since 2014. CONCLUSIONS: The strategies implemented in the security-challenged states improved the quality of polio surveillance during the review period.

Strengthening Routine Immunization in Areas of Northern Nigeria at High Risk for Polio Transmission During 2012-2014.

BACKGROUND: Following the 2012 declaration by World Health Organization (WHO) Regional Director for Africa and the WHO Executive Board to ramp up routine immunization (RI) activities, began to intensify activities to strengthen RI. This study assessed how the intensification of RI helped strengthen service delivery in local government areas (LGAs) of northern Nigeria at high risk for polio transmission. METHODS: A retrospective study was performed by analyzing RI administrative data and findings from supportive supervisory visits in 107 high-risk LGAs. RESULTS: Our study revealed that administrative coverage with 3rd dose of diphtheria-pertussis-tetanus vaccine in the 107 high-risk LGAs improved from a maximum average coverage of 33% during the preintensification period of 2009-2011 to 74% during the postintensification period of 2012-2014. CONCLUSIONS: Routine immunization could be strengthened in areas where coverage is low, and RI has been identified to be weak when certain key routine activities are intensified.

Role of Serial Polio Seroprevalence Studies in Guiding Implementation of the Polio Eradication Initiative in Kano, Nigeria: 2011-2014.

BACKGROUND: Nigeria was one of 3 polio-endemic countries before it was de-listed in September 2015 by the World Health Organization, following interruption of transmission of the poliovirus. During 2011-2014, Nigeria conducted serial polio seroprevalence surveys (SPS) in Kano Metropolitan Area, comprising 8 local government areas (LGAs) in Kano that is considered very high risk (VHR) for polio, to monitor performance of the polio eradication program and guide the program in the adoption of innovative strategies. METHODS: Study subjects who resided in any of the 8 local government areas of Kano Metropolitan Area and satisfied age criteria were recruited from patients at Murtala Mohammed Specialist Hospital (Kano) for 3 seroprevalence surveys. The same methods were used to conduct each survey. RESULTS: The 2011 study showed seroprevalence values of 81%, 75%, and 73% for poliovirus types 1, 2, and 3, respectively, among infants aged 6-9 months age. Among children aged 36-47 months, seroprevalence values were greater (91%, 87%, and 85% for poliovirus types 1, 2, and 3, respectively).In 2013, the results showed that the seroprevalence was unexpectedly low among infants aged 6-9 months, remained high among children aged 36-47 months, and increased minimally among children aged 5-9 years and those aged 10-14 years. The baseline seroprevalence among infants aged 6-9 months in 2014 was better than that in 2013. CONCLUSIONS: The results from the polio seroprevalence surveys conducted in Kano Metropolitan Area in 2011, 2013, and 2014 served to assess the trends in immunity and program performance, as well as to guide the program, leading to various interventions being implemented with good effect, as evidenced by the reduction of poliovirus circulation in Kano.