Surveillance Review System to Track Progress Towards Polio Eradication in the Horn of Africa.

BACKGROUND: The risk for importation and reintroduction wild poliovirus in areas that have been cleared of the wild poliovirus in the Horn of Africa will remain if the surveillance systems are weak and porous. METHODS: Consequently, the Horn of Africa Polio Coordinating Office in Nairobi, together with partners conducted surveillance reviews for some of the countries in the Horn of Africa, especially Ethiopia, Kenya and Somalia to identify gaps in the polio surveillance and provided recommendations for improved surveillance. Structured questionnaires collected information about acute flaccid paralysis (AFP) surveillance resources, training, data monitoring, and supervision at provincial, district, and health facility levels. Other information collected included resource availability, management and monitoring of AFP surveillance. RESULTS: The result revealed that although AFP surveillance systems were well established in these countries, a number of gaps and constraints existed. Widespread deficiencies and inefficient resource flow systems were observed and reported at all levels. There were also deficiencies related to provider knowledge, funding, training, and supervision, and were particularly evident at the health facility level. These weaknesses were corroborated with the sustained transmission of polioviruses in the region, where the surveillance systems were not sensitive enough to pick the viruses. CONCLUSION: The review teams made useful recommendations that led to strengthening of the surveillance systems in these countries, including the formation and use of village polio volunteers in the south and central zones of Somalia, where security was heavily compromised and surveillance officers lacked regular access to the communities.

Overview of Polio Outbreak Response in Kenya, 2013 to 2015.

BACKGROUND: Globally, tremendous improvement has been made in Polio eradication since its inception in 1988. For the third time in a decade, Kenya has experienced a Polio outbreak along the border with Somalia. The affected areas were in Garissa County, replete with previous occurrences in 2006 and 2012. This article, give an account of series of events and activities that were used to stop the transmission within 13 weeks, an interval between the first and the last case of the 2013 outbreak. METHODS: In an attempt to stop further transmission and time bound closure of the outbreak, many activities were brought to fore: the known traditional methods, innovative approaches, improved finances and surge capacity. These assisted in case detection, implementation, and coordination of activities. The external outbreak assessments and the six-monthly technical advisory group recommendations were also employed. RESULT: There were increased case detections of >=2/100,000, stool adequacy >=80%, due to enhanced surveillance, timely feedbacks from laboratory investigation and diagnosis. Sustained coverage in supplemental immunisation of > 90%, ensured that immune profile of >=3 polio vaccine doses was quickly attained to protect the targeted population, prevent further polio infection and eventual reduction of cases coming up with paralysis. CONCLUSION: Overall, the outbreak was stopped within the 120 days of the first case using 14 rounds of supplemental immunisation activities.

Polio Outbreak Investigation and Response in The Horn of Africa: 2013-2016.

BACKGROUND: There has been civil strife, spanning more than two decades in some countries and recurrent natural disasters in the Horn of Africa (HoA). This has consistently maintained these countries in chronic humanitarian conditions. More important however is the fact that these crises have also denied populations of these countries access to access to lifesaving health services. Children in the difficult terrains and security compromised areas are not given the required immunization services to build their immunity against infectious diseases like the poliovirus. This was the situation in 2013 when the large outbreaks of poliovirus occurred in the HoA. This article reviews the epidemiology, risk, and programme response to what is now famed as the 2013-204 poliovirus outbreaks in the HoA and highlights the challenges that the programme faced in interrupting poliovirus transmission here. METHODS: A case of acute flaccid paralysis (AFP) was defined as a child <15 years of age with sudden onset of fever and paralysis. Polio cases were defined as AFP cases with stool specimens positive for WPV. RESULTS: Between 2013 and 2016, when transmission was interrupted 20,266 polio viruses were in the Horn of Africa region. In response to the outbreak, several supplementary immunization activities were conducted with oral polio vaccine (OPV) The trivalent OPV was used initially, followed subsequently by bivalent OPV, and targeting various age groups, including children aged <5 years, children aged <10 years, and individuals of any age. Other response activities were undertaken to supplement the immunization in controlling the outbreak. Some of these activities included the use of various communication strategies to create awareness, sensitize and mobilize the populations against poliovirus transmission. CONCLUSIONS: The outbreaks were attributed to the existence of clusters of unvaccinated children due to inaccessibility to them by the health system, caused by poor geographical terrain and conflicts. The key lesson therefore is that the existence of populations with low immunity to infections will necessary constitutes breeding grounds for disease outbreak and of course reservoirs to the vectors. Though brought under reasonable control, the outbreaks indicate that the threat of large polio outbreaks resulting from poliovirus importation will remain constant unless polio transmission is interrupted in the remaining polio-endemic countries of the world.

Simulation Exercises To Strengthen Polio Outbreak Preparedness in The Horn of Africa: Experiences and Lessons Learnt.

BACKGROUND: Poliovirus importations and related outbreaks occurred in the Horn of Africa (HoA) following an initial outbreak, which started in Somalia, spread into Kenya within ten days and later into Ethiopia and gradually to other countries in the region. National preparedness plans for responding to poliovirus introduction were insufficient in many countries of the Region. We describe a series of polio outbreak simulation exercises that were implemented to formally test polio outbreak preparedness plans in the HoA countries, as a step to interrupting further transmission. METHODS: The Polio Outbreak Simulation Exercises (POSEs) were designed and implemented. The results were evaluated and recommendations made. The roles of outbreak simulation exercises in maintaining regional polio-free status were assessed. In addition, we performed a comprehensive review of the national plans of all for seven countries in the HoA Region. RESULTS: Seven simulation exercises, delivered between 2016 and 2017 revealed that participating countries were generally prepared for poliovirus introduction, but the level of preparedness needed improvement. The areas in particular need of strengthening were national preparedness plans, initial response, plans for securing vaccine supply, and communications. CONCLUSIONS: Polio outbreak simulation exercises can be valuable tools to help maintain polio-free status and should be extended to other high-risk countries and subnational areas in the HoA Region and elsewhere. There is also need to standardize the process and methods for conducting POSE for comparability.

Lessons Learnt from Interregional and Interagency Collaboration in Polio Outbreak Response in the Horn of Africa.

Following the outbreak of poliovirus in the countries in the Horn of Africa, Somalia, Kenya and Ethiopia, in two WHO regions, an outbreak response involving the WHO Africa and WHO East and Mediterranean Regions and partner agencies like the UNICEF in East and Southern African was developed. This paper documents response to polio virus outbreak in the Horn of Africa and the lessons learnt for the interregional and inter-agency collaboration on the response. This collaboration led to speedy interruption of the outbreak and within a period of one year the total virus load of 217 in 2013 was brought down to mere six. This resulted from collaborative planning and implementation of activities to boost the hitherto low immunity in the countries andimprove surveillance among others. A number of lesson were generated from the process. Some of the lessons is critical role such collaboration plays in ensuring simultaneous immunity boosting, information and resources sharing, among other. Some challenges were equally encountered, chiefly in the appropriation of authorities. In conclusion, however, one is safe to note that the collaboration was very fruitful given the timely interruption of transmission.

Effectiveness of the Horn of Africa Polio Outbreak Coordination Office in Nairobi, Kenya.

Background: The WPV1, first detected in Somalia in April 2013, quickly spread to Kenya and Ethiopia and triggered a multi-country coordinated effort. In February 2014, a formal HoA Polio Outbreak Coordination Office was established by WHO AFRO and WHO EMRO in Nairobi to provide technical and managerial leadership. An independent assessment was conducted to ascertain the usefulness of the HoA Coordination in response to the outbreaks. Methods: The independent assessment team conducted desk review of the rules and guidelines forming the HoA Coordination office and committee. It also reviewed minutes of meetings and interviewed various stakeholders at the Regional levels. Results: This independent review of the work of the office, in September 2016, showed that the office was fully functional and had benefited from financial and technical support from regional and global GPEI partners. The office is based in the WHO Kenya Country Office which also provides administrative, logistics and until August 2016, data management support. The close working relationship with technical partners ensured alignment and close coordination of outbreak response activities. The mechanism also allowed partners to identify areas of work based on their expertise and avoided duplication of efforts at the local level. Overall, the office was effective in close monitoring of implementation of the outbreak response, strengthening of cross-border activities, monitoring implementation of the TAG recommendations, improving SIA planning and quality, and expanding independent monitoring in Somalia and South Sudan. Key constraints included limited office space for day-to-day operations, and disruption of some activities due to interruption of contracts of technical staff. However, the closure of the HoA outbreak in August 2015 led to some complacency, resulting in a lost sense of urgency, negatively impacting the coordination. Conclusions: The HoA Coordination Office should continue to function into the foreseeable future. To ensure sustainability of activities, the technical staff should be given contracts for a minimum of 12 months. The Office should reintroduce and schedule the Joint Polio Outbreak Response team meetings at least once every three months.