Malaria elimination in Zanzibar: where next?

In 2018, Zanzibar developed a national malaria strategic plan IV (2018-2023) to guide elimination of malaria by 2023. We assessed progress in the implementation of malaria activities as part of the end-term review of the strategic plan. The review was done between August and October 2022 following the WHO guideline to assess progress made towards malaria elimination, effectiveness of the health systems in delivering malaria case management; and malaria financing. A desk review examined available malaria data, annual work plans and implementation reports for evidence of implemented malaria activities. This was complemented by field visits to selected health facilities and communities by external experts, and interviews with health management teams and inhabitants to authenticate desk review findings. A steady increase in the annual parasite incidence (API) was observed in Zanzibar, from 2.7 (2017) to 3.6 (2021) cases per 1,000 population with marked heterogeneity between areas. However, about 68% of the detected malaria cases were imported into Zanzibar. Malaria case follow-up and investigation increased from <70% in 2017 to 94% and 96% respectively, in 2021. The review noted a 3.7-fold increase of the health allocation in the country's budget, from 31.7 million USD (2017/18) to 117.3 million USD (2022/23) but malaria allocation remained low (<1%). The varying transmission levels in the islands suggest a need for strategic re-orientation of the elimination attempts from a national-wide to a sub-national agenda. We recommend increasing malaria allocation from the health budget to ensure sustainability of malaria elimination interventions.

Process of developing Country Cooperation Strategy in Tanzania, as an effective tool for aligning WHO's support to the member state in achieving health and health-related sustainable development goal.

Introduction: an organization's long-term success and relevance are linked with compelling strategic development. To that end, the country office of WHO in the United Republic of Tanzania, in collaboration with stakeholders, developed a 6-year Country Cooperation Strategy (CCS), 2022-2027. This paper describes the various steps taken in developing the CCS for the United Republic of Tanzania. Methods: we reviewed the global guideline for the development of CCS. In addition, we analysed documents on the national health sector strategic plan, the 13th Global Program of Work for WHO (GPW13), and the Sustainable Development Goal (SDG). We also reviewed data from routine HMIS, the Global Burden of Disease (GBD), and assessment results of the UN on the status of SDGs through the Common Country Assessment (CCA). Results: the performance on the overall Universal Health Coverage (UHC) effective coverage index, on a scale of 0-100, for Tanzania improved from 45.2 in 2010 to 55.2 in 2019. Strengthening health systems, protecting communities against public health emergencies, reducing or controlling exposure of individuals to risk factors, and better health governance, leadership, and accountability were the identified priorities for the CCS. Conclusion: the process of alignment of the CCS document with the national and global strategic goals would help the WHO to support and lead the country's effort towards achieving health-related SDGs. We believe the process we employed will lead to having detailed operational plans for implementation for achieving SDG targets. Keywords: Country cooperation strategy (CCS), sustainable development goal (SDG), strategic document, 13th global program of work (GPW13), health sector strategy, stakeholders, Tanzania.

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.

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.

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.

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.

Institutionalizing documentation for WHO Nigeria country office visibility and improved donor relations, 2013-2016.

BACKGROUND: The mandate and unique experience of the World Health Organization (WHO) globally, enables over 190 countries, Nigeria inclusive, to depend on the technical support provided by the organization to define and mitigate the threats to public health. With other emerging health actors competing for scarce donors' resources, the demand for visibility has invariably equaled expectations on WHO's expertise and technical support. However, the inability to systematically document activities conducted by WHO personnel before 2013 overshadowed most of its invaluable contributions due to poor publicity. The inauguration of the Communications Group in December 2013 with a visibility plan necessitated a paradigm shift towards building a culture of documentation to engender visibility. METHODS: We used a pre-post design of activities to evaluate the effectiveness of specific interventions implemented to improve visibility from 2013 to 2016. The paper highlights how incorporating communication strategies into the accountability framework of staff contributed in changing the landscape as well as showcasing the activities of WHO in Nigeria for improved donor relations. RESULTS: With the specific interventions implemented to improve WHO's visibility in Nigeria, we found that donor relations improved between 2013 and 2015. It is not a mere coincidence that the period corresponds with the era of incorporation of documentation into the accountability framework of technical staff for visibility as locally mobilized resources increased to record 112% in 2013 and 2014. The intervention assisted in the positive projection of WHO and its donors by the Nigeria media. CONCLUSION: Despite several interventions, which worked, made WHO ubiquitous and added awareness and visibility for donors who funded various projects, other factors could have contributed towards achieving results. Notwithstanding, incorporating documentation component into the accountability framework of field staff and clusters has significantly improved communication of WHO's work and promoted healthy competition for increased visibility.

The global switch from trivalent oral polio vaccine (tOPV) to bivalent oral polio vaccine (bOPV): facts, experiences and lessons learned from the south-south zone; Nigeria, April 2016.

BACKGROUND: The globally synchronized switch from trivalent Oral Polio Vaccine (tOPV) to bivalent Oral Polio Vaccine (bOPV) took place in Nigeria on April 18th 2016. The country is divided into six geopolitical zones. This study reports the experiences and lessons learned from the switch process in the six states that make up Nigeria's south-south geopolitical zone. METHODS: This was a descriptive retrospective review of Nigeria's switch plan and structures used for implementing the tOPV-bOPV switch in the south-south zone. Nigeria's National Polio Emergency Operation Centre (NPEOC) protocols, global guidelines and reports from switch supervisors during the switch were used to provide background information for this study. Quantitative data were derived from reviewing switch monitoring and validation documents as submitted to the NPEOC RESULTS: The switch process took place in all 3078 Health Facilities (HFs) and 123 Local Government Areas (LGAs) that make up the six states in the zone. A total of $139,430 was used for this process. The 'healthcare personnel' component received the highest budgetary allocation (59%) followed by the 'logistics' component (18%). Akwa Ibom state was allocated the highest number of healthcare personnel and hence received the most budgetary allocation compared to the six states (total healthcare personnel = 458, total budgetary allocation = $17,428). Validation of the switch process revealed that eight HFs in Bayelsa, Cross-River, Edo and Rivers states still possessed tOPV in cold-chain while six HFs in Cross-River and Rivers states had tOPV out of cold-chain but without the 'do not use' sticker. Akwa-Ibom was the only state in the zone to have bOPV and Inactivated Polio Vaccine (IPV) available in all its HFs monitored. CONCLUSION: The Nigerian tOPV-bOPV switch was successful. For future Oral Polio Vaccine (OPV) withdrawals, implementation of the switch plan would be more feasible with an earlier dissemination of funds from global donor organizations, which would greatly aid timely planning and preparations. Increased budgetary allocation to the 'logistics' component to accommodate unexpected hikes in transportation prices and the general inefficiencies with power supply in the country is also advised.

Enhancing transit polio vaccination in collaboration with targeted stakeholders in Kaduna State, Nigeria: Lessons learnt: 2014-2015.

INTRODUCTION: In Kaduna State of Nigeria, the high influx of people from neighboring states with eligible children for polio vaccination represents a significant proportion of the target population. Many of these children are often missed by the vaccination team. The purpose of the study was to determine the contribution of targeted stakeholders in transit polio vaccination. METHODS: We used the trends of vaccinated children at transit points, motor parks and markets, well as total children vaccinated by transit teams in Chikun, Igabi and Sabon Gari Local Government Areas (LGAs) of Kaduna State, Nigeria, four rounds before and after the introduction of transit polio vaccination with targeted stakeholders in Kaduna State. RESULTS: A total of 87,502 under-5 children were vaccinated by the various transit teams in the three LGAs, which accounted for 3.2% of the total 2,781,162 children vaccinated by the three LGAs. For transit point vaccination, the number of vaccinated children increased from 1026 to 19,289 (302%), while motor park vaccination increased from 1289 to 4106 (318%) and market vaccination increased from 10,488 to 14,511 (138%), four rounds after the introduction of transit polio vaccination with targeted stakeholders. CONCLUSION: Engagement of targeted stakeholders significantly enhanced transit polio vaccination in Kaduna State, Nigeria.