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NIGERIA NATIONAL RECOMMENDATIONS ON POLIO ERADICATION, NOVEMBER 2013

Monday, 17th of February 2014

 

 

Final Report of the

26th Meeting of the Expert Review Committee (ERC)

On Polio Eradication & Routine Immunization
in Nigeria

 

 

 

 

 

 

 

Abuja, Nigeria

 

26-27 November 2013

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Executive Summary

 

Nigeria has made remarkable progress in (i) reducing cases of Wild Polio Virus (WPV), (ii) restricting the geographic spread of the virus (noting the significant wild poliovirus transmission in Kano State, which is in North West), (iii) reducing the genetic clusters of WPV1 from eight to two, and (iv) reducing the number of missed children and underserved communities. This improvement in performance is the result of a massive effort by the Government and partners. In particular, the establishment of the national and State Polio Emergency Operations Centres have been instrumental in maintaining focus and fully implementing the 2013 National Emergency Action Plans (NEAP). The Government of Nigeria has developed a strong structure for managing the polio eradication programme in Nigeria.

 

However, the country is still at high risk of polio transmission due to substantial gaps in quality of Immunization Plus Days (IPDs) activities in several Very High Risk (VHR) LGAs; poor access to children in insecure areas and poor level of accountability in some States and LGAs. Other major risks include potential distraction of political leaders as the country prepares early for the 2015 national elections which may result in gaps in oversight and political and financial commitment.

 

The ERC remains convinced that with the remarkable progress achieved in 2013, Nigeria can stop the transmission of WPV in 2014 despite the aforementioned challenges by improving SIA quality; enforcing rigorous accountability; accessing children in insecure areas and enhancing political commitment and oversight at all levels.

 

Major Recommendations:

 

• Oversight: Enhancing political commitment, particularly at sub national level, is critical during the next low transmission season (December 2013-May 2014) as well as during the period that the country prepares for national elections. The ERC therefore urges the Presidential Task Force on Polio Eradication (PTFoPE) to develop a monthly oversight & advocacy activity plan - to be updated quarterly. This plan should guide advocacy to critical States and LGAs to shore up the dwindling political commitment at the State and LGA levels. PTFoPE should also closely track accountability processes and report as recommended by ERC.

 

·         Improve quality of IPDs: ERC concurs with the program’s focus on micro-planning; vaccination team selection & performance; reduction in non-compliance and rigorous accountability. However, quality must be improved in the very very high risk (VVHR) and very high risk (VHR) as well as persistently poor performing LGAs while improvement should be sustained in areas with improved performance.

 

·         Declining population immunity in Kano: ERC is deeply concerned about substantial decline in polio sero-prevalence among 3-9 months old infants in Kano. ERC therefore recommends that the programme should quickly and objectively review the programme, identify the reasons for this decline and report to ERC at its next meeting in March 2014.

 

• Operating in insecure areas: The programme should capitalize on the improving access to children in Borno State and urgently develop an operational plan for Borno and Yobe States, with clear goals for the next six months and establish permanent vaccination posts at major transit points. Priority should be given to addition of IPV as part of fixed site services in areas where contact with children is intermittent or limited and ensure adequate preparations before the introduction.

 

 

• Reducing Non-Compliance & Generating Demand: The national programme should sustain recent community engagement strategies which are showing impact and increase focus on high risk poor performing areas while expanding implementation to Borno and Yobe States and tailoring strategies to the local context of insecurity and conflict. Partners and other large public health programs should help finance high impact health and civic services in Borno and other insecure areas in close collaboration with the polio eradication program me.

 

• Managing Financial Risks to the Programme: ERC is extremely concerned by the escalating budget of the programme in Nigeria and consequently recommends that the national programme should urgently undertake a review of the budget to identify cost efficiencies with focus on vaccine wastage and supply management and accountability. SIA target population should be estimated based on more accurate house-based micro-plans.

 

• Aggressive SIA strategy: The ERC endorses the national SIA plan for up to 9 IPDs for 2014 (2 national rounds and 7 subnational rounds out of which 2 are special rounds focusing on the underserved) using tOPV in at least 2 of the rounds. The national programme should undertake a rapid risk assessment to identify areas at risk in the South given the report of a case of polio caused by aVDPV in Cross River State in week 48, and the detection of WPV1 in neighboring Cameroon. Cross-border vaccination posts may need to be established as necessary.

 

• Vaccine Supply Shortage: The Government of Nigeria and Partners should order vaccines early and ensure adequate logistics support for all rounds. The logistics working group should be responsible for vaccine wastage and accountability.

 

• Surveillance and laboratory: ERC endorses the plan to enhance surveillance in security-compromised areas. ERC recommends that the national programme should ensure the continued improvement of surveillance in identified underserved communities and that the national laboratories receive the technical and material support they need to continue to function at the highest possible level of quality. Positive environmental samples should trigger an immediate investigation and response plan and sampling should continue until site is consistently negative

 

 

Broader Immunization Goals: ERC appreciates the improvements in reported RI coverage and recommends that the improvements reported should be maintained and encourages Government and partners to increase their financing for the National RI Strategic Plan. ERC urges NPHCDA to conduct independent validation of the reported improvements in RI coverage to identify both well performing and lagging areas and that the RI capacity building activities should be scaled up beyond the 100 LGAs, where RI capacity building activities are currently ongoing, to include additional high risk LGAs.

• Harmonized immunization plans: The experience and lessons learned from harmonization activities between different immunization campaigns in 2013 should be documented and used to further optimize synergies between all priority immunization activities in 2014. 2014 Harmonized immunization plan should include increased alignment between PEI and RI activities as outlined in the 2013-2015 National Routine Immunization Strategic Plan.

 

Introduction

 

The 26^th Expert Review Committee (ERC) for Polio Eradication and Routine Immunization (RI) was convened on 26-27 November, 2013 in Abuja.  The ERC acknowledges and commends the Federal Government of Nigeria and Partners, particularly the National Polio Emergency Operations Centre (EOC) as well as State and Local Governments for the progress made so far in the programme generally. In particular, the ERC notes the 57% reduction in WPV1; geographical restriction as no case reported in the North West (excepting Kano State); reduction of circulating WPV1 genetic cluster from eight to two and the absence of WPV3 in the last 12 months. Communication strategy is contributing significantly to reduction in non-compliance, reduction in missed children and underserved communities and establishment of environment surveillance in Maiduguri. The ERC notes the increase in RI coverage, and improving accountability, especially at the national level with overall improvement in quality of supplemental immunization activities (SIAs).

 

The ERC commends His Excellency, the Nigerian President for his continuous commitment to Polio Eradication Initiative (PEI) as evidenced by his chairing of two meetings of the Presidential Task Force on Polio Eradication in 2013 and urged State Governors and Local Government Area (LGA) Chairmen to follow this example.  

 

The ERC notes the sustained partnership between the programme and traditional leaders and the budding partnership with religious leaders and calls for strengthening of the relationship. The ERC expresses pleasure with the coordination of the programme by the national and state EOCs and commends the national, Borno and Kano State EOCs for the re-commencement of PEI activities.

 

The ERC acknowledges the full participation at the meeting of representatives of key State and Partner Agencies and observes with the greatest respect and admiration, the continuous sacrifices made by health workers and vaccinators despite security challenges, especially in Borno, Yobe and Kano States. The ERC commends the Federal Government for the donation of N5m each to the families of vaccinators killed while performing national service. 

 

 

This report summarizes the main findings, conclusions and recommendations of the 26^th meeting of the ERC.

 

Report on the 25th ERC Recommendations

 

The ERC reviewed the report on the status of implementation of the 25th ERC recommendations and congratulates the national program on progress made in implementing all the key recommendations.  The ERC believes that the National Primary Health Care Development Agency (NPHCDA) and the state Primary Health Care Agencies have had a major impact not only on the implementation of national and state emergency plans but also on the implementation of ERC recommendations and institutionalization of the accountability frame work.

 

With respect to the 25^th ERC recommendations, National Polio Emergency Action Plan (NPEAP) 2013 is being implemented fully. Two NIPDs, Six SIPDs and two special rounds were implemented while the December Round is scheduled for 14^th to 17^th 2013. Outbreak response was timely in almost all polio outbreak-prone States, except Gombe where delay was due to the conduct of walk-through micro planning.

 

Special Strategies for Borno and Yobe States are being implemented (Permanent Health Teams; Firewalling, Borno and Yobe borders; “Hit and Run” vaccination exercises during the calm periods; health camps, intensified Routine Immunization and Maternal Newborn and Child Health (MNCH). It is noteworthy that intelligence and security agents are incorporated into the state EOCs and LGA Task Forces, to guide monthly security assessment and reporting.

 

Kano and Borno have re-commenced IPDs since April 2013; however security challenges in Borno State have led to the implementation of flexible strategies. The availability of vaccines is assured till April 2014. The Ibadan and Maiduguri laboratories are fully accredited. Environmental sampling is ongoing with expansion of environmental sites in June and September 2013. This has led to improvement in epidemiology of polio in Nigeria. Volunteer Community Mobilizer (VCM) network has been scaled up from 2200 to 8000 to strengthen household and community mobilization. The integration of polio with other SIAs commenced in October and is ongoing.

 

However, the programme still needs to improve in the following areas – gaps in quality of campaigns; suboptimal team performance, declining sero-prevalence and declining political commitment at State and LGA levels and insecurity.

 

Current epidemiological situation

 

To date in 2013 transmission is significantly lower than in 2012, with more than 50% reduction in the number of cases. A total of 50 WPV cases, all WPV1, had been reported by 22 November, from 9 states, (Bauchi, Borno, FCT, Gombe, Kano, Nasarawa, Niger, Taraba and Yobe,) in 2013 compared to 117 cases from 11 States for the same period of 2012. In addition, 2 cases due to circulating Vaccine Derived Poliovirus type 2 (cVDPV2) were reported from one state (Borno) compared to 6 cases from 3 States in 2012. Transmission of WPV was concentrated in the northeast polio reservoir with 72% of cases reported from Borno, Kano and Yobe.

 

WPV1 is the dominant serotype. WPV3 was last reported in November 2012 and only one case of WPV3 has been reported in the past 12 months. In 2013, environmental surveillance detected 3 WPV1 - Kano (1) and Sokoto (2) and 12 cVDPV2, Sokoto (9) Kano (1) and Borno (2). The most recent cVDPV2 was reported in Borno in 2013.

 

 

Programme developments  

 

The ERC noted some key developments since the last meeting:

·         The national and state EOCs are now fully functional and coordinating the PEI programme and overseeing the implementation of National and State Emergency Action Plans (NEAP) for 2013, and are monitoring the Abuja Commitments.

·         Institutionalization and enforcement of accountability at all levels. The dashboard is being used to monitor accountability and sanctions and rewards meted out as appropriate.

·         Review of high risk LGA algorithm to prioritize LGAs for focused interventions.

·         The Lot Quality Assurance (LQAs) data, the Enhanced Independent Monitoring (EIM) and Geographic information system (GIS) data are complimentarily used to guide data interpretation and decision making every round.

·         Deployment of Management Support Teams (MST) to prioritized VVHR and VHR LGAs to provide high level management support to Ward and LGA teams.

·         Polio survivors, Doctors Against Polio and Religious focal persons supporting household mobilization and advocacy in non-compliant communities.

·         Deployment of emerging technology to disseminate messages at household and community levels through, Bluetooth; community viewing centres and compound meetings.

·         Increased number of VCMs from 2200 to 8000 who are tracking and reporting newborns, AFP cases and referring to health facility for RI services

·         Health camps in non-compliant communities providing integrated services to address communities’ health needs.

·         Strengthening of AFP reporting networks including informants, and further capacity building and engagement of the surge capacity in surveillance activities. Environmental surveillance established in Maiduguri in spite of the security challenge

·         National EOC trouble-shooting to low performing and stagnant LGAs and holding teleconference/video conference with the state EOCs, and field personnel.

·         Reduction of missed children in underserved hard-to-reach communities

 

Key Risks

  

The ERC however, has identified key risks to achieving polio eradication in Nigeria, as follows:

 

1. Substantial gaps in;
   1. Quality
   2. Security-compromised areas
   3. Accountability
2. Distraction of leadership and administration during preparations for the national elections
3. Gaps in oversight and political commitment
4. Financial risk

 

·         Any relaxation in effort, or failure to fully implement the 2014 NEAP, and in particular, the  distraction of political leaders at Federal, State, and LGA levels as we go into the penultimate year before the elections, will significantly derail the progress being made at this critical stage.

 

·         Persistently poor performing LGAs, with some having declining performance based on LQAs especially in the north west zone post a threat of re-infection

 

·         The continued transmission of WPVs in Bauchi State and Kano State, in particularly, as late as October 2013 poses a great threat of re-infection of the states in North West and North East.

 

·          The continued transmission in security compromised States of Borno and Yobe poses a threat to the goal of stopping transmission in 2014. Borno State has not been able to conduct all the planned rounds in 2013 due to inaccessibility caused by insecurity while Yobe State has not conducted quality rounds due to security concerns. These pose threat of delay in stopping transmission.

 

·         The intense nomadic movements during the low transmission period pose a great risk of polio spread from areas with breakthrough transmission to states that have not reported any case in 2013.

 

Conclusions and Recommendations

 

The ERC carefully considered the epidemiological situation and programme data in developing conclusions and formulating recommendations on actions to interrupt polio transmission in 2014.

 

Although there has been reduction in the geographical restriction of polio transmission in the country with only 4 out of 11 very high risk states infected in 2013, the population immunity is still relatively low with the risk of re-infection of states that have not reported any cases in 2013. Re-infection of these states will be a great set-back to the progress being made and eradication may be delayed.

 

 

The sustained improvement in performance since the last ERC meeting has been the result of concerted efforts by the Government and partners. The tactical changes and improvements in microplanning and monitoring have been coupled with efforts to improve team performance, with efforts to identify and reach underserved communities and with household level communications strategies. All these have been driven by much better oversight at LGA, State, and Federal levels, assisted by new tools and by the information gathering and analysis functions performed by the new EOC. The national programme has been implementing the Emergency Plan for 2013.

 

 

The ERC observes the strong progress that has been made and still convinced that Nigeria has the capacity to stop poliovirus transmission in 2014. However, there are still significant challenges and risks that need to be overcome. These can be overcome despite the challenges, through enhanced oversight by Government at the sub national level; improvements in SIA quality; Accountability and access to children in insecure areas.

 

Recommendations

 

The ERC requests that the recommendations of the 26^th meeting be taken in conjunction with recommendations of previous meetings which remain valid.

 

Overall, there has been improvement in quality of SIAs, reduction in noncompliance due to impact of community-based communications strategy. Also, there has been reduction in missed children in nomadic and underserved communities while environmental surveillance has been established in Maiduguri. There has been improved routine immunization coverage and launching of the National RI Strategic Plan.

 

 

Oversight & Political Support Key for 2014 success

 

As the preparations for national elections heighten in 2014, the programme faces the risk of distraction of political leaders at all levels Consequently, the direct engagement and oversight by State Governors and LGA Chairmen is essential to sustain progress in improving areas, improve stagnating and persistently low performing LGAs, and facilitate access to children for  vaccination in security compromised areas.

 

ERC appreciates the commitment of the President of Nigeria who has shown exemplary leadership in personally chairing the last two meetings of the PTFoPE; commitment of some Governors; the sustained support of the traditional leaders and increasing engagement of religious leaders.

 

ERC recommends that;

• The Presidential Task Force should develop a monthly oversight & advocacy activity plan - to be updated quarterly. This plan should guide advocacy to critical States and LGAs to shore up the dwindling political commitment at the State and LGA levels
• The Presidential Task Force should closely track accountability processes recommended by ERC
•  The Honorable Minister of Health to preside over at least one EOC meeting every month for briefing on progress and challenges.

 

2014 National Emergency Action Plan

 

ERC recommends that;

 

• The 2014 NEAP should be finalized immediately, emphasizing the strategies to ensure quality of SIA; improvements in political oversight and accountability; operational plans for Borno and Yobe and effective management of financial risks.

 

 

Improve quality of IPDs

ERC identifies with the program’s focus on micro-planning; vaccination team selection & performance; reduction in non-compliance and rigorous accountability. ERC therefore recommends that

·         IPDs quality must be improved in the very very high risk (VVHR) and very high risk (VHR) as well as persistently poor performing LGAs while improvement should be sustained in areas with improved performance.

 

Population Immunity in Kano

 

ERC is deeply concerned about the continuing decline in polio sero-prevalence among 3-9 months old infants in Kano. ERC therefore recommends that;

·         The programme should quickly and objectively review the programme, identify the reasons for this decline and report to ERC at its March 2014 meeting.

 

Operating in Insecure Areas

ERC notes the programme’s categorization of LGAs in Borno State according to risk assessment and the operational strategies proposed. The programme should capitalize on the improving access to children in Borno State immediately. ERC recommends that;

·         The national programme should urgently finalize the operational plan for Borno and Yobe States, with clear goals for the next six months,

·         For each of the risk categories, the programme should map and develop specific operational strategies. The plans should include mechanism to monitor and adapt strategies as access evolves.

• Partners and other large public health programs should help finance high impact health and civic services in Borno and other insecure areas in close collaboration with the polio eradication programme.

·         The programme should establish permanent vaccination posts at major transit points

·         The catch-up vaccination activities should be completed by end 2013

 

IPV Use as proposed by the programme

The programme has proposed as Plan B the use of IPV where security has made access difficult. ERC concurs with the technical and strategic rationale for using IPV. ERC recommends that;

 

• Priority should be given to addition of IPV as part of fixed site services in areas where contact with children is intermittent or limited and ensure adequate preparations prior to the introduction.
• Preparations should include:

•         a rapid social research to assess community attitudes and potential acceptance of IPV;

•         a robust communication strategy to ensure demand for both IPV and OPV and management of rumors and

•         detailed operational planning to maximize coverage and ensure adequate vaccine supply.

 

Reducing Non-Compliance & Generating Demand

ERC commends the impact of the VCM network in reducing zero-dose and the work of Religious Focal Persons and notes that the strategies are showing impact. ERC therefore urges the programme to;

 

• Sustain recent community engagement strategies which are showing impact and increase focus on high risk poor performing areas.
• Expand implementation to Borno and Yobe States and tailor to the local context of insecurity & conflict.
• Expand the use of  health camps in priority areas
• Use health centers for health education messaging
• Rapidly deploy new technology & social media to ensure data management, analysis and program messaging.
• Begin as soon as possible the planned polling of communities to access knowledge attitude and practice (KAP) and reasons for missed children as soon as possible.

 

Stopping WPV transmission requires complete and exceptionally rigorous accountability

ERC notes that exceptionally rigorous accountability is essential to stop WPV transmission in 2014. Consequently, the ERC recommends that;

• The programme should update & enforce IPDs Dashboard indicators (e.g. timely release of funds, quality of micro plan, etc)
• The programmes should undertake independent validation of micro-plans, vaccination team selection and track vaccinator substitutions.
• For each IPDs, the programme should independently validate 20% of micro plans in VVHR & VHR LGAs; and 20% of vaccinator selection and track all cases of vaccinator substitution
• Programme should develop a transparent and fair accountability process, with clear responsibilities per accountability framework agreed upon.
• Government and Partner Agencies should respectively hold their staff accountable for their responsibilities.
• Full report on accountability with actions taken, including rewards and sanctions should be documented and reported to the ERC at its next meeting.

 

Managing Financial Risks to the Programme

ERC deeply appreciates the commitment of the President of Nigeria to increase financial support by Government of Nigeria (GoN) to the tune of $50million. ERC has noted with appreciation the support of partners in bridging the financial gaps. However, ERC is deeply concerned by the escalating budget of the programme in Nigeria. Consequently, the ERC recommends that;

 

• The programme and its partners should urgently undertake a review of the budget to identify cost efficiencies with focus on vaccine wastage and supply management and accountability.
• Given concerns about inflated estimates, SIA target population should be estimated based on more accurate house-based micro-plans.

 

SIA Schedule

The ERC notes that in view of the national goal to interrupt transmission of WPV by end 2014, the first six months of the year are most critical. Therefore the objectives of the recommended IPDs schedule for 2014 include (a) interrupting transmission of WPV1 by end 2014; (b) preventing spread to high risk states; (c) sustaining population immunity in other states and (d) conducting mop ups for WPV3 and cVDPV anywhere. The ERC endorses the national programme SIA plan of five week interval between rounds from January to December 2014 and recommends that;

 

• Given the detection and ongoing circulation of WPV1 in Cameroon and noting that it has the same genetic composition with the one detected in Chad in 2012, the programme should undertake a rapid risk assessment to identify areas at risk in the South; establish cross-border vaccination posts and include high risk areas in the planned December round.
• Up to 9 national and sub-national rounds (including special targeted rounds) recommended for 2014:

•         Two of these rounds should be national rounds in March and April

•         Up to 7 of these rounds should be subnational rounds targeting all polio endemic states, 2 of these rounds should target the underserved

•         During the April NIPDs, tOPV should be used in the South and bOPV in the North.

•         tOPV should be used during May and September SIPDs.

•         The selection of areas to be covered and vaccine of choice for August to December 2014 rounds should be reviewed and adapted to the evolving epidemiology.

• Outbreak response (mopping up strategy)

The ERC re-emphasizes its past recommendations on mop-ups and the critical role they are expected to play in preventing re-establishment of poliovirus transmission to polio-free states. It recommends:

 

Vaccine Supply Shortage

 

ERC recommends

 

• That the national programme should endeavor to place orders for vaccine as early as possible; Establish mechanisms to hold logistics working group responsible for vaccine wastage and accountability

 

Surveillance and laboratory

ERC endorses the plan to enhance surveillance in security-compromised areas. ERC recommends that;

• The programme ensures continued improvement of surveillance in identified underserved communities
• Ensure that the national laboratories receive the technical and material support they need to continue to function at the highest possible level of quality
• Positive environmental samples should trigger an immediate investigation and response plan and sampling should continue until site is consistently negative

 

 

Broader Immunization Goals

ERC appreciates the improvements in reported RI coverage and recommends that;

• The improvements reported should be maintained
• ERC encourages the Government and partners to increase their financing for the National RI Strategic Plan
• ERC encourages NPHCDA to conduct independent validation of the reported improvements in RI coverage to identify both well performing and lagging areas.
• The RI capacity building activities should be scaled up beyond the 100 LGAs to include additional high risk LGAs.

 

 

ERC Meetings

Given the critical nature of year 2014 to eradication of polio in Nigeria, ERC proposes to meet in March, July, and October 2014.  Exact dates of meetings will be discussed with the NPHCDA