Polio Outbreak in the Horn of Africa: Best Practices, Lessons Learned, & Innovations

Tuesday, 15th of December 2015

Polio Outbreak in the Horn of Africa: Best Practices, Lessons Learned, & Innovations

Publication Date 2014

Summary below; full text is at http://www.unicef.org/cbsc/files/GPEI_Polio_Outbreak_in_the_Horn_of_Africa_Report_Aug_2015.pdf

"This report...tells a story of government leadership, of engagement and a vibrant partnership between countries and Global Polio Eradication Initiative [GPEI] partners. Other lessons emerging from the Horn range from strengthening routine immunization, importance of reaching mobile and pastoralist populations, adapting to security challenges to sustaining support and momentum for critical communication interventions." - Leila Pakkala, Regional Director, UNICEF Eastern and Southern Africa

This document from the United Nations Childrens Fund (UNICEF) details the communication strategies developed by GPEI partners in the Horn of Africa (HoA) in response to a polio outbreak that presented a set of unique communication challenges - for example, reaching remote and mobile populations and ensuring that religious beliefs did not become a barrier to vaccine acceptance. In each country, a cadre of social mobilisers was trained to engage the community and raise awareness about polio and vaccination. However, strategising on the most effective way to reach mobile nomadic and pastoralist populations required critical thinking, and the initiation of new approaches to outreach.

Many strategies are described in this document, such as: cross-border coordination meetings and campaign synchronisation; the establishment of expanded local networks of social mobilisers; the use of mass media; the engagement of young people; and the commissioning of research studies that have provided evidence-based social data. These strategies were developed in response to the fact that, over the past 18 months (at the time of this writing), the HoA had experienced a polio virus outbreak - transmission of wild poliovirus (WPV) type 1 - which paralysed over 200 children and young adults in Somalia, Kenya, and Ethiopia. Low routine immunisation (RI) coverage across the region, porous borders, and large population movements also left under-immunised children at risk from the virus in Uganda, Sudan, South Sudan, Djibouti, Eritrea, Tanzania, and Yemen. "Much progress has been made with only six wild polio cases detected in 2014, but the possibility of continued transmission, and/or of the failure to detect the virus in remote pastoralist areas of Somalia and Ethiopia, have not been ruled out by polio experts. The outbreak response in the HoA (implemented in eight countries) has been complicated by difficult operational contexts in Somalia and South Sudan, and within the outbreak areas of Kenya and Ethiopia, all posing significant implementation, surveillance and polio communication challenges."

This publication is designed to share "innovations, best practices and lessons with the broader GPEI network, development partners, donors, media entities and the general public. While there are already a number of technical assessments of the Horn of Africa outbreak response, this report represents a first attempt to tell the story of the intense efforts undertaken by GPEI partners to reach over 160 million children in the HoA, and in relation to what remains to be done to ensure that transmission of the virus is halted once and for all. The region still remains at risk..."

It begins with a description of the role that mobile populations play in GPEI effort to ensure that all children who are moving with their families across the vast HoA region receive multiple polio vaccinations. This has required a thorough understanding of population movements at the regional and country level; focused planning to better reach mobile populations; and greater operational flexibility in approaches to vaccination. This challenge is reflected in the GPEI partners 6-month strategy, which involved a series of intensive "house-to-house" polio campaigns. Furthermore, to vaccinate children crossing the borders of high-risk outbreak zones, permanent transit points (PTP) were established. The sensitivity of the surveillance system, including community-based surveillance, was heightened in order to better detect the virus, analyse its path and origin, and possibly predict where it may emerge next.

"When the news of the first case in Somalia broke, partners immediately mobilized and organized the first sub-national vaccination response campaign for Somalia. Recognizing that there were most likely many other cases yet to be discovered in Somalia and neighboring countries, emergency responses were set into motion, resulting in unprecedented multi-country coordination, and in a very short time, the rolling out of a massive public health response. Through advocacy and partnerships with high-level national government officials, local governments, NGOs [non-governmental organisations], private sector entities, mass media, and community and religious leaders, GPEI partners and national governments established the key relationships critical to stopping the virus. Working together at a global, regional and country level resulted in a timely and intensive partner response that stopped transmission quickly at the very epicenter of the outbreak in Banadir. In neighboring Kenya in the same week that Somalia reported its initial case, a steering committee was put into place and the Kenyan government called a high-level meeting to discuss the national response..."

As detailed here, Dadaab, "the worlds largest refugee camp with close to 350,000 registered Somali refugees, was the epicenter of Kenyas polio cases in 2013. Frequent cross-border movements between Kenya and Somalia and low population immunity contributed to fourteen confirmed cases of polio, seven of which originated in the Dadaab camp." In order to boost immunity with the inactivated polio vaccine (IPV), 6 immunisation rounds were held. They were complemented by trainings for health workers and social mobilisers to overcome challenges posed by weak health infrastructure. Intensive social mobilisation activities were then conducted to sensitise communities and caregivers about this new and unknown form of polio vaccine and to inform them about the location of the fixed posts. "Researching community perceptions about IPV and its combined use with the already familiar polio drops [oral polio vaccine, or OPV] was a vital part in gaining information for the communication strategy and subsequent campaigns. Rates of acceptance throughout the campaigns were high, indicating that social mobilization activities, adapted to fit the varying social contexts and norms within the camps, were highly effective. Good coordination between the Kenyan Ministry of Health, UNCHR [United Nations High Commissioner for Refugees], WHO [World Health Organization] and UNICEF played a significant role in successfully carrying out the first time ever co-administered polio vaccination campaign in Kenya. Overall, 120,000 children in the camps and host communities of Garissa County received both oral and injectable polio vaccine in December 2013. Consequently, no polio-virus has since been detected in Kenya."

Radio is one of the tools that has been used to raise public awareness of and demand for polio vaccine in the HoA at the time of outbreak. "Responding to Somalias first polio case, UNICEF, in coordination with GPEI partners, rapidly rolled out a comprehensive communication response. Within a matter of hours, the Government of Somalia declared an outbreak; within 48 hours, radio announcements hit the airways in Mogadishu and South Central Somalia; and, within a few days NGOs [non-governmental organisations] were supported to establish a social mobilization workforce to inform communities about the risks of polio and immediate and up-coming vaccination campaigns. The urgency of the communication response was critical."

The document also includes a section on "Dhibcaha Nolosha" or "Drops for Life" (see Related Summaries below), which involved UNICEF Somalia partnering with BBC Media Action in recognition of the power of radio and its potential to reach populations across borders. On February 7 2014, the BBC aired its first hour-long episode "What is Polio"?, broadcast in the Somali language and reaching Somali listeners in Somalia and in the Somali regions of Ethiopia and northern Kenya. The episode content was informed by focus group discussions with caregivers that revealed some of the most common concerns about polio and the polio vaccine. Noting that misconceptions about OPV also lead some caregivers to believe, for example, that illness caused from the polio virus is a result of the "evil eye" and, as such, it can only be treated with traditional means, not preventive medicine, the "Drops for Life" episode aimed to inform vulnerable populations about the efficacy of the vaccine, and dispel myths at the root of the mistrust. "The educational content and entertaining format of these radio programmes engendered discussion and audience engagement on a range of sensitive issues." Phase II of the project, launched in January 2015, focuses on linkages with RI and other child health messages. The Voice of America Somalia, supported by the United States Center for Disease Control, also rolled out news content and educational and entertainment-framed content to build awareness and to stimulate discussions on polio-related issues across the HoA. "Moving beyond intensive, campaign-focused, public service announcements these interventions generated a deeper level of public discourse on immunization, and helped to amplify the prominence of health issues in the media."

Strategies evolved when the outbreak expandeded in scope and magnitude, in that communication strategies were refined and specifically adapted to high-risk groups as part of the response. For example, approaches evolved to include: establishing communication networks across the region; training and equipping social mobilisers; undertaking social mapping exercises to improve micro-planning; engaging community leaders and influencers to support polio vaccination campaigns; producing and broadcasting radio public service announcements; utilising cross-border communication platforms; and engaging religious leaders as key community mobilisers. Throughout the process, there was also a shift away from focusing exclusively on polio campaign awareness to generating stronger community support, and towards the use of tailored strategies to address specific communication challenges identified through analysis of social and campaign data. In addition, campaign messaging has shifted from a focus only on polio vaccination to include messaging on other key child health interventions, including the importance of RI.

UNICEF notes that: "Understanding the audience is the key to effective communication. What do people know, hear, and feel about polio? How risky do they think is it for their children? Do they know how to prevent polio? What do they know about polio vaccination? Do they think it is safe and effective? Who is the most credible person to speak about health in the community? Getting answers to these and many other questions was needed to inform the development of communications interventions. As a consequence of years of conflict and a general neglect of the social sectors, very little research into health seeking behavior had been undertaken in the region. To fill this gap, UNICEF commissioned a number of studies in Somalia and Ethiopia to capture the thoughts and perceptions of parents and community members about polio and vaccination....Overall, results were encouraging and demonstrated broad public awareness and acceptance of vaccination. Findings were then used to shape messaging addressing specific issues, including, for example, false beliefs that polio is curable. More attention was given to communicating preventive information about polio, including messages that emphasize the vaccine as the only means by which to protect children from the polio-virus. Study results clearly pointed to the need to train health workers and social mobilizers at the community level, but also to the wide reach of short-wave radio stations (a highly regarded and popular source of information among Somali audiences across the HoA), and the mediums effectiveness as a means to disseminate key messages, and polio related information."

The section on innovations and best practices in communication discusses challenges such as the fact that "communicating with mobile populations, which required adapting messages to the social and cultural contexts of nomadic and pastoralist populations. Insecurity and conflict in some parts of Somalia and South Sudan also demanded new and creative ways to engage with communities. Finding innovative ways to engage religious leaders as polio mobilizers was also deemed critical to an effective communication response." Examples of involvement of religious communities in the effort to reach out to Pastoralists in the Somali Region of Ethiopia:

"There is a strong tradition of oral communication among Somali populations, and information is most commonly spread by word of mouth. The dissemination of important messages and information is usually initiated and brokered by clan leaders and other community members of influence, including religious leaders and key cattle market traders. As such, prominent community figures such as these were engaged to communicate polio related messages. Cattle buyers and sellers from rural areas then conveyed these message back their communities."
In 2013, the Regional Health Bureau of the Somali Region of Ethiopia signed a memorandum of understanding with the Islamic Affairs Supreme Council (IASC) that includes collaborative efforts to stop the transmission of polio and to inform and educate the community on how to prevent polio and avail themselves of immunisation services.
UNICEF Somalia used the event of the Hajj (holy pilgrimage) as an opportunity for national advocacy. Campaigns coincided with the launching of the Hajj in September 2013, and polio public service announcements (PSAs) were aired on radio and television, in addition to coverage in the print media before the October, November, and December immunisation rounds. The PSAs included images of male and female pilgrims being administered OPV as a condition to their entry into the country to participate in the Hajj. Pilgrims were also asked to pray for the eradication of polio during their holy journey.

The document describes several ways in which young people have been part of the polio eradication efforts in the HoA. For instance:

"When the Kenyan government learned of the outbreak, they were committed to engaging stakeholders in the community to stop transmission. Community participation was key to raising awareness and reducing the number of missed children. This also included active young members of the community, who were engaged as volunteers and tasked with protecting the children in their communities from polio.... Mtoto Kwa Mtoto, piloted in Nairobi....engage[d] school children to disseminate key messages on polio to their families and neighbors, to identify missed children, and to take action to ensure that children under five years of age are vaccinated....The enthusiastic participation of the students resulted in 15,700 children under five years old being registered and vaccinated. In addition, 384 missed children were identified by the pupils, and were reported to teachers who then relayed the information to vaccination team supervisors. Educators involved in the initiative also increased their knowledge about the polio virus, and now have acquired the skills and knowledge to train other teachers in the areas where the pilot is replicated. UNICEF has since collaborated further with the Kenyan ministries of Health and Education, and expanded the Mtoto kwa Mtoto initiative to Garissa County, the center of the Kenyan outbreak."
"Reaching communities in Turkana is always a challenge. Remote populations, mobile populations and traditional modes of communication all present obstacles to social mobilization in these communities. Given these difficulties, UNICEF, in partnership with the County Ministry of Health devised a strategy to expand the reach of mobilization activities through engaging a group of young people with energy and desire to be a positive force in their communities....First tested in November 2013 in the Turkana Central sub-county, 31 young people participated in the programme resulting in the vaccination of 1,073 children. Building on the success of the first campaign, in April 2014, 57 young people were trained by the County Health Management Team with technical support from UNICEF and WHO on social mobilization and the basics of the polio virus and prevention. Their task was three fold: 1) house to house registration of all children under the age of five in their villages and talking to the caregivers of these children about polio and the importance of vaccination prior to the campaign; 2) monitoring and checking the finger markings of the children they had previously registered after the vaccination teams have passed through; and, 3) informing the village chiefs and elders about children who had missed vaccination in order that vaccination teams could return to vaccinate the missed children. During the pilot phase, 7,831 children were registered, and 132 missed children were identified and subsequently vaccinated"
In May 2011, UNICEF Uganda launched U-Report, a free mobile application aimed at giving Ugandan youth a voice. Research conducted prior to the launch of U-Report showed that 48% of the target population had access to mobile phones. "Combining the power of radio and mobile phones as tools of communication, UNICEF Ugandan polio team utilized the U-Report platform to create awareness and mobilize communities around polio, as well as measure the impact of communication channels used to raise awareness. Radio spots announcing campaign dates were aired in 37 high risk districts throughout the country. In order to measure the impact of these radio spots, UNICEF sent out a poll using U-Report 3 days after the first spot was aired....Six days later, an identical poll was sent out. Results from this poll showed a 20% increase in awareness [of immunisation campaigns] among respondents, and a 21% increase in respondents who identified correct campaign dates. While it is not possible to assess what percentage of information was spread by word of mouth, the increase in knowledge around campaign dates has demonstrated both the effectiveness of radio spots, and of using mobile polling to measure impact."

As highlighted above, there is a role for mobile technology in mapping awareness and sharing knowledge. For example, in partnership with UNICEF and ahead of the November 2013 campaign, the South Sudan Red Cross trained 52 volunteers on the use of a mobile application to conduct household surveys and map immunisation coverage using global positioning system (GPS) coordinates to identify where the surveys had taken place in order to flag missed children and to identify high-risk areas. After social mobilisation activities were conducted, mapping surveys showed that immunisation coverage increased by 10.4%, awareness by 7%, and that the percentage of payams (administrative division) that reported less than 90% coverage decreased by almost 22%. "Pre-campaign community education and awareness of polio campaigns significantly increases immunization coverage during campaign."

The final section of the report provides strategies for maintaining the momentum in the HoA, citing key factors critical to ending WPV transmission, including reaching nomadic populations through prioritising outreach to clan leaders and encouraging community participation within pastoralist populations to sustain their support and their demand for the polio vaccine and RI services.