Lessons from Nigeria’s Delivery of Polio Vaccinations in Conflict Regions

Background

In 1988, the World Health Organization (WHO) declared polio its next eradication target. Since then, the global partnership aimed at polio eradication has become one of the world’s largest public-private partnerships. This has led to the successful elimination of the wild poliovirus in all but three countries: Nigeria, Afghanistan, and Pakistan. Borno State, where the last wild poliovirus cases in Nigeria were found, has been faced with severe conflict and insecurity for several years. This insecurity has hindered the provision of health services due to the destruction of health facilities, limitation of intra-state movement and displacement of health workers.

Nigeria came close to being declared polio-free in September 2016, but 3 cases of WPV were isolated from individuals who have recently escaped previously inaccessible locations in the state. The findings did not surprise many experts, who feared that wild polio, though not being found in much of the country, was likely lurking in inaccessible populations who had not been reached with vaccines for years.

In response to this particular situation in Borno, Borno State Government, GPEI partners and various security agencies devised innovations to expand polio eradication activities to security compromised areas. Again, Nigeria is on its way to being declared polio-free, but all stakeholders remain on high alert, learning from the previous resurgence.

Regardless, enormous progress has been made in the fight against polio in this last frontier, and valuable lessons have been learned that can impact the way health and other humanitarian services are delivered in regions of conflict-induced insecurity across the world. This will be important, as conflict and insecurity remain rife in many parts of the world, including Syria, Yemen and Afghanistan, causing mass displacement of populations and situations often requiring delivery of humanitarian services in dangerous circumstances.

GPEI Innovations to Circumvent Insurgency in Borno

The goal of the Global Polio Eradication Initiative (GPEI) is the complete eradication and containment of all wild, vaccine-related and Sabin polioviruses. GPEI Polio Endgame Strategy comprises rests on four pillars; the use of supplementary immunization activities (SIAs), routine immunization, active surveillance activities and mop-up campaigns. In our context, SIAs differ from mop-up campaigns as the former is conducted as a synchronised national exercise targeted at every child under five years of age regardless of location and/or immunisation status while the latter is conducted only in areas where the poliovirus is known or suspected to still be in circulation. Priority areas for mop-up campaigns include regions where cases have been reported in the preceding three years and access to healthcare is limited. Also considered are areas with high population density, high human traffic, poor sanitation and low routine immunization coverage.

The government works with GPEI partners – WHO, Rotary International, CDC, UNICEF, Bill and Melinda Gates Foundation, and other non-governmental organizations, to implement the various agreed strategies for polio eradication. The generally accepted strategies are used in all safe areas of Borno however, polio eradication interventions had to be tailor-made for the security compromised areas of the state

Borno State Security Context

The conflict and security tensions in Borno state result from the uprising of Jama’ah al-Ahlu al-Sunnah Li al-Da’wah wa al-Jihad commonly known as Boko Haram, a terrorist organization founded in 2002 as a peaceful local Salafist Islamic movement aimed at preaching and assisting the needy (Shuibu, Salleh and Shehu, 2015) Their activities however, took a violent turn in 2009 (Umar 2012) and, since then has involved:

• Capturing of communities, and declaring them territories while keeping the community members as hostages as in the case of Gwoza LGA which was captured by the terrorist group in August 2014 and declared headquarters of the Islamic Caliphate by the now-deceased leader of the group Abubakar Shekau (Malik 2015)
• Attacking schools, killing teachers and abducting pupils. In the past nine years, over 2,295 teachers have been killed and 1,400 schools destroyed (UNICEF 2018, online resource).
• Frequent terror attacks on military formations and other government facilities across the state to hinder the delivery of services
• In Borno, there are no safe havens or passageways where essential services can be delivered as done in some conflict regions such as Syria. This is as a result of Boko Haram’s ideological aversion to western education and consequently modern medicine (Shuaibu and Salleh, 2015). Similar to happenings in other conflict regions, regular activities have been destabilized across the state:
• Restriction of movement within the state as certain major roads have become too dangerous to ply due to land-mines and insurgent ambushes
• Massive displacement of health providers and other skilled workers from security-compromised areas to more secure locations
• Large-scale destruction of public infrastructure, including health facilities, and private property

To combat this insurgency, the Nigerian Army started a special operation - “Operation Lafiya Dole” and deployed troops to various locations across the state. The government also supported local vigilante groups to complement the activities of the military in combating the insurgency. These groups are known collectively as the civilian joint task force (cJTF).

The polio program in Borno has been working with the different bodies to reach these children and have done so despite the dynamic situation of things in Borno.

Description of GPEI Innovations in Borno

• In Borno, certain innovations were developed to address immunization and surveillance activities in security-compromised areas.
• The innovations primarily born include the Reaching Every Settlement (RES) initiative in areas with mild to moderate security threat, while the Buratai Initiative/Reaching Inaccessible Children (RIC) targeted the very high-security risk settlements. Also, vaccination teams were stationed across transit locations
• Working at settlement level and settlement categorization
• To ensure that every child was vaccinated and to avoid duplication of efforts by any strategy, all settlements in Borno were fell into three distinct classes depending on their accessibility to the polio program
• Accessible settlements are those that can be reached by civilian vaccination teams without security cover. These settlements implement the IPD strategy
• Partially accessible settlements can only be visited by immunization teams with security cover, most often cJTF. This class of settlements implement the RES strategy
• Inaccessible settlements cannot be reached by civilians and all services must be provided by the military. In these settlements, the RIC strategy has been deployed.

Reaching Every Settlement (RES) strategy was developed in October 2016 to reach children trapped in communities that were inaccessible to civilian vaccination teams. The RES strategy involved the use of local vigilante groups known as civilian Joint Task Force (cJTF) to conduct vaccination services after training or provide security cover to the civilian vaccination teams depending on the level of threat. The strategy was conducted in rounds each lasting about four weeks.

Reaching Inaccessible Children (RIC) strategy was co-developed with the Nigerian military in March 2017. As part of the RIC strategy, military personnel are trained and deployed to vaccinate children. RIC activities are conducted in rounds. These rounds begin with micro-planning, during which settlements are selected based on the capacity of implementing teams and the security/habitation status (based on satellite imagery or field team feedback) of each of the settlements outlined.

Once planning is completed and logistics and vaccine supplies are secured, implementation commences over a predetermined period. Technical support is provided to the implementing teams in terms of pre-implementation and on-the-job training on the use of the various tools deployed during RIC operations. In addition to technical support, the SPHCDA, through the Borno EOC, provides strategic oversight and maintains advocacy to the military hierarchy to ensure the proper coordination of RIC operations. As part of the military support to RIC operations, local vigilante groups also are added to implementing teams to leverage their knowledge of the local terrain. Vaccination in inaccessible settlements depends on the realities on the field; children in inhabited settlements could either be vaccinated at the settlement location or evacuated from location found, whereas, at abandoned settlements, geo-evidence of a visit alone is collected. Inhabited settlements are revisited 5 times except in cases where the inhabitants are subsequently evacuated.

Results

The RES initiative targeted 99% of all partially accessible settlements in the states. After 22 rounds of implementing RES in Borno state, 99.9% (4,327 of 4,332) of settlements were visited vaccinating an estimated 279,994 children. Following the completion of five-plus contacts in more than 90% of all the partially accessible settlements, implementation of vaccination in the 5,000+ RES settlements was transitioned to Borno State Primary Health Care Development Agency and WHO in June 2018. The RIC initiative targeted 90% of all inaccessible settlements in the states. As at April 2019, 11 rounds of RIC have been implemented across 4,465 inaccessible settlements with an estimated 109,708 children vaccinated in Borno state. However, there are still an estimated 43,507 children spread across 2,391 unreached settlements

Lessons from the Borno Experience

• Important to respond quickly and nimbly, due to the rapidly evolving security situation with migrating populations. Think about rapid shifts in both security situation and populations – RES example, plan was to do 5 rounds but after that, we realized we may not be achieving real herd immunity because folks were on the move, so different children reached each time.
• Proper response coordination among all stakeholders is critical. Important to have all partners and government working as one, with the government as the lead in this case. No silos or parallel implementation. Food programs, health programs, etc all offer a platform to deliver polio vaccines to people
• Partnership with the military and other security apparatuses is key – in this case cjtf, police, military - to understand their limitations and make sure they understand program goals and how they fit in. align objectives. Need to be sure health program does not compromise the ability of the military to do their primary job – keep people safe. Else there will be conflict.
• Planning is best done at the decentralized, local level. Planning and implementation must be at the micro-level to the extent practicable. In this case, initially lined up against the political LGA and ward system, working at LGA, and even ward level revealed that there are large swaths of opportunity being missed within LGAs and even wards.
• Data is key – real-time visibility into progress – where are teams going, how many are being vaccinated and how does that stack up against goals. Up to date harmonization of settlements, line listings were crucial for all implementers to work with
• Also use of technology, GPS trackers for teams, Satellite imaging to map settlements and estimate populations etc

Rapid mobilization of resources – logistics costlier in times of conflict and security problems, as well as emergency responses. These two factors raise the cost but must be deployed. Resources must, however, be managed quite rigorously and efficiently to ensure that there is minimal wastage

Conclusion

The nature of armed conflict has continued to evolve but its negative effects are as reaching as ever. Lessons learnt from the health system strengthening efforts in this context especially in the polio endgame will remain significant. This paper contributes to the domain of knowledge by sharing vital lessons learnt from successful efforts to eradicate polio in conflict-affected northeast Nigeria.