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Stop Transmission of Polio (STOP) Katsina State, Nigeria 21 June 2011 Richard Niska, MD, MPH CAPT, USPHS CDC STOP-33 Consultant

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Goals of this presentation To describe efforts of the Stop Transmission of Polio (STOP) program Focus on 2 local government areas (LGA) in the state of Katsina, Nigeria Collaborative effort among: World Health Organization (WHO) Centers for Disease Control and Prevention (CDC) Rotary International

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Objectives At the end of this session, participants will be able to describe activities, issues and recommendations in Nigeria concerning: 1.Routine immunization 2.Acute flaccid paralysis surveillance 3.Polio eradication

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Nigeria http://www.state.gov/r/pa/ei/bgn/2836.htm http://www.state.gov/r/pa/ei/bgn/2836.htm Population (2010): 152 million 250 ethnic groups, largest are: Hausa-Fulani Igbo Yoruba Religions: Muslim Christian indigenous Languages: English (official) Hausa Fulani others Life expectancy (2010): 47 years

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Katsina http://en.wikipedia.org/wiki/Katsina_State http://en.wikipedia.org/wiki/Katsina_State Population (2010): 3.9 million Main ethnic group: Hausa-Fulani Predominant religion: Muslim Languages: English Hausa Fulani

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Background STOP participants serve as consultants for: Monitoring routine immunization programs: WHO Expanded Program of Immunizations (EPI) Ongoing surveillance: Acute flaccid paralysis Polio eradication: Preparation for supplemental oral polio vaccine campaigns Program assessment, supervision and training

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Summary of Activities: Routine immunizations (RI) Monitoring of 4 health centers in Batsari & Safana local government areas (LGA) Debriefing of local and LGA staff Training topics identified

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Major Issues Identified: Routine Immunization Low volume (0-13 immunization candidates per half day) Effective organization of work space Unsafe clinical practices (used medical equipment left out)

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Major Issues Identified: Routine Immunization High-risk sharps disposal practices Incomplete burning of medical waste

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Recommendations: Routine Immunization Increase outreach efforts to encourage full immunization schedule in time allotted. Use bed nets as incentives for completion of DPT-3 during RI rather than just giving them out during IPD. Encourage organized immunization station setup in training sessions. Add burial after burning to sharps (and other medical waste) disposal procedure.

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Summary of Activities: AFP surveillance Verified or followed up on 11 AFP cases in Batsari and Safana LGAs

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Summary of Activities: AFP surveillance Ruled out paralysis in several more cases

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Major Issues Identified: AFP Surveillance Excellent non-polio surveillance efforts Surveillance rates exceed WHO standards for polio-endemic countries. Good stool collection performance

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Recommendations: AFP Surveillance Continuous training of LGA health personnel in correct assessment of AFP Reinforce correct injection techniques (i.e. not in buttocks) to prevention injection neuropathies.

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Summary of Activities: Polio Eradication Met with traditional leaders at district and village levels to encourage involvement Conducted training sessions for campaign #2 to reflect observations in campaign #1 Extensive field work during campaigns in remote villages and nomadic settlements

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Performance by Batsari LGA wards in March IPD round

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Performance by Safana LGA wards in March IPD round

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Practices improving performance (Social mobilization) Participation in flag- off by traditional leaders and wives Location chosen by high risk status General health messages reinforced to mothers by district heads wife

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Practices improving performance (Social mobilization) Active participation of task force members in supervision and resolving noncompliance Plan was to resolve non-compliances the next day But many were actually resolved the same day

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Practices improving performance (Social mobilization) Availability of pluses Mosquito bed nets for pregnant women Candy for kids

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Practices improving performance (Operational) Finding new settlements (Fulani) Immediate mop-ups on day 5 for: Wards not reaching 90% coverage Settlements not reached in any ward

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Barriers to improved performance

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Barriers to better performance (Team factors) Interpersonal communication (IPC) skills of teams Male recorders (cant enter households) Training male supervisors in role-plays But not female vaccinators in back of room

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Barriers to better performance (Timing) Fatigue and hardship for vaccinators Households and communities not visited Vaccination teams finishing just after noon Husbands not present till late afternoon Children absent from home

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Barriers to better performance (Documentation) Not recording noncompliant households Not recording absent children Not marking households appropriately Not tallying as vaccinations are done Not reporting acute flaccid paralysis (AFP)

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Noncompliance or child absent? Noncompliance or child absent?

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Way forward! (Social mobilization) Engagement of traditional leaders Advance mobilization of husbands Resolve non- compliance before it happens Town criers

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Way forward! (Training) Selection of high quality team and supervisors Local trusted people Recorders should be able to read Better supervisor training Use IPC training guide and WHO procedures Use women trainers to train vaccinators

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Way forward! (Training) Improved training quality Less use of lectures More practical demonstrations Involve female vaccinators in role-plays

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Way forward! (Training) Incorporate ethical teaching To address false reporting of non- compliance, house- marking, etc. To reassure population that religious leaders support immunization

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Way forward! (Operational) Plan for high workloads to prevent hurried work Separate morning and afternoon shifts with different teams Revisit strategy

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Mongode!