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Context

Deliberations of the 19 th Meeting of the Expert Review Committee on Polio Eradication in Nigeria (ERC) 22-24 March 2009. Context. 3 rd Quarter 2008. 4 th Quarter 2009. New Tactics in Nigeria: impact of engaging sub-national & local leaders in 2009. Feb: Nigeria's state Governors sign

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  1. Deliberations of the 19th Meeting of the Expert Review Committee on Polio Eradication in Nigeria (ERC)22-24 March 2009

  2. Context

  3. 3rd Quarter 2008 4th Quarter 2009 New Tactics in Nigeria: impact of engaging sub-national & local leaders in 2009 Feb: Nigeria's state Governors sign 'Abuja Commitments on Polio' June: Sultan of Sokoto & traditional leaders constitute Polio Committee

  4. Uttar Pradesh Nov 09 Dec 09 Jan 10 Feb 10 Bihar Feb 10 Jan 10 Nov 09 Dec 09 New Tactics in India: very high population immunity is leading to similar progress! Type 1 immunity in late 2007 vs 2009, West UP

  5. Africa Synchronized Polio Campaign 19 countries; 85 million children 6 Mar & 24 Apr 2010 type 1 type 3 types 1 & 3 Now we have a 'Golden Opportunity' globallyPolio-reporting districts, last 6 months

  6. 'Today, I declare the war against polio in Chad' H.E. the President of Chad M. Idress Deby6 March 2010

  7. Questions to the ERC

  8. Questions What population immunity threshold stops WPV in Nigeria? Is North/South, urban/rural same? What add'l strategies/activities could achieve the population immunity threshold to interrupt WPV? What is the optimal SIA schedule & vaccine(s) for the rest of 2010 to interrupt WPV & cVDPV?

  9. Questions cont’d How can recent IPD quality gains be rapidly applied to routine EPI? How do we balance? Pros & Cons of an extensive ‘mop up’ approach? Could SIA number be reduced in return for better quality in 2nd half of 2010?

  10. Questions cont’d & cont'd…. LQAS: how frequent & how wide? What levels of failure in LQAS prompt a ‘re-do’? What are the key research questions for Nigeria? What is ERC’s self-evaluation at this stage?

  11. Major ERC Findings

  12. ERC Findings (1) Polio & EPI progress since 2009 The ERC is deeply impressed by the progress towards polio eradication & EPI strengthening due to an unprecedented drive co-ordinated by Federal Authorities, led by State Governors & Traditional Leaders, implemented by LGAs and supported by partners!

  13. Most recent polio-paralyzed child was in Kano was on 17 Feb due to the cVDPV2! Polio cases: 2 Infected states: 2 Impact:comparison of polio cases in 2009 & 2010 at 12 March each year, Nigeria 2010 2009 Polio cases: 86 Infected states: 20 Polio cases: 1 Infected states: 1

  14. ERC Findings (2) Population Immunity Thresholds Models using data from Nigerian states show population immunity must be >80% to stop polio. There is no difference in this 'immunity threshold' between north & south Nigeria. The immunity threshold appears to be higher in urban areas (e.g. > 85%).

  15. Estimated Population Immunity Thresholds to Stop Wild Poliovirus Transmission, Nigeria 1997-2009* Serotype 3 >80% population immunity >80% population immunity Serotype 1 * district-year observations (# above each bar); data at Aug; district-years where 10+ NPAFP; mOPV3 efficacy = mOPV1

  16. ERC Findings (3) Population Immunity Thresholds ERC is alarmed that vaccine-induced immunity is not above threshold: • in at least 2 'extremely' high risk states (Kano, Zamfara). • in 85 high risk LGAs in 12 states & FCT. ERC cautions that in these areas, the extremely low virus numbers are only due to a combination of natural immunity & vaccine-immunity.

  17. Vaccine-induced immunity in children 0-4 years 2005- Jun 2009: serotype 1 Persistent VERY High Risk Zone for ongoing polio transmission Type 1 case % of children protected by direct OPV immunisation against type 1 *

  18. 2009 >= 20% 10 - 19% 0 - 9% Persistent sub-optimal population immunity Proportion of Non Polio Cases never vaccinated with OPV State & LGA-level AFP AFP & monitoring data tell you the same thing, but much faster, than fancy models!! Source: National AFP Surveillance Database

  19. ERC Findings (4) Risk of Ongoing Polio & New Importations Nigeria remains at very high risk of polio due to: • undetected poliovirus due to ongoing surveillance gaps as evidenced by orphan viruses & poor AFP-performing LGAs (& anecdotal reports of possible specimen tampering!). • risk of new importations from Chad (as in 2009) and/or Senegal (largest type 1 outbreak so far in 2010!).

  20. Variables associated with outbreaks: Africa 2003-9* • poor population immunity • bordering Nigeria. • movement of people to/from Nigeria. • high proportion of population aged 0-14. THE RISKS OF WILD POLIOVIRUS SPREAD IN AFRICA COULD NOW BE REVERSED! *Imperial College Analysis, Feb 2010 Pattern of wild poliovirus spread, 2003-2009 Importations of Nigeria origin Importations of India origin Endemic countries Countries with outbreak due to imported wild poliovirus

  21. ERC Findings (5) Immunization Systems Strengthening Though routine coverage is still low, ERC recognizes & congratulates the major progress in: • Political attention & resources to routine immunization, • Scrutinizing & beginning to reconcile major data problems, • A multi-pronged approach to both raise coverage & strengthen the underlying system, and • State efforts to achieve rapid gains in reducing the 'unimmunized' (but premature to promote best practices!)

  22. Major ERC Recommendations

  23. Polio Eradication

  24. ERC Recommendations (1.1) Engagement of Political Leaders The ERC strongly supports the tracking & public reporting on the Abuja Commitments and recommends this be implemented quarterly. Given the critical important of Very High Risk LGAs, key indicators should also be reported publicly for these LGAs & Chairmen on a quarterly basis (e.g. functional LGA Task Force, daily LGA mtgs with Chairman).

  25. ERC Recommendations (1.1) Role of Traditional Leaders ERC recognizes & strongly commends the essential role of Traditional Leaders in improving IPD quality through social mobilization, team supervision & addressing non-compliance. ERC requests Traditional Leaders to ensure 100% of Ward & Village Heads play a supervisory role in upcoming IPDs in HR/VHR LGAs & track this closely.

  26. Answer 2: stopping types 1, 2 & 3 poliovirus by end-2010 requires the right mix of (a) campaign schedule, (b) vaccine & (c) SIA quality improvements. (this goal appears feasible!)

  27. ERC Recommendations (2.1) IPD/SIA Schedule & Vaccine of Choice tOPV in Child Health Week (CHW) bOPV (high risk) bOPV/mOPV (high risk) tOPV?/bOPV (Kano & very high risk areas) Jul Aug Sept Oct Nov Dec Apr May Jun

  28. ERC Recommendations (2.2) IPD/SIA Schedule & Vaccine of Choice Any WPV or cVDPV must now trigger mop-ups! Mop-ups are additive to the larger SIA schedule & cannot replace IPDs. Replacing IPDs with mop-ups would be highly risky, as seen in Pakistan & India in the early 2000s where a shift to mop-ups contributed to large outbreaks.

  29. ERC Recommendations (2.3) IPD Schedule & Choice of Vaccine (cont'd) IPDs in 1st half of 2011 • 2 sub National IPDs in highest risk areas. • 2 nationwide IPDs (consideration should be given to aligning activities with measles campaigns & CHWs).

  30. ERC Recommendations (3.1) Improving IPD Quality = Very High Risk LGAs VHR & HR LGAs are different! LGA-specific plans, LGA Chairmen oversight & Task Forces are essential for April IPD! For these areas Traditional Leaders should aim for supervisory role by 100% of Ward & Village Heads. These areas should be targeted for the high impact social mobilization activities (e.g. Majigi films, IPC).

  31. Reasons for missed childrenMarch 2010 IPDs 34 VHR LGAs Other LGAs ERC Recommendations (3.2) Improving IPD Quality = Very High Risk LGAs! Proportion of wards with > 10% missed children HR LGAs (51 LGAS) VHR LGAs (34 LGAs)

  32. ERC Recommendations (3.3) Improving IPD Quality – Social Mobilization The ERC is impressed with the range & of the scope of social mobilization activities and recommends: • mass awareness raising activities (eg. media, celebrities), must now be complemented with specific, tailored approaches for the VHR & HR areas, and • clear parameters/indicators should be established for 'scaling-up' specific communications interventions, esp. in HR/VHR wards, and reported out at the next ERC.

  33. ERC Recommendations (4.1) Monitoring the Quality of IPDs & Mop-ups Independent monitoring should be the standard for monitoring IPD quality. At this critical point, any area in a with <90% in a High Risk State should be recovered & reported immediately & tracked at both state & Federal levels. LQAS should be reserved for any LGA that poses a particular risk to national health security (see criteria).

  34. Sufficient missed children to sustain polio transmission Comparison of Independent Monitoring & LQAS Results, Nov 2009 IPD, Nigeria) IM (Inside) IM (Outside) LQAS

  35. ERC Recommendations (4.2) Monitoring the Quality of IPDs & Mop-ups Primary criteria for use of LQAS: • HR/VHR LGAs with inconsistent IPD performance data (e.g. NPAFP cases vs. IM data; strong anecdotal reports; coverage vs. epidemiologic data). • urban & peri-urban HR/VHR LGAs (due to higher risk of persistent transmission). • re-infected areas (WPV or cVDPV).

  36. ERC Recommendations (5) Surveillance & Lab Priorities Further analyze existing data (within 1 month): for HR/VHR areas (a) scrutinize Sabin & NPEV trends, (b) analyze trend in Sabin excretion rates, (c) analyze history of orphan viruses. Generate new data: environmental surveillance (Kano, Maidiguri), seroprevalence survey (e.g. high priority for Kano). Establish mechanism to validate authenticity of stool samples. The 1st priority for surveillance strengthening should be any HR or VHR LGA areas with orphan viruses.

  37. Immunization Systems

  38. ERC Recommendations (1.1) Immunization System – Overall Strategy ERC stresses importance of dual approach that raises coverage and strengthens the immunization system: • Raising coverage: ERC endorses the Child Health Weeks, 2 times per year. • Systems strengthening: fully implement Reaching Every Ward (REW) strategy; infrastructure plan (cold chain, transport); vaccine forecasting; HR mapping & sessions monitoring. • Targets: align national targets with National Strategic Health Development Plan (NSHDP).

  39. Child Health Weeks: the package Nutrition Vit A, De-worming, MUAC screening Immunization OPV, DPT/HepB, MV LLIN Distribution Care for Pregnant Women TT, SP for IPT, Fe/Folate Health Education KHHP, Hand washing nphcda

  40. ERC Recommendations (1.2) Immunization System – Overall Strategy ERC further recommends: • State Task Forces: state & LGA polio Task Forces should be expanded by end-2010 to include full immunization agenda. • Financing: every State & LGA should have a budget line item for routine immunization; this should be tracked at State & Federal levels. • Traditional Leaders: should be invited by State/LGA authorities to systematically promote & support the broader immunization agenda, building on their very successful role in polio eradication.

  41. ERC Recommendations (2) Immunization System - Data

  42. ERC Recommendations (2) Immunization System - Data The ERC is impressed with the particular attention being given to reconciling the major (& ongoing!) data quality problems. • Data Quality Self-Assessment (DQS): the limitations of this tool must be clearly understood so that it can be applied appropriately. • Data Quality Checks (DQC): supplement vaccine data with systems capacity & performance data (e.g. human resources, facilities, completeness of planned & outreach sessions). DHS and similar data are the gold standard for assessing immunization performance, and should guide further improvements to data collection & accuracy!

  43. ERC Recommendations (3) Immunization System – Service Delivery REW Strategy: states should complete & prioritized plans for implementation based on (a) HR and VHR LGAs, and (b) the number of unimmunized children. The '1,2, 3 Strategy': ERC endorses the strategy of implementing and monitoring • 1 routine session/week in all Health Centers, • 2 outreach sessions/week from all Health Centers, and • 3 LGA-level supervisory visits/month of each HC's activities.

  44. ERC Recommendations (4) Immunization System – Infrastructure • Vaccine management • Cold chain • Facilities • Human resources • Transport Issue-specific recommendations in the main ERC Report

  45. Accelerated Disease Control & Other Issues

  46. ERC Recommendations (1) Accelerated Disease Control The full agenda of ADC activities must be included in NPHCDA's multi-year plan to optimize coordination across the broad range of SIAs now being promoted in Nigeria. ERC welcomes the Special Measles Consultation & requests to be informed of the outcomes to guide ERC's work; if possible, such meetings should be held before the ERC in future.

  47. ERC Recommendations (2) Research Priorities ERC notes & endorses NPHCDA's Special Consultation on Polio Research Priorities, requesting: • the deliberations, findings and recommendations be shared with the ERC within 10 days, and • rapid attention be given to implementing the major recommendations & reporting on these to the ERC.

  48. ERC Recommendations (3) Self-Evaluation NPHCDA should review the ERC with particular attention to: • reducing overlapping &/or over-represented expertise. • addressing potential gaps in critical expertise (e.g. health systems, communications). • reconciling real or perceived conflicts of interest (e.g. due to potential for self-evaluation). • ensuring full delineation & application of rules of procedure, membership, terms, etc.

  49. There is much too celebrate….but remember! Within the past 4 months, Nigerian children have still been paralyzed by a type 1, 2 & 3 poliovirus!

  50. Everyone must do the extra-ordinary to 'END POLIO NOW'!

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