Outcomes of the Deployment of the Auto-Visual Acute Flaccid Paralysis Detection and Reporting (AVADAR) System for Strengthening Polio Surveillance in Africa From 2017 to 2018: Evaluation Study.

BACKGROUND: As we move toward a polio-free world, the challenge for the polio program is to create an unrelenting focus on smaller areas where the virus is still present, where children are being repeatedly missed, where immunity levels are low, and where surveillance is weak. OBJECTIVE: This article aimed to describe a possible solution to address weak surveillance systems and document the outcomes of the deployment of the Auto-Visual Acute Flaccid Paralysis Detection and Reporting (AVADAR) project. METHODS: This intervention was implemented in 99 targeted high-risk districts with concerns for silent polio circulation from eight countries in Africa between August 1, 2017, and July 31, 2018. A total of 6954 persons (5390 community informants and 1564 health workers) were trained and equipped with a smartphone on which the AVADAR app was configured to allow community informants to send alerts on suspected acute flaccid paralysis (AFP) and allow health worker to use electronic checklists for investigation of such alerts. The AVADAR and Open Data Kit ONA servers were at the center of the entire process. A dashboard system and coordination teams for monitoring and supervision were put in place at all levels. RESULTS: Overall, 96.44% (24,142/25,032) of potential AFP case alerts were investigated by surveillance personnel, yielding 1414 true AFP cases. This number (n=1414) reported through AVADAR was higher than the 238 AFP cases expected during the study period in the AVADAR districts and the 491 true AFP cases reported by the traditional surveillance system. A total of 203 out of the 1414 true AFP cases reported were from special population settings, such as refugee camps and insecure areas. There was an improvement in reporting in silent health areas in all the countries using the AVADAR system. Finally, there were 23,473 reports for other diseases, such as measles, diarrhea, and cerebrospinal meningitis, using the AVADAR platform. CONCLUSIONS: This article demonstrates the added value of AVADAR to rapidly improve surveillance sensitivity. AVADAR is capable of supporting countries to improve surveillance sensitivity within a short interval before and beyond polio-free certification.

Using the polio programme to deliver primary health care in Nigeria: implementation research.

Objective: To evaluate a project that integrated essential primary health-care services into the oral polio vaccine programme in hard-to-reach, underserved communities in northern Nigeria. Methods: In 2013, Nigeria's polio emergency operation centre adopted a new approach to rapidly raise polio immunity and reduce newborn, child and maternal morbidity and mortality. We identified, trained and equipped eighty-four mobile health teams to provide free vaccination and primary-care services in 3176 hard-to-reach settlements. We conducted cross-sectional surveys of women of childbearing age in households with children younger than 5 years, in 317 randomly selected settlements, pre- and post-intervention (March 2014 and November 2015, respectively). Findings: From June 2014 to September 2015 mobile health teams delivered 2 979 408 doses of oral polio vaccine and dewormed 1 562 640 children younger than 5 years old; performed 676 678 antenatal consultations and treated 1 682 671 illnesses in women and children, including pneumonia, diarrhoea and malaria. The baseline survey found that 758 (19.6%) of 3872 children younger than 5 years had routine immunization cards and 690/3872 (17.8%) were fully immunized for their age. The endline survey found 1757/3575 children (49.1%) with routine immunization cards and 1750 (49.0%) fully immunized. Children vaccinated with 3 or more doses of oral polio vaccine increased from 2133 (55.1%) to 2666 (74.6%). Households' use of mobile health services in the previous 6 months increased from 509/1472 (34.6%) to 2060/2426(84.9%). Conclusion: Integrating routine primary-care services into polio eradication activities in Nigeria resulted in increased coverage for supplemental oral polio vaccine doses and essential maternal, newborn and child health interventions.

Using the polio programme to deliver primary health care in Nigeria: implementation research

Objective To evaluate a project that integrated essential primary health-care services into the oral polio vaccine programme in hard-toreach, underserved communities in northern Nigeria.Methods In 2013, Nigeria's polio emergency operation centre adopted a new approach to rapidly raise polio immunity and reduce newborn, child and maternal morbidity and mortality. We identified, trained and equipped eighty-four mobile health teams to provide free vaccination and primary-care services in 3176 hard-to-reach settlements. We conducted cross-sectional surveys of women of childbearing age in households with children younger than 5 years, in 317 randomly selected settlements, pre- and post-intervention (March 2014 and November 2015, respectively). Findings From June 2014 to September 2015 mobile health teams delivered 2 979 408 doses of oral polio vaccine and dewormed 1 562 640 children younger than 5 years old; performed 676 678 antenatal consultations and treated 1 682 671 illnesses in women and children, including pneumonia, diarrhoea and malaria. The baseline survey found that 758 (19.6%) of 3872 children younger than5 years had routine immunization cards and 690/3872 (17.8%) were fully immunized for their age. The endline survey found 1757/3575 children (49.1%) with routine immunization cards and 1750 (49.0%) fully immunized. Children vaccinated with 3 or more doses of oral polio vaccine increased from 2133 (55.1%) to 2666 (74.6%). Households' use of mobile health services in the previous 6 months increased from 509/1472 (34.6%) to 2060/2426(84.9%). Conclusion Integrating routine primary-care services into polio eradication activities in Nigeria resulted in increased coverage for supplemental oral polio vaccine doses and essential maternal, newborn and child health intervention

AVADAR (Auto-Visual AFP Detection and Reporting): demonstration of a novel SMS-based smartphone application to improve acute flaccid paralysis (AFP) surveillance in Nigeria.

BACKGROUND: Eradication of polio requires that the acute flaccid paralysis (AFP) surveillance system is sensitive enough to detect all cases of AFP, and that such cases are promptly reported and investigated by disease surveillance personnel. When individuals, particularly community informants, are unaware of how to properly detect AFP cases or of the appropriate reporting process, they are unable to provide important feedback to the surveillance network within a country. METHODS: We tested a new SMS-based smartphone application (App) that enhances the detection and reporting of AFP cases to improve the quality of AFP surveillance. Nicknamed Auto-Visual AFP Detection and Reporting (AVADAR), the App creates a scenario where the AFP surveillance network is not dependent on a limited number of priority reporting sites. Being installed on the smartphones of multiple health workers (HWs) and community health informants (CHIs) makes the App an integral part of the detection and reporting system. RESULTS: Results from two phases of tests conducted in Nigeria point to the effectiveness of the App in the surveillance of AFP. CONCLUSION: We posit that appropriate use of the App can soon bring about a worldwide eradication of poliomyelitis.

The Public Health Legacy of Polio Eradication in Africa.

The legacy of polio in Africa goes far beyond the tragedies of millions of children with permanent paralysis. It has a positive side, which includes the many well-trained polio staff who have vaccinated children, conducted surveillance, tested stool specimens in the laboratories, engaged with communities, and taken care of polio patients. This legacy also includes support for routine immunization services and vaccine introductions and campaigns for other diseases. As polio funding declines, it is time to take stock of the resources made available with polio funding in Africa and begin to find ways to keep some of the talented staff, infrastructure, and systems in place to work on new public health challenges. The partnerships that helped support polio eradication will need to consider funding to maintain and to strengthen routine immunization services and other maternal, neonatal, and child health programs in Africa that have benefitted from the polio eradication infrastructure.

Mass immunization with inactivated polio vaccine in conflict zones--Experience from Borno and Yobe States, North-Eastern Nigeria.

The use of Inactivated Polio Vaccine (IPV) in routine immunization to replace Oral Polio Vaccine (OPV) is crucial in eradicating polio. In June 2014, Nigeria launched an IPV campaign in the conflict-affected states of Borno and Yobe, the largest ever implemented in Africa. We present the initiatives and lessons learned. The 8-day event involved two parallel campaigns. OPV target age was 0-59 months, while IPV targeted all children aged 14 weeks to 59 months. The Borno state primary health care agency set up temporary health camps for the exercise and treated minor ailments for all. The target population for the OPV campaign was 685,674 children in Borno and 113,774 in Yobe. The IPV target population for Borno was 608,964 and for Yobe 111,570. OPV coverage was 105.1 per cent for Borno and 103.3 per cent for Yobe. IPV coverage was 102.9 per cent for Borno and 99.1 per cent for Yobe. (Where we describe coverage as greater than 100 per cent, this reflects original underestimates of the target populations.) A successful campaign and IPV immunization is viable in conflict areas.

Progress toward poliomyelitis eradication in Nigeria.

BACKGROUND: Transmission of wild poliovirus (WPV) has never been interrupted in Afghanistan, Pakistan, and Nigeria. Since 2003, infections with WPV of Nigerian origin have been detected in 25 polio-free countries. In 2012, the Nigerian government created an emergency operations center and implemented a national emergency action plan to eradicate polio. The 2013 revision of this plan prioritized (1) improving the quality of supplemental immunization activities (SIAs), (2) implementing strategies to reach underserved populations, (3) adopting special approaches in security-compromised areas, (4) improving outbreak response, (5) enhancing routine immunization and activities implemented between SIAs, and (6) strengthening surveillance. This report summarizes implementation of these activities during a period of unprecedented insecurity and violence, including the killing of health workers and the onset of a state of emergency in the northeast zone. METHODS: This report reviews management strategies, innovations, trends in case counts, vaccination and social mobilization activities, and surveillance and monitoring data to assess progress in polio eradication in Nigeria. RESULTS: Nigeria has made significant improvements in the management of polio eradication initiative (pei) activities with marked improvement in the quality of SIAs, as measured by lot quality assurance sampling (LQAS). Comparing results from February 2012 with results from December 2013, the proportion of local government areas (LGAs) conducting LQAS in the 11 high-risk states at the ≥90% pass/fail threshold increased from 7% to 42%, and the proportion at the 80%-89% threshold increased from 9% to 30%. During January-December 2013, 53 polio cases were reported from 26 LGAs in 9 states in Nigeria, compared with 122 cases reported from 13 states in 2012. No cases of WPV type 3 infection have been reported since November 2012. In 2013, no polio cases due to any poliovirus type were detected in the northwest sanctuaries of Nigeria. In the second half of 2013, WPV transmission was restricted to Kano, Borno, Bauchi, and Taraba states. Despite considerable progress, 24 LGAs in 2012 and 7 LGAs in 2013 reported ≥2 cases, and WPV continued to circulate in 8 LGAs that had cases in 2012. Campaign activities were negatively impacted by insecurity and violence in Borno and Kano states. CONCLUSIONS: Efforts to interrupt transmission remain impeded by poor SIA implementation in localized areas, anti-polio vaccine sentiment, and limited access to vaccinate children because of insecurity. Sustained improvement in SIA quality, surveillance, and outbreak response and special strategies in security-compromised areas are needed to interrupt WPV transmission in 2014.

Achieving polio eradication: a review of health communication evidence and lessons learned in India and Pakistan.

Since 1988, the world has come very close to eradicating polio through the Global Polio Eradication Initiative, in which communication interventions have played a consistently central role. Mass media and information dissemination approaches used in immunization efforts worldwide have contributed to this success. However, reaching the hardest-to-reach, the poorest, the most marginalized and those without access to health services has been challenging. In the last push to eradicate polio, Polio Eradication Initiative communication strategies have become increasingly research-driven and innovative, particularly through the introduction of sustained interpersonal communication and social mobilization approaches to reach unreached populations. This review examines polio communication efforts in India and Pakistan between the years 2000 and 2007. It shows how epidemiological, social and behavioural data guide communication strategies that have contributed to increased levels of polio immunity, particularly among underserved and hard-to-reach populations. It illustrates how evidence-based and planned communication strategies - such as sustained media campaigns, intensive community and social mobilization, interpersonal communication and political and national advocacy combined - have contributed to reducing polio incidence in these countries. Findings show that communication strategies have contributed on several levels by: mobilizing social networks and leaders; creating political will; increasing knowledge; ensuring individual and community-level demand; overcoming gender barriers and resistance to vaccination; and reaching out to the poorest and marginalized populations. The review concludes with observations about the added value of communication strategies in polio eradication efforts and implications for global and local public health communication interventions.