Deliberations of the 19 th Meeting of the Expert Review Committee on Polio Eradication in Nigeria (ERC) March 2009

Context

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

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

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

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

Questions to the ERC

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?

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 2 nd half of 2010?

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?

Major ERC Findings

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! ERC Findings (1) Polio & EPI progress since 2009

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

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%). ERC Findings (2) Population Immunity Thresholds

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

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. ERC Findings (3) Population Immunity Thresholds

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

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

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!). ERC Findings (4) Risk of Ongoing Polio & New Importations

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

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!) ERC Findings (5) Immunization Systems Strengthening

Major ERC Recommendations

Polio Eradication

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). ERC Recommendations (1.1) Engagement of Political 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. ERC Recommendations (1.1) Role of Traditional Leaders

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!)

JulSeptOctAugNovDec ERC Recommendations (2.1) IPD/SIA Schedule & Vaccine of Choice tOPV in Child Health Week (CHW) MayJunApr bOPV/mOPV (high risk) bOPV (high risk) tOPV?/bOPV (Kano & very high risk areas)

Any WPV or cVDPV must now trigger mop-ups! ERC Recommendations (2.2) IPD/SIA Schedule & Vaccine of Choice 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.

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

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). ERC Recommendations (3.1) Improving IPD Quality = Very High Risk LGAs

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

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. ERC Recommendations (3.3) Improving IPD Quality – Social Mobilization

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). ERC Recommendations (4.1) Monitoring the Quality of IPDs & Mop-ups

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

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). ERC Recommendations (4.2) Monitoring the Quality of IPDs & Mop-ups

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 1 st priority for surveillance strengthening should be any HR or VHR LGA areas with orphan viruses. ERC Recommendations (5) Surveillance & Lab Priorities

Immunization Systems

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). ERC Recommendations (1.1) Immunization System – Overall Strategy

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

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. ERC Recommendations (1.2) Immunization System – Overall Strategy

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! ERC Recommendations (2) Immunization System - Data

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. ERC Recommendations (3) Immunization System – Service Delivery

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

Accelerated Disease Control & Other Issues

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. ERC Recommendations (1) Accelerated Disease Control

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. ERC Recommendations (2) Research Priorities

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. ERC Recommendations (3) Self-Evaluation

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!

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

Nigeria is in the best position in the world to finish rapidly polio eradication…

…but only if the children who are always missed finally get OPV!

Optimizing mOPV use & validating coverage is more difficult than anticipated. Routes of poliovirus spread & outbreaks are now largely predictable. Virus persists in smaller areas & sub-groups than previously thought. Major Lessons bivalent types 1& 3 OPV (bOPV) independent campaign monitoring immunization systems strengthening. new outbreak response standards. pre-planned, synchronized campaigns. district-specific plans & capacity. special tactics for underserved groups. What's Different in ? New Strategic Plan,

* Vaccine-induced immunity in children 0-4 years Jun 2009: serotype 3 % of children protected by direct OPV immunisation against type 3 Type 3 case