Conducting Public Health Surveillance in Areas of Armed Conflict and Restricted Population Access: A Qualitative Case Study of Polio Surveillance in Conflict-affected Areas of Borno State, Nigeria

"[T]he development of novel strategies and monitoring systems demonstrated how a bottom-up approach to partner collaboration in Borno was employed to achieve a common goal through innovation, collaboration, attention to data, and accountability."

Sensitive poliovirus surveillance is a key component of the effort to eradicate polio, a disease that remains endemic in parts of Pakistan and areas of conflict in Afghanistan. The ability to conduct sensitive surveillance is substantially curtailed in situations of insecurity and inaccessibility due to armed conflict. This complex problem, which can have far-reaching implications, is exemplified in the northern Nigeria State of Borno, where ongoing attacks by Boko Haram and offshoot terrorist groups have left millions in need of humanitarian assistance. In Borno, wild poliovirus (WPV) was detected in 2016 and linked to transmission of lineages last detected in 2011, representing five years of undetected transmission. This study examines the impact of armed conflict on public health surveillance systems, the limitations of traditional surveillance in this context, and strategies to overcome these limitations.

The poliovirus surveillance system is centred primarily on active surveillance for any case of acute flaccid paralysis (AFP) in children, with laboratory testing of faecal specimens. Drawing on a review of 15 key documents and semi-structured interviews with polio programme staff, this study employed a qualitative single case study design to examine the AFP surveillance system in inaccessible areas of Borno State, Nigeria. Inaccessibility was defined as the inability of civilians to safely move in and out of a given area due to the risk of attack by insurgents. A conceptual framework (see above) was developed that encompasses the key factors that affect the AFP surveillance system in conflict-affected areas; it was revised following data analysis.

The main inhibitors of surveillance were inaccessibility, the destroyed health infrastructure, and the destroyed communication network. These three challenges created a situation in which the traditional polio surveillance system could not function. The traditional polio surveillance system relies on active surveillance in facilities, passive reporting, and prompt communication and could not function in the inaccessible areas. Other challenges to the traditional AFP surveillance system, including traumatising violence and widespread malnutrition, were considered surmountable. Population movement was viewed as a potential surveillance advantage because migrating families were primarily fleeing inaccessible areas to accessible areas, where they could more easily be captured in the surveillance system.

Three strategies to overcome these challenges were viewed by respondents as the most impactful:

1. Use of local community informants in inaccessible areas (CIIAs) for surveillance - Lay adults (e.g., hunters, traders, nomads, and others identified at markets) were recruited as CIIAs to search for children with suspected AFP. To protect them from anti-government sentiment, CIIAs were uninvolved in government programmes, and a separate coordination system was set up with ward and local government area (LGA) coordinators who were also intentionally distanced from the polio programme. CIIAs' exact activities depended on the security risk level in the areas they reached and ranged from simply observing children to directly asking adults if they had any paralysed children in their or neighbouring households. Respondents agreed that CIIAs were reaching most, but not all, settlements in inaccessible areas.
2. Local-level negotiation for evacuation of AFP cases - Given that CIIAs were not health workers and often illiterate, and inaccessible areas had no electricity, the most feasible but sometimes dangerous approach for collecting specimens and conducting case investigations and clinical examinations was to bring the patient to an accessible area of Borno. While this strategy greatly improved case investigation, cases were often investigated late after onset due to the challenges of evacuation. Of note, many respondents explained that the work of the CIIAs, including evacuation of cases, required direct negotiation with the insurgents at the local level and thus required an existing basis of trust.
3. Use of geographic information system (GIS) technology - Respondents enthusiastically described the benefits of GIS technology for implementing and monitoring of surveillance in inaccessible areas. Most respondents discussed the value of global positioning system (GPS)-enabled phones as an accountability tool for tracing and documenting the places CIIAs visited, although several reported logistical difficulties in providing phones to CIIAs. This challenge led to the development of a modified monitoring system that tracked tailored indicators such as the number of places reached for surveillance and the number of AFP cases detected and investigated, and it utilised GIS technology to map the reach of the programme.

"Although the surveillance data for Borno, as a critical geography, was sufficient for certification of the eradication of indigenous WPV from the World Health Organization (WHO) Region of Africa in August 2020, the remaining challenges include pockets of settlements still unreached by vaccination and surveillance activities, uncertain regularity and quality of surveillance in the inaccessible areas, and challenges with investigating contacts of AFP cases and conducting 60-day follow up examinations when case specimens cannot be promptly collected."

To further improve surveillance performance in the inaccessible areas of Borno State, the researchers recommend developing systems to: (i) report and track suspected AFP cases that are not evacuated for investigation; (ii) track the regularity of surveillance visits by CIIAs and categorise settlements by frequency of visits; (iii) track the collection of specimens from contacts of AFP cases when specimen collection from patients is not timely; (iv) continually enumerate the number of children under 15 years of age unreached by surveillance and under 5 years of age unreached by vaccination using GIS tracking data and satellite imagery analysis; and (v) use this AFP surveillance approach to detect other priority diseases in the inaccessible areas.

In conclusion: "This study revealed a very effective system of collaboration to address an adaptive problem with no easy solutions. The approach used in Borno along with some of the specific strategies of local negotiated access, collaboration with security forces, and use of GIS technology, may be useful for other public health interventions in areas of armed conflict."