Expanding Polio Surveillance Reach beyond Vaccination Reach in Borno State, Nigeria: The Contribution of Community Informants from Insecure Areas Engaged to Conduct Polio Surveillance in Security Compromised Areas, 2018-2019

"The involvement of CIIA [community informants from insecure areas] is an effective strategy in ensuring polio surveillance is conducted in security compromised locations where access appeared seemingly impossible."



As the world nears achieving global wild poliovirus (WPV) eradication, conflict and insecurity limiting access to population has emerged as a significant obstacle to polio eradication. Borno state in northeastern Nigeria is the epicentre of insurgency activities that have affected the region since 2009, resulting in security challenges sufficiently intense, widespread, and persistent to warrant the declaration of a state of emergency. This article demonstrates how the engagement of community informants from insecure areas (CIIA) to conduct acute flaccid paralysis (AFP) surveillance in security-challenged settlements of Borno state contributed to the expansion of polio surveillance reach.



In each of the 19 security-compromised local government areas (LGAs) with CIIA, the researchers held a planning meeting with stakeholders of the State Ministry of Health (SMOH) and Disease Surveillance and Notification Officers (DSNOs) with their assistants. All possible places, such as markets, health centres, and traditional leaders' homes where local information indicated that persons living in security-compromised areas frequently visited were line-listed, and the DSNOs were tasked to identify key persons with direct contacts with populations of insecure regions as resource contact persons for identifying and engaging potential informants. The volunteer informants from insecure settlements were predominantly male with Koranic education or primary education and included traders, traditional leaders, traditional barbers, hunters, fishermen, nomads, informal healthcare providers, and community members.



The engaged informants were trained by the LGA DSNOs on how to identify AFP cases. Informants searched for AFP cases by visiting all households and any informal healthcare provider in their area of responsibility every week, reminding them on signs of AFP and to report any child who develops such symptoms or signs immediately to the informant. The CIIA also used the opportunity of community active case search to sensitise people on measles, yellow fever, cholera, and viral haemorrhagic fever. Once a suspected AFP case was identified, the reporting informant linked up with the ward coordinating informant or LGA focal person to make arrangement for the evacuation of the AFP case along with three contacts and the caregiver to a secure area for investigation by LGA DSNO after seeking the consent of the caregiver.



The CIIA were also trained on capturing of geo evidence, which is the capturing of geo-coordinates as evidence (geo evidence) for polio surveillance activity conducted. Before embarking on AFP surveillance, the informant switched on the Android phone provided. Each phone was enabled with Vaccination Tracking System (VTS) technology and Open Data Kit (ODK) mobile applications. The geo evidence captured was uploaded and mapped to show insecure settlements reached with polio surveillance and those yet to be reached.



Engagement of CIIA was piloted in February 2018 with the recruitment of 17 informants in one security-compromised LGA of Borno state. As of October 2019, a total of 1,241 CIIA had been engaged to conduct polio surveillance in 19 security compromised LGAs. A total of 3,183 security-compromised settlements were reached for polio surveillance between March 2018 and October 2019 with valid geo evidence, 542 of which had not been previously reached by any other intervention for polio surveillance or polio vaccination.



As reported here, the capturing of geo evidence as a proxy indicator of polio surveillance activity conducted by informants provided significant feedback on settlements reached for sustained AFP surveillance, even if a case of AFP had not being reported from these settlements. The stool adequacy for cases reported by CIIA in 2019 as of October 2019 was above the minimum threshold value of 80% recommended globally as an indicator of good surveillance performance.



In conclusion: "This strategy if sustained and used effectively alongside other intervention would contribute immensely to the interruption of all forms of polio virus transmission in Borno state as well as other states in Nigeria where insecurity limits access of regular health workers to provide health interventions."



Full list of authors, with institutional affiliations: Abede Momoh Mohammed, WHO; Audu Musa, WHO; Sume Gerald Etapelong, WHO; Mohammed Tahir Bolori, WHO; Dankoli Raymond Salanga, WHO; Danladi Ndahi, WHO; Sule Meleh, State Primary Health Care Development Agency (SPHCDA); Ijaya Kunle, WHO; Aliyu Shettima, SPHCDA; Kabiru Mohammed, National Primary Health Care Development Agency (NPHCDA); Salawu Musa Siyaka, Bill and Melinda Gates Foundation; Idris Jibrin Manu, Nigeria Stop Transmission of Polio Program; Oluwatosin Ilesanmi, Health Africa; Usman S Adamu, NPHCDA; Faisal Shuaib, NPHCDA; Erbeto Tesfaye, WHO; Fiona Braka, WHO; Walter Kazadi Mulombo, WHO

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