Report of the 9th Meeting of the Expert Review Committee (ERC) on Polio Eradication in Nigeria

The 9th meeting of the Expert Review Committee (ERC) on Polio eradication in Nigeria was held in Abuja, Nigeria from March 15-16 2006. Participants included ERC members, as well as representatives of the various partner agencies (Centers for Disease Control & Prevention (CDC), United Nations Children's Fund (UNICEF), US Agency for International Development (USAID), the World Health Organization (WHO), and Rotary International). While appreciating the progress made in the revitalisation of routine immunisation, polio eradication, and accelerated measles control, those in attendance noted that there is still a lot more to be done and pledged their full commitment to supporting routine immunisation and polio eradication in Nigeria. This 12-page report summarises these, and many other, key observations and recommendations from the 8th ERC meeting.

Executive Summary

"Since the 8th Meeting of the Expert Review Committee (ERC), major developments in the administration and oversight of the National Immunization Programme (NPI), combined with important developments in the epidemiology of polio at the national and international levels, has had substantial implications for accelerating the eradication of polio and strengthening of routine immunization services in Nigeria.

Nationally, a new Blueprint for Strengthening Routine Immunization has been established with broad support from the partner community and an interim NPI Chief Executive appointed with a Presidential Mandate to interrupt polio transmission by end-2006, improve routine immunization coverage, and oversee the re-integration of NPI into the Federal Ministry of Health.

Internationally, 2 of the last 6 remaining polio endemic countries have now interrupted wild poliovirus transmission and all but a handful of the recently reinfected countries are again polio-free. Furthermore, monovalent OPV has replaced the trivalent vaccine in an accelerated schedule of supplementary immunization activities (SIAs) in all of the other remaining polio-infected areas.

At the same time, programmatic and epidemiologic data demonstrate that the vast majority of Nigeria is also now polio-free....Of critical importance, ongoing polio virus transmission now correlates very strongly with poor quality routine and supplementary immunization services....The ERC is most concerned about the low coverage rates in these 8 states due to 'non compliance' of households due to a number of factors, particularly inappropriate vaccinator teams and insufficient endorsement by local leaders.

Recognizing the time-limited Presidential Mandate under which NPI is now operating and the very focal nature of polio problem in Nigeria, the ERC is proposing a radical change in the approach to polio eradication and routine immunization during the coming 3 months to improve the attractiveness and acceptability of these services, as well as the authority under which they are implemented. This approach should be implemented from April-June 2006 and be evaluated by the ERC with NPI and the key State authorities in July, as the basis for refining activities for the remainder of 2006.

Major Recommendations

• To rapidly strengthen routine immunization, NPI should promote the accelerated adoption of the 'Reaching Every Ward' [REW] approach...
• NPI should establish with the states and LGAs [local government associations], by July 2006, the capacity to track the number of immunization sites, sessions and stock-outs in all areas which are priorities for accelerated improvement of routine services.
• ERC recommends that the NPI should engage the Nigerian National Forum of traditional rulers and religious leaders and the media to step up advocacy for routine immunization and the polio eradication initiative.
• The 10 highest risk states (i.e. with >20% zero dose children) should conduct 2 rounds of intensified 'Immunization-Plus Days' (IPD) in May and June 2006, with the target of reducing the zero-dose children to <10%. The IPDs should consist of 2 days of fixed site activity, through existing health facilities and supplementary sites in high traffic areas such as markets and transit points, followed by 3 days of house-to-house 'mop-up teams'.
• Given the limited time for planning of these IPDs, the ERC recommends that key interventions included in May and June are (a) fixed sites: measles vaccine, mOPV1, DPT, vitamin A and, potentially, anti-helminthics, and (b) mop-up teams: mOPV1, vitamin A and, potentially, anti-helminthics.
• The acceptability of the IPD should be improved by (a) ensuring that all vaccinators are of an appropriate age and stature in their community to deliver a health intervention, (b) publicly engaging key influencers especially those who had previously endorsed the suspension of OPV immunization.
• In the 10 high risk states the IPDs should be improved through a strengthened partnership with traditional leaders who will have oversight responsibilities and accountability for reducing non-compliance and reducing missed children in particular reducing zero-dose, with corresponding remuneration.
• Social mobilization and training activities should be rapidly adapted and oriented to the new 'Immunization-Plus Days' strategy for May and June rounds and guided by social and epidemiological data.
• In the polio-free states, the detection of a wild poliovirus during this period should trigger two large-scale mop-up rounds using the appropriate monovalent OPV...
• The ERC proposes to meet in Kano with NPI and appropriate representatives of key states on 12-13 July 2006 to review the experience and impact of Immunization-Plus Days..."