Impact of engaging security personnel on access and polio immunization outcomes in security-inaccessible areas in Borno state, Nigeria

Following the global launch to eradicate polio by 2000 [1], tremendous progress has been made with the disease now being contained all over the world except for Nigeria, Afghanistan, and Pakistan [2]. Nigeria was polio free from August 2014 to June 2016, when new polio cases were isolated in Borno state in the northeastern part of the country; this negatively impacted the global polio eradication effort as indigenous wild poliovirus (WPV) transmission now persists in three countries [3]. These countries have a high infrastructural health deficit, a high prevalence of enteric diseases, a high level of malnutrition, and a suboptimal implementation of routine immunization activities. They rely on several supplemental immunization activities (SIAs) to increase population immunity [4, 5].

The combined use of oral polio vaccine (OPV) and inactivated polio vaccine (IPV) in vaccination campaigns confers better population immunity and needs to be employed routinely in endemic countries and countries that are prone to the reintroduction of WPV [6]. The monovalent and bivalent virus strains induce higher levels of immunity than the trivalent vaccine; however, they can only elicit a response for the specific type of virus. This means that monovalent OPV1, OPV2, and OPV3 can only elicit a response for WPV1, WPV2, and WPV3, respectively [4].

Some oral polio vaccine-derived viruses may be genetically altered during replication on excretion, which could then circulate through and cause paralysis in populations with low immunity; these viruses are called circulating vaccine-derived polioviruses (cVDPVs), and there is surveillance in place to detect and test specimens in World Health Organization-accredited laboratories [7, 8]. There are standardized global polio eradication initiative performance indicators that are used to evaluate the quality of acute flaccid paralysis (AFP) surveillance and to identify where WPV transmission might go undetected [9‐12]. To interrupt the cVDPV2 that was largely responsible for the cVDPV cases, the strategic group of experts (SAGE) proposed the withdrawal of type 2 OPV by globally switching from trivalent OPV (tOPV) to bivalent OPV (bOPV) (types 1 and 3) in April 2016 [3]. The increased risk for outbreaks of cVDPV2 necessitated a strategic path to eventual cessation of OPV and the polio eradication end-game strategic plan of 2013–2018, which provided comprehensive, long-term strategies to deliver a polio-free world by 2018 [13, 14].

Borno state, in the northeast of Nigeria, recorded a cVDPV2 from an environmental sample taken on 23 May 2013 from the Abbaganaram site in the Lamisula ward of Maiduguri Metropolitan Council (MMC). The virus was an orphan virus, although it was closely related to a virus isolated in an adjacent community in Konduga, Nigeria, in 2003 and Chad in 2012. The laboratory result came after the switch from tOPV to bOPV. The burden was then on the state to conduct three outbreak responses while ensuring that there was an effective vaccine management system in place that could account for all the vials of monovalent OPV (mOPV) type 2. There was also the challenge of insecurity from an insurgency that rendered about 50% of the state inaccessible. The need to ensure that vaccinations got to most of these areas was strengthened by the fact that there was a plan to withdraw mOPV2 after the outbreak response.

In an attempt to reach these security-inaccessible areas, the government and the natives adopted several innovative ways to leverage existing security structures to deliver immunization services to these underserved inaccessible populations with low immunity. Security personnel were engaged to support the vaccination teams to get access to these inaccessible areas.

This article describes the processes of engagement of security personnel in the three outbreak response campaigns in Borno state and highlights the impact on immunization outcomes between May 2016 and July 2016. The goal of this article is to document and share a feasible approach for accessing conflict areas in Africa.

The percentage of LGAs accessed increased by 47% between May 2016 and July 2016 (Fig. 1). There was also an increase in the number of wards and settlements accessed in May 2016 and July 2016. However, there was a decrease in the number of LGAs, wards, and settlements accessed in June 2016. Despite the dip in June 2016, there was still a stepwise increase in the number of households accessed in May, June, and July 2016 (Fig. 1).

The average percentage of missed children decreased in June 2016 and July 2016 when the DOPV was conducted. The average percentage of missed children was 8% in January 2016 while it was reduced to 2 and 3% in June 2016 and July 2016, respectively, after the introduction of DOPV (Fig. 2).

Table 1 shows the percentage coverage with OPV2 in the four LGAs that implemented DOPV in Borno state. The data from the campaigns from January to July 2016 revealed that the percentage coverage increased after the introduction of DOPV in June 2016. The highest coverage with OPV before the introduction of DOPV was 123% in May 2016 in Jere LGA. After the introduction of DOPV, the highest coverage was 154% in Jere LGA.

LQAS survey data revealed that, in January 2016, 85% of the LGAs had coverage ≥ 80% while, with the engagement of security personnel, all the LGAs had over 80% coverage in the July 2016 campaign (Fig. 3).

The ‘hit and run’ strategy was conducted with the support of the CJTF to reach 33 inaccessible settlements in five wards where a total of 10,074 eligible children were vaccinated (Table 2). This was realistically the only way of reaching such populations that otherwise would have been missed.

Table 3 reveals an increase in access to inaccessible settlements from 231 in May 2016 to 359 in July 2016, while the number of households visited increased from 21,240 to 42,354. It was also shown that a total of eight cases of AFP were detected in the three campaigns.

Data from the tally sheet showed that the trend in percentage of zero-dose children (i.e., children who had never received a dose of OPV) declined between May and July 2016. In May 2016, the zero-dose percentage was 1.7%, in June 2016 it was 1.4%, while in July 2016 it was 1.1% (Fig. 4).

Our engagement of security personnel in the polio SIA in Borno state led to an increase in the number of LGAs, wards, settlements, and households accessed by the polio vaccination teams. The systematic engagement of security personnel improved access to security-compromised settlements. This is similar to the findings of Ager et al. in 2015 in Yobe State, where counter-insurgency arrangements were made with the joint task force leading to security personnel escorting patients from their homes to health facilities when contacted through a medical emergency telephone number [15]. Our engagement with security personnel allowed free movement of teams and logistics during curfew periods, unlike with Ager et al. 2005, where imposition of a curfew led to travel restrictions and limited access to security-compromised settlements [15], thus expanding the service delivery window.

We also found that the number of children vaccinated with the engagement of the security personnel increased. Similarly, the number vaccinated in the four LGAs that conducted DOPV with support from members of the CJTF increased. These are similar to the findings of Fekadu et al. in Angola [16], where it was possible to engage the military to reach children in insecure areas with vaccines and other interventions. Similar findings from Dadgar et al. [17] also revealed high measles vaccination coverage with the support of the military in Afghanistan despite the security challenges.

In our specific context, we can confirm that strategic engagement and deployment of security personnel and local intelligence can help AFP detection and investigation in security-compromised and conflicted areas. This has improved the number of times polio teams interface with the community members, similar to the findings of Fekadu et al. [16] where the partnership with the military in Angola improved the AFP detection and notification and other epidemic-prone diseases in areas with limited access to health services.

The implementation of the polio SIAs with the support of security personnel has improved postimplementation evaluation outcomes in Borno state. The analyses of LQAS surveys conducted revealed an increase in the number of LGAs accepted at ≥ 90% coverage. Similarly, the end-process monitoring outcome revealed a decrease in the percentage of missed children after we engaged security personnel to conduct DOPV. These security personnel guaranteed unhindered access to many settlements in the LGAs that were not previously accessed because of insecurity.

We also discovered that the percentage zero-dose was decreased, which is an indication that the cohorts who were previously not reached because of the insurgency are gradually being reached, and this is expected to improve the herd immunity that will interrupt transmission of poliovirus.

There were some limitations with the study. These include the fact that many other interventions were concurrently happening with the engagement of security personnel, and hence the improved outcome seen may also be attributed to some of these other interventions, thus making it difficult to statistically prove a positive outcome of engaging security personnel. However, the fact that these other interventions were ongoing before the engagement of the security personnel but the outcome did not show the improvement seen makes it easier to appreciate the contributions of the security personnel to the improved outcome. Another limitation was the high population dynamics in the state. As the war against insurgents was ongoing, there was a resultant movement of people in search of areas with relative peace.

Despite these limitations, the engagement of security personnel played a critical role in the improvement in the number of LGAs, wards, settlements, and households accessed by the polio vaccination team. This improved access invariably led to increased coverage and reduction in the number of missed children and overall improvement in outcome.

In conclusion, the engagement of security personnel to accompany polio SIA teams was a watershed moment in the quality of polio SIAs in Borno state. There is a need to sustain this approach as it is one feasible way to ensure the safety of teams while serving as a way of improving access to polio vaccines in security-compromised areas of Borno state. We recommend that the lessons learned from this approach should be applied in improving routine immunization in security-compromised areas in conflict-prone areas of Africa.