AFP Surveillance & Polio Eradication Program

By FCT EPI/PEI TeamSensitization of Nurses during their

Annual conference

The Global Polio Eradication Initiative

Background:• In 1988, the forty-first World Health Assembly,

consisting then of delegates from 166 Member States, adopted a resolution for the worldwide eradication of polio. It marked the launch of the Global Polio Eradication Initiative, spearheaded by WHO, Rotary International, the US Centers for Disease Control and Prevention (CDC) and the United Nations Children’s Fund (UNICEF).

65th World Health Assembly:

"DECLARES polio

eradication….emergency

for global public health"

May 2012

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Strategies to Eradicate Polio

Routine immunization (Given at birth, 6 weeks, 10 weeks and 14 weeks) –at least 80% coverage

Supplemental Immunization campaigns (such as house to house polio vaccination) – at least 90 % Coverage.

Mop-ups - Vaccination of children living near a confirmed polio case to prevent spread

Surveillance - Searching for/reporting to the nearest health centre all cases of children who suddenly experience weakness or paralysis of one or more limbs.

2013 NIGERIA POLIO ERADICATION EMERGENCY PLAN

• Goal: The overall goal of the plan is to achieve

interruption of poliovirus transmission in Nigeria by December 2013

• Focus • Best people in worst places• Improve access in zero dose communities• Sanctuaries• Early detection and rapid response

Strategic Priorities for 20141. Containing transmission in the breakthrough LGAs /

States2. Increasing reach in the security compromised areas3. Improving quality in persistently poor performing LGAs /

wards4. Timely and adequate outbreak response5. Reaching children in underserved populations6. Intensifying advocacy, community demand and trust7. Intensifying surveillance8. Expanding use of technologies9. Intensifying in-between round activities

2015 Nigeria Polio Eradication Emergency Plan

Target 1: Interruption of WPV

transmission by 3rd quarter 2015

Target 2: Zero cVDPV cases in AFP and

the environment by 2nd quarter 2015

and interruption of cVDPV transmission

by end 2015 7

Nigeria has convened multi-level polio-focused entities, in collaboration with partner agencies, to facilitate its polio eradication efforts

Presidential Taskforce

National EOC

State Taskforce

State EOCs

LGA Taskforce

Ward Health CommitteeWard

LGA

State

National

National Polio EOC

▪ Technical assistance (social mobilization, etc.)

▪ Resource provision▪ Operational and logistic

support

▪ Advocacy▪ Community engagement

▪ Advocacy▪ Operations support▪ Resource mobilization

▪ Technical assistance (staffing, NSTOP)

▪ Facilities management

Rotary club

eHealth Nigeria

▪ Primary health care support

▪ Technical assistance (staffing, surge capacity)

Coordination mechanisms deployed to ensure implementation of Plan

• Increased oversight by political and traditional institutions– Inauguration of Presidential Task force, State and

LGA Task Forces(march 2012)– Strenthening of Northern Traditional Leaders

Forum• Establishment of the National Polio

Emergency Operations Centre (EOC) and 5 State EOCs (October 2012)

• Highest level of political commitment by Mr. President

• Governors of HR States and Chairmen of 45 vulnerable LGAs met with Mr President on October 16, 2012

• Advocacy visits to High Risk (HR) States

• Renewed engagement of traditional leaders in the supervision of IPDs and resolution of Non-compliant cases.

• MOU signed with traditional leaders to personally ensure ownership and accountability for PEI

Presidential Taskforce Activities

…as well as to international border communities

Customs Border station, Jibia, Katsina

Immunization records, Ilela border, SokotoVaccinating children crossing the border

Community interaction at Jega, Kebbi state

HE Executive Govenor, Kano HE Executive Governor, Jigawa

05/03/2023 12

Highest level political commitment and advocacy

HE Executive Governor, KebbiHE Executive Governor, Zamfara

Social Mobilization at all levels

• Advocacy/sensitization meeting with LGA Chairmen in each state

• Advocacy meeting with health professionals/ medical bodies in each state

• Orientation/sensitization meeting with various stakeholders: e.g.

Traditional leaders Nigeria Inter-faith Action Association Leaders of Islamic and Christian bodies (Supreme

Council of Islamic Affairs, Jamatu Nasir Islam, Christian Association of Nigeria and other religious bodies

Officials of MDAs. Youth/women oriented NGOs, CBOs, FOMWAN

STRATEGY: ADVOCACY/SOCIAL MOBILIZATION/PARTNERSHIP ENGAGEMENT

EOC Abuja

Data analystsData analysts

Data analysts

Polio Emergency Operations in Nigeria

Abuja EOC

Data analystsKano EOC

Presidential Task Force

NPHCDA (Secretariat)

Katsina EOC

Kaduna EOCSokoto EOC

Borno EOC

▪ Presidential Task Force established and mandated to drive emergency response to polio eradication

▪ NPHCDA serves as Secretariat to Task Force and responsible for implementation of Emergency Plan

▪ Abuja Emergency Operations Center commissioned by Presidential Task Force as management tool for NPHCDA to coordinate overall emergency response

▪ Incident Manager (NPHCDA) and Deputy Incident Manger (MOH) deputized with executive authority by MOSH and ED

▪ All GPEI partners to assign senior staff to EOC▪ McKinsey recruited to provide strategic and management support

to EOC

▪ State Emergency Ops Centers planned for Kano, Sokoto, Katsina, Kaduna and Borno

15

2005 2006 2007 2008 2009 2010 2011 2012 2013 20140

500

1000

1500

2000

2500

1979 1998

1351

1652 1604

975

650

223

416358

Global Trend of WPVs (2005-2014)

Year of onset

No.

of W

PV ca

ses

So far in 2015, 51 cases have been detected in 2 Countries – Afghanistan (13) and Pakistan (38)

Trends of WPV1 and WPV3 in Nigeria (2000 – 2015)

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WPV 3 Interrupted

Trend of WPV in Nigeria (2012-2015)• Strong political support

by the government• Inception of the EOC in

2012• Strengthening

accountability at all levels

• The use of innovative strategies to reach more children

57% reduction

89% reduction

EOC Objective 1: Zero case

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As at October 23, 2015 Nigeria has

• No confirmed WPV for 2015 compared to 6 cases for the same period in 2014– Date of onset of latest WPV1 case is 24 July, 2014

– Date of onset of latest WPV3 case is 10 November, 2012

• One confirmed vaccine derived poliovirus (cVDPV2) for 2015 compared to 27 cases in 5 States for the same period in 2014 – Date of onset of latest cVDPV2 case is 16 May, 2015

Nigeria: Polio cases as at Week 43, 2015

Latest onset of confirmed WPV was 24-Jul-2014 from Sumaila LGA, Kano State.

Nigeria: Total Poliovirus 2013 – 2015* cases by Zones and States

Nigeria: Total Poliovirus 2013 - 2015 in Environmental Samples by Zones and States

Sites were not starting during this period-

Nigeria: Polio Compatible Cases Jan – Oct 23, 2014/2015 as at week 43, 2015

2014 2015

Compatibles (n=17)

# Infected State: 11

Compatibles (n=30)

# Infected State: 15

Challenges

• Insecurity is the major challenge • Operational gaps in worse performing LGAs

(poor team performance, supervision) • Anti polio campaigns• Accountability at the operational levels• Unmet needs of the populace

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• Provide pluses – e.g., soap, ORS, deworming tablets, vitamin A, milk sachets are being provided to during the May IPD

• Providing bore holes in communities that have identified water shortage as one of their felt needs

• Integrating OPV campaigns with measles, Men A and Yellow Fever campaigns; OPV administered at fixed posts during campaigns

• Distribution of bed nets as pluses during IPDs and as incentive for mothers to complete immunization

Addressing unmet health needs of communities and linkage to PEI

Free Drugs by NPHCDA

Provision of Bed nets Integrating OPV & MCH

Potable water supply

VCM newborn tracking, 7 Apr- 12 Jul 2013

14713 new births recorded in VCM network 11337 given 0 dose by or with support of VCM 12239 linked to facility for RI 8980 naming ceremonies attended by VCM

Disease Surveillance

Ongoing, systematic collection, analysis, and interpretation of health-related data essential for the planning, implementation, and evaluation of health practice, closely integrated with the timely dissemination of these data to those responsible for prevention and control.

AFP surveillanceWhat is it?

• detect any case of AFP < 15 years of age and any case of any age in which a clinician suspects polio

• collect 2 stool specimens at 24 hours interval < 14 days of paralysis onset

• perform virus isolation in a WHO-accredited laboratory

• classify cases according to WHO scheme

Acute Flaccid Paralysis

• Acute: sudden onset of new/recent paralysis– as opposed to chronic (e.g., from birth) or very

gradual onset

• Flaccid: loss of muscle tone, “floppy” (as opposed to spastic or rigid)

• Paralysis: weakness, loss or diminution of motion of one or more limbs

• Any case of sudden onset of weakness of one or more limbs in a child <15 years of age

or• Any case of paralytic illness (regardless of

age) in which a clinician suspects polio

Case Definition for Acute Flaccid Paralysis (AFP) Surveillance

AFP Surveillance Cntd.

•It should be stressed that surveillance is carried out for all cases of AFP, regardless of cause.

•Note that it is acute onset of flaccid paralysis for which no obvious cause (such as severe injury or birth trauma) is found.

•When in doubt, the case should be reported, and surveillance officers will investigate and verify them.

Events of AFP Surveillance Immediate reporting of AFP cases. Immediate case investigation. Collection of 2 stool specimens, Additional case findings (contact-tracing) and

outbreak response immunization (ORI) 60+ Day follow-up examination Case Classification

Acute Flaccid Paralysis

Paresis, WeaknessFloppy limb

Can’t move leg, arm

Can’t walk

Can’t sit-up

Paralysis - sudden onset

Clues to the Presence of AFP Major Clinical features

Acute Flaccid Paralysis

Transverse myelitis

Traumatic neuritis

Guillain - Barre Syndrome

Other enteroviruses

Coxsackie virusEchovirus

Poliovirus

Differential Diagnosis for AFP

Transient weakness of unknown cause

Overview of Poliomyelitis

Definition of Poliomyelitis: An endemic virus infection which attacks the motor neurons

of the anterior horns in the brain stem and spinal cord.An attack may or may not lead to paralysis with loss of muscular power and flaccidity i.e acute flaccid paralysis (AFP).

Sensory neurons are not affected so there is still a sense of feeling in the limb.

When it occurs within two days of vaccination the term provocative paralytic poliomyelitis is used. This is also known as Vaccine Activated Paralytic Poliomyelitis (VAPP) and it occurs in less than 1 in 3 million cases.

Suspected polio is:Any case of acute flaccid paralysis in a child aged less than 15yrs, including Gullian-Barre syndrome, for which no other obvious cause such as trauma is evident at onset.

AFP = Sudden loss of strength, tone and/or reflexes in a limb or limbs – is the indicator of surveillance for Poliomyelitis.

EPIDEMIOLOGYDisease of young children 80 – 90% of cases occur in

children less than 5 yrs oldCluster of susceptible population is required to

maintain circulationSeasonal increase in cases in the wet or rainy season

May to JulySilent transmission >99% of cases are sub-clinical /

asymptomatic /carrier stateRisk of paralysis is increased by

TonsillectomyExercisePregnancyI.M Injections

Clinical Outcome of Poliovirus Infections

asymptomatic infection

clinical illness, no paralysis

paralytic poliomyelitis

CLINICAL FEATURES OF POLIOMYELITIS

Acute onset of flaccid paralysisFever, sneezing, runny nose,+/- loose

motionsFatigue, headache, vomiting, and pain in the

limbsAsymmetricLegs affected most oftenMortality rate 5 – 10%Paralysis is permanentNB: Poliomyelitis is a highly communicable

disease which must be eradicated.

What Makes Polio Eradication Possible

It is found only in human beings. No extra human reservoir.

Poliovirus is heat sensitive and does not survive long in the environment, especially tropical climates like Nigeria

There is no long term carrier state Fewer than 1% of polio infections ever

result in paralysisPermanent immunity following infectionOPV is a proven vaccine for eradication

POLIO VACCINE• Protective immunity against polio infection develops

by immunization or natural infection.• Immunity to one polio virus type (as occurs by

natural immunity) does not protect against infection from other polio virus types, this is why trivalent vaccination is vital.

• Immunity conferred is lifelong .• Infants born to mothers with high antibody levels

against the polio virus are protected for the first few days of life but this is highly inadequate.

• There are two types:ORAL POLIO VACCINE (OPV)INACTIVATED POLIO

VACCINE(IPV)

Some Drawbacks in Polio Eradication

• Poor RI coverage (routine immunization and primary health care systems are weak).

• Failure to reach enough children during polio immunization campaigns (missed children – child absent, non-compliance and households not visited)

• Religious beliefs – Some Muslims do not believe in disease prevention; some Christians don’t take medicines.

• Lack of awareness by health care providers on polio eradication process with particular reference to SIAs and necessity for multiple/several OPV doses.

• Lack of trust in polio immunization by some sections of the public – including health workers.

• Lack of commitment some political/traditional leaders and policy makers at both federal, state and LGAs.

FAQ• What is polio?• Polio is a highly infectious disease caused by a virus. • The virus invades the nervous system, and can cause

total paralysis in a matter of hours. • In some cases, the poliovirus can even cause death. • Poliovirus is a communicable disease which cannot

be controlled and therefore must be eradicated.

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Why are there so many rounds of Polio Campaigns in Nigeria?

• Multiple rounds are necessary to eradicate polio; every child under 5 years must receive the polio vaccine multiple times, regardless of previous immunization status.

• The strategy is to immunize children who are either not immunized, or only partially protected (ie who have not received sufficient doses of OPV), as well as to boost immunity levels in those children who have already been immunized.

• It is important to note that these strategies only work if each and every child is immunized during each and every immunization campaign. It is the only way to stop the transmission and circulation of wild poliovirus, and to eradicate the disease once and for all.

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Key facts

• Polio (poliomyelitis) mainly affects children under five years of age.• One in 200 infections leads to irreversible paralysis. Among those paralysed,

5% to 10% die when their breathing muscles become immobilized.• Polio cases have decreased by over 99% since 1988. The reduction is the

result of the global effort to eradicate the disease.• In 2012, only three countries (Afghanistan, Nigeria and Pakistan) remain

polio-endemic, down from more than 125 in 1988.• Persistent pockets of polio transmission in northern Nigeria and the border

between Afghanistan and Pakistan are the current focus of the polio eradication initiative.

• As long as a single child remains infected, children in all countries are at risk of contracting polio. In 2009-2010, 23 previously polio-free countries were re-infected due to imports of the virus.

• In most countries, the global effort has expanded capacities to tackle infectious diseases by building effective surveillance and immunization systems.

• These efforts can only work if all hands are on deck.

ConclusionWhat are Nurses required to do?• Immediately report any case(s) of AFP to HF focal

person, DSNO for the Area Council, FCT State DSNO or WHO Surveillance officers for prompt case investigation and verification.

• Support clinicians in diagnosis and complete (traceable) address of the AFP case in the record book.

• As much as possible, admit all AFP cases immediately.• Keep the Patient (if possible) until 2 stool specimens

are collected.• Support the DSNO to collect two stool specimens, 24-

48 hours apart; Specimen should reach NPL within 72 hrs of collection.

• Support the Polio Eradication Initiative by also encouraging your clients to present eligible children for RI (<1yr) and SIAs/IPDs (<5yrs).

Polio – a paralysing disease for life

FIND & VACCINATE

THIS CHILD!!!!

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Thank You