Somalia polio outbreak and
response update – May 2014
For the Polio Eradication Independent
Monitoring Board
Somalia Ministry of Health
WHO/UNICEF – Somalia
Contents
• Status of the implementation of the
recommendations of the 1st OA mission
• Key findings of the 2nd Outbreak Assessment
mission
• Outbreak - Update
• Outbreak response strategies and challenges
• Conclusion
Status of implementation of the 1st Quarterly
Outbreak Assessment Mission (August 2013)
Overarching
Coordination
Government
commitment
Conduct post
campaign review
meetings at zonal
level
SIAs
operations
Scaling up TPV for < 10
and all IPDs
SIADS in newly
accessible areas
Establish weekly
coordination
meeting
Maintain aggressive
and flexible SIAs
schedule
Achieved
Routine
immunization
Human
resources
Improve access
to public and
private hospitals
Establish RI in all
hospitals
Finalize surge
staff and VPV
recruitment
AFP training
package
Improve stock
management
Finalize
recruitment of
Nairobi based
SIAs coordinator
(UNICEF)
Train and
Involved VPV in
AFP surveillance
Explore outreach
sessions in IDPs
Recruitment of
Social data
analyst (UNICEF)
Finalize and share
improved standards
micro planning tool
with all zones
Review of the
outbreak response
plan
Address funding gap in
maintaining current
organogram
Surveillance
Review training
package for
immunization
Expand IM and CRA
Appoint cross
border
coordinator
Analysis of SIAs data,
improve SIAS quality
through Monitoring by
National and zonal
staff, SOP for
communication
Partially achieved
Not achieved
Key conclusion of the 2nd Outbreak Assessment
Mission (April 2014)
AFP
surveillance
sensitive to
detect WPV
circulation
Transmission
in
inaccessible
and remote
areas can not
be ruled out
Routine EPI
Suboptimal
use of
community
comm.
structure
Outbreak
appears to
have
slowed
down
Continued
low routine
EPI coverage
poses a risk
Milestone
related to
SIAs quality
missed
AFP surveillance
Routine IM
should be
strengthened
Intensive
and flexible
outbreak
response
maintained
SIAs
Phase 2 Outbreak response activities
November 2013 – April 2014
Objective
Activities/Strategies
Status of
implementation
Comment
1.
Interrupt transmission
in non-SIA
(inaccessible) areas of
south central zone,
Somalia by April 2014
• Continuation of vaccination at
permanent transit points (< 10 yrs)
• Fixed sites vaccination (< 10 yrs)
• Continue efforts for opportunities to
get access to children in non-SIAs
areas through local NGOs
Ongoing – on track
All the efforts and activities
to reach children in nonSIAs areas will continue. At
least 4 rounds of SIADs will
be conducted using bOPV
once access is granted (first
response within 1 week) At
least round < 10 yrs.
2.
Sustain high immunity
throughout the
epidemiologic block
(Banadir and rest of
SCZ Somalia)
• Continuation of successful strategies
implemented in Phase 1 and multiple
large scale SIAs (with bOPV) at 4
week intervals.
• Continue efforts to improve routine
immunization.
• Avail all opportunities to provide
additional doses of OPV (CHDs)
Ongoing – On track
2014 SIAs plan approved
and implementation
initiated
3.
Sustaining high
population immunity
in areas at high risk of
transmission from
outbreak areas.
• Continuation of successful strategies
implemented in Phase 1 and multiple
large scale SIAs (with bOPV).
• Continue efforts to improve routine
immunization.
• Avail all opportunities to provide
additional doses of OPV (CHDs)
Ongoing – on track
2014 SIAs plan approved
and implementation
initiated
Activities to jumpstart RI
initiated
5
Somalia polio outbreak update
Somalia polio outbreak
• Phase 1 and phase 2 outbreak response
activities implemented
• An intense SIAs plan (Jan – December)
currently implemented
• The second outbreak assessment mission
conducted (April 2014)
What is the situation of the WPV
outbreak in Somalia?
Somalia polio outbreak in short
sNID
CHDs
NID
SIAD
WPV notification by the lab
Intervention (Mop-up, Banadir) and ERP
50
Phase 1 of Outbreak Response Activities May – Oct 2013
40
Phase 2 of Outbreak Response Activities Nov 2013 – April 2014
30
20
10th TAG
10
0
April
May
June
July
Aug
Sept
WPV
Oct
NPAFP
Nov
PENDING
Dec
Jan
Feb
March
April
Receipt in
lab
Date of
onset of
index case
•
•
Last
WPV
case in
Banadir
1st
Outbreak
assessment
mission
8th IMB
194 WPV cases reported
Last WPV case in Banadir in July 2013
Since the 8th IMB
• Three additional cases reported (two in North West Somalia)
• Last case with date of onset on December 20th 2013
• No cases in 2014
Last WPV
2st
Outbreak
assessment
mission
WVP cases in Somalia, 2013
•
•
No cases reported in 2014 (in
accessible and inaccessible
areas)
The two cases reported from
Bosaso in November and
December 2013 remained the
only cases outside of South and
Central zone
ZONE
CENTRAL
Number of WPV cases
139
NORTH-EAST
2
NORTH-WEST
0
SOUTH
53
TOTAL
194
2013 = 194
2014 = 0
Outbreak and accessibility
AFP by final classification
30
25
20
In accessible districts
Last WPV case
20 December 2013
15
10
5
0
1
2
3
4
5
7
8
9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 1
2
3
4
5
6
2013
7
8
9 10 11 12 13
8
9 10 11 12 13
2014
30
25
20
In districts with accessibility issues
Last WPV case
26 November 2013
15
10
5
0
1
2
3
4
5
6
7
8
9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 51 52 1
2013
•
•
•
Last case in Banadir, the Epicenter of the outbreak, in 19 July 2013
No WPV from accessible districts for 4 months
No WPV from districts with accessibility issues for 4 months
2
3
4
5
6
7
2014
Weekly incidence by final classification
40
South
30
20
10
0
1
2
3
4
5
6
7
8
9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 51 52 1
2
3
4
5
2013
40
30
6
7
8
9 10 11 12
8
9 10 11 12
2014
Central
20
10
0
1
2
3
4
5
6
7
8
9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 42 43 44 45 47 48 49 50 51 52 1
2
3
4
5
2013
40
6
7
2014
North East
30
20
10
0
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 1 2 3 5 6 7 8 9 10 11 12 13
2013
40
2014
North West
30
20
10
0
1
2
3
4
5
6
7
8
9 10 11 12 13 14 15 16 17 18 19 21 22 23 24 25 27 28 29 31 32 33 34 35 36 37 38 40 41 42 43 46 48 49 50 51 52 1
2013
2
3
4
5
6 10 11 12 13
2014
Outbreak response activities
and challenges
AFP Surveillance quality
• How confident is the
program about the quality
of AFP surveillance in
Somalia?
• How about the quality of
AFP surveillance in
inaccessible areas?
• Are we likely to miss WPV
circulation anywhere in
Somalia?
National
Coordination, monitoring, capacity
building, supervision, management
Zonal polio officers
Case investigation, sample collection
and shipment. Reporting site visit,
monitoring, supervision, capacity
building, management
Regional polio officers
Case investigation, sample collection
and shipment. Reporting site visit,
active case search, monitoring,
supervision, capacity building,
management
District polio officers
DFAs, VPV (300), Vaccinators, Traditional healers,
religious leaders, clan elders, communities/reporting
sites (500)
Case investigation, sample
collection and shipment.
Reporting site visit, active
case search
Case notification
(VPV conduct active
case search of AFP
cases)
Activities implemented to strengthen
surveillance in the context of the outbreak
•
•
•
•
•
•
•
Update of AFP surveillance guides for
field staff
Refresher training of polio officers and
reporting sites staff
Weekly regional and zonal calls include
review of surveillance performance at all
levels
Surge staff include regional and zonal
data managers to compile, analyze and
provide feedback
AFP surveillance performance tracking at
zonal and regional levels (Zonal and
regional data managers)
Village polio volunteers dedicated to
active search of AFP cases
Sensitization activities (inclusion of AFP
message in radio spots, AFP posters)
Active case search of AFP cases during
SIAs and TPV
160
AFP cases notified
•
140
Number of AFP cases notified in
the first quarter of the year
134 AFP cases
from 87
districts
120
100
80
60
36 cases from
30 districts)
40
33 AFP cases
from 28
districts
20
0
2012
2013
2014
Surveillance quality
All key AFP surveillance indicators maintained at certification standards at
national and subnational levels in 2014, irrespective of districts accessibility
status
Key AFP surveillance indicators and district accessibility
Specimen arriving in
NPEV
Sabin-like
rates
isolation rate
100.00%
2(9.1%)
11(14.7%)
20(94.8%)
100.00%
1(1.32%)
1(4.5%)
15 (5.5)
21(80.8%)
100.00%
1(3.85%)
2(7.7%)
5 (3.7)
12(100%)
100%
0(0.0%)
0(0.0%)
Number of AFP
NP AFP Rate
Investigated < 2 Days
cases notified
(annualized)
of Notification (>80%)
Accessible districts
76
50 (6.9)
72(90.1%)
Inaccessible districts
22
9 (3.3)
Partially accessible districts
26
Districts with security challenges
12
“Good-Condition
(>90%)
Quarterly non polio AFP rate and stool adequacy by accessibility status
Area
Quarterly non polio-AFP rate
2013
Stool adequacy
2014
2013
2014
Q1
Q2
Q3
Q4
Q1
Q1
Q2
Q3
Q4
Q1
Accessible districts
3.1
5.7
6.8
6.4
6.9
100%
90%
96%
91%
95%
Inaccessible districts
2.3
3.2
5.5
5.6
3.3
100%
78%
85%
95%
97%
Partially accessible districts
1.1
3.8
5.9
6.5
5.5
100%
90%
85%
100%
92%
Districts with security challenges
0.8
4.1
4.5
4.7
3.7
100%
97%
71%
100%
100%
Data as of 25 April 2014
Immunization response Jan – Dec 2014
Immunization response
• Six rounds of NIDs/sNIDs conducted from January
to April 2014
• One round of CHDs (multi antigens campaign)
conducted in North East and North West zones.
• Updated micro planning tools to improve SIAs
quality
• Introduction and extension of independent
monitoring to 62 districts
• SIAs review meeting at zonal and regional
levels conducted
• Coverage close to 90% reported in all districts (IM
by finger marking)
Independent monitoring of SIAs
• Independent Monitoring Implemented initially in the
16 districts of Banadir region in June 2013 SIAs
• Number of IM districts increased from 29 to 42 by end
of 2013 and 62 by April 2014, representing 68% of all
SIA districts
• IM conducted with support of local NGOs and local
academic institutions (school of medicine, school of
nursing, etc..)
• IM plan for 2014 ongoing to further increase number
of IM districts
• Findings of IM: Number of <5 yrs children surveyed,
total & proportion of finger-marked, June – Jan, 2014
Independent monitoring outcomes
Coverage by IM
Zones
Sep 13
Oct 13
Nov 13
CHD
Jan 14
Feb 14
Mar 14
South
94
84
84
No IM
87
87
89
Central
78
94
88
No IM
78
86
-
NEZ
95
92
91
No IM
94
96
97
NWZ
90
77
83
No IM
81
-
91
Number of districts with IM
Zones
SIA
Districts
Sep 13
Oct 13
Nov 13
CHD
Jan 14
Feb 14
Mar 14
South
16
8
8
10
0
12
13
13
Central
36
0
26
26
0
30
7
24
NEZ
19
5
5
5
0
8
5
8
NWZ
19
5
6
9
0
9
CHD
15
IM conducted at least once in 62 districts in 2014 (≈68% of SIAs districts) compared
to 49 districts in 2013
Impact of SIAs: Immunity profile of AFP
cases and accessibility
1 – 3 doses
Zero doses
• Program continues to
track zero-doses at
district and by
accessibility
• Improvement of
immunity profile in
SIAs areas
• Bulk of zero doses in
districts with
accessibility issues
60
50
40
30
20
10
0
≥ doses
Accessible (61)
1
2
3
4
5
6
7
8
9
10
11
12
1
2
2013
40
30
20
10
0
3
4
2014
2
3
4
5
6
7
8
9
10
11
12
1
2
2013
50
4
Inaccessible (27)
1
60
3
2014
Partially accessible (12)
40
30
20
10
0
1
2
3
4
5
6
7
8
9
10
11
12
1
2
2013
60
50
40
30
20
10
0
3
4
2014
Accessible with security challenges (9)
1
2
3
4
5
6
7
2013
8
9
10
11
12
1
2
3
2014
4
Adequate vaccine stock and supply
•
•
•
•
No vaccine stock-out at any level
Vaccine procured for SIAs till June 2014
305,710 vials of bOPV in stock at Nairobi as on 14 April 2014
Vaccine Prepositioned (for SIAs + transit points) in various
places of Somalia:
Zones
Pre-positioned bOPV Stock
Puntland - NEZ
45,590 vials to cover April – June 2014 SIAs
Somaliland - NWZ
34,977 vials to cover May – July 2014 SIAs
SCZ – 7 Hubs
142,264 vials to cover needs for April-May 2014
SIAs
21
VACCINE SUPPLY ROUTES
1. Nairobi -> Mogadishu
2. Mogadishu -> cold chain hubs
Except
No regular flights -> Afmadow
Replenishment done using missions
or UNHAS charters from available
locations (Mogadishu, Nairobi,
Baidoa)
BY AIR
IN-BOUND
Commercial (regular)
UNHAS (charter)
INTERNAL
Commercial (regular)
UNHAS (regular)
UN mission
BY ROAD
Vaccine Supply Chain Management
Transition
Safety
Cost
efficiency
Availability &
Flexibility
Beginning of outbreak
Mogadishu hub
• 1 month of stock (SIAs; remaining balance
used as rolling stock)
Other hubs
• 1 month of stock (SIAs; remaining
balance used as rolling stock)
Commercial round charter flight from NBO
• Appr. USD 80,000
Improved vaccine supply chain mgmt
Mogadishu hub
• 1-2 months of stock (SIAs and PVP)
Other hubs
• 2-3 months of stock (SIAs and PVP)
• Optimized preparedness
Additional
stockpile
Additional cold chain capacity added
Most cost efficient route available
used
1. Low cost UN or Commercial flights
Physical cold chain
assessments not
conducted
6/8 cold chain hubs assessed for capacity
and quality
•
•
•
•
Equipment
Human resource
Security
Infrastructure
Evolving C4D Strategies
• Vehicles with mounted megaphones have been used in
underserved and high populated areas,
• More than half of the population reached with radios
• Radio is the only mean to reach communities in
inaccessible areas
• Advocacy /sensitization meetings for religious leaders
• Regular Mosque announcements
• House-to-House social mobilisers added in each team
areas
• Orientations for the media journalists and doctors from
medical association
24
Somalia: Parent/ Caretaker aware of the
campaign before team arrival
20000
100%
91.68% 91.31% 94.26%
18000
90.22%
89.37%
77.61%
80%
16000
64.69%
14000
12000
90%
70%
58.00% 59.41%
60%
10000
50%
8000
40%
6000
30%
4000
20%
2000
10%
0%
0
RND 1
RND 2
RND 3
RND 4
RND 5
RND 6
RND 7
RND 8
Total houses Monitor
Caregivers Aware About Campaign before the arrival of Vaccination Team
% Caregivers Aware About Campaign before the arrival of Vaccination Team2
RND 9
25
Somalia: Source of Information
regarding NIDs (in %)
60%
50%
40%
30%
20%
10%
0%
RND 1
Radio
RND 2
TV
RND 3
News Paper
RND 4
RND 5
SMS/ Mobile
RND 6
RND 7
Soc Mobilizers
RND 8
RND 9
Mounted Vehicle
Sources of Community Awareness NID
March, 2014 Somaliland
SMS/Mobile,
13%
Others, 1%
Radio, 14%
TV, 17%
Mosque, 1%
Health
stafff/Vaccinator,
18%
Community
Mobilzers/
Megaphones,
85%
Mobile
Announcement,
1%
Investment in Social Mobilization substantially improved
parental awareness and increased coverage in successive
SIAs, NWZ, Somalia
Social Mobilization
70000
65000
Mass Media
115%
110%
Advocacy
55000
IEC
50000
% Persons Vaccinated (coverage)
105%
% Parental Awareness of Campaign
100%
45000
40000
35000
30000
25000
20000
95%
Increased focus on
social mobilization in
2013 led to a 20%
increase in parental
awareness
83 - 89%
90%
85%
80%
75%
15000
70%
10000
63%
5000
65%
0
60%
r1
r2
2012
r1
r2
r3
r4
r5
2013
Year and Vaccination Campaign Round (r)
r6
r7
r8
r9
Percentage Aware (%)
Capacity Building
60000
Cost in USD
120%
Other costs
Harvard KAP of WPV cases: study findings
Source of Information for SIAs
35%
30%
Radio
Megaphones
Posters
25%
20%
15%
10%
5%
0%
South Central Zone
North West zone
North East Zone
29
Join outbreak response organogram
(staff surge)
UNICEF
REP
WHO REP
NATIONAL
TEAM
P4
LEADER
Admin/Fin/Log
s Fin Assistant
Admin/HR
Assistant Logistics
Assistant Driver
Deputy Team
Leader
Surveillance
Coordination
SIA
Coordinator
Consultant
P3/4
Data
Assistan
t
ZONAL
SOMALILAND
IFP
TIP P3/4
Operations
Officer
TIP P3/4
Security
Consultant
VSL/S
M
ZPOs
REGIONAL
DISTRICT
VILLAGE
DPO
SOUTH IFP
TIP P3/4
Govt focal
Point in DOH
VSL/S
M
ZPOs
Admin/Fin/Lo
gFin Assistant
Logs
Assistant
SIA
Coordinato
r
PVSL/SM
VPV
VSL
NO
B
TPV teams
PUNTLAND
IFP
TIP P3/4
ZPOs
PEOs
Admin/Fin/Lo
gFin Assistant
Logs
Assistant
Driver
Zonal Data
Assistant
Admin/Fin/Log
Fin Assistant
Logs Assistant
SIA
Coordinato
r
PEOs
Reg. Data
&Admin (4)
Reg. Data
&Admin (4)
DPO
DPO
VPV
STOP
TEAM
Govt focal
Point in DOH
ZPOs
SIA
Coordinato
r
DVSL
DPO
STOP
TEAM
Securit
y
Assistan
t
Reg. Data
&Admin (4)
DVSL
M&
E
P3
Zonal Data
Assistant
PVSL/SM
PEOs
Reg. Data
&Admin (5)
C4
D
P3
Gov’t Focal Point
- NOA
Zonal Data
Assistant
Admin/Fin/Lo
gFin Assistant
Logs
Assistant
PEO
s
Polio Control
Room WHO &
UNICEF
POLIO
MANAGER
P3
STOP
TEAM
Sec
Ass
Zonal Data
Assistant
SIA
Coordinato
r
SOUTH
CENTRAL
COORDINATOR
P4
CENTRAL IFP
TIP P3/4
Govt focal
Point in DOH
Govt focal
Point in DOH
Outbreak
Response Support
Officer
NOA
Informati
on
Assista
nt
Comms
Officer
STOP
TEAM
Project
Assistan
t
POLIO
MANAGER
P4
TTPV Teams
Human resources - Staff surge update
• Recruitment of key staff surge completed with
additional map-power at regional and zonal
levels including within MOH
• Training of staff surge completed
Coordination
• Weekly UNICEF /WHO coordination meting
• Zonal coordination meeting (With regional
staff of WHO, UNICEF and MOH)
• Ongoing cross-border AFP notification and
investigation
• Ongoing communication with polio lab: Adhoc calls, visits, meetings
• Coordination activities through Horn of Africa
WHO and UNICEF HoA coordinators
Permanent
vaccination posts
(PVP) at cross border
and transit points
• Close to 300 permanent
vaccination posts were
identified at locations in the
country, all of them functional
• Transit points established at key
passage points between
districts (bus stations, airports,
check-points, markets,
hospitals, etc..) and at local and
international borders (crossborders, check points, airports
etc..)
• Weekly reporting of TPV data to
National level
Location and
number of
permanent
vaccination
posts by
districts
Zone
Central
South
Somaliland
Puntland
Total
PVP
116
76
54
54
300
Number of children vaccinated at transit
points, by zone and by month
November - 2013
December -2013
January -2014
February -2014
March -2014
Number
% of Zero
Number
% of Zero
Number
% of Zero
Number
% of Zero
Number
% of Zero
vaccinated
dose
vaccinated
dose
vaccinated
dose
vaccinated
dose
vaccinated
dose
Central
180732
0.0%
165695
1.7%
194751
1.4%
212984
1.0%
144,823
1.7%
Puntland
44815
0.3%
45463
0.6%
49109
0.5%
43052
0.3%
21,756
0.1%
Somaliland
15569
8.7%
14184
4.6%
17146
2.6%
14996
1.6%
7,319
1.6%
South
34929
0.0%
43092
8.3%
45972
8.9%
45853
10.9%
34,923
15.0%
Grand Total
276045
0.5%
268434
2.7%
306978
2.4%
316885
2.4%
208,821
3.7%
Zone
• 250, 000 children < 10 vaccinated every month at 300 transit points throughout Somalia
• The % of zero doses is tracked on a weekly basis
• The highest proportion of zero-doses reported from South zone and may reflect the
influx of population coming from inaccessible areas of South zones
Data as of 4 April 2014
Village Polio Volunteer
• Selected from the community
to extent AFP surveillance
down to the community level
(Community surveillance of
AFP cases
• Training and oversight of VPVs
conducted by DPO
• Standards reporting tools
developed and used
• Report submitted to Zonal and
Nairobi on weekly basis
• Impact on AFP surveillance
noted
Zone
VPV
North West
27
North East
54
South
127
Central
157
Total
365
Proportion of AFP cases notified by community volunteers
30%
25%
20%
15%
10%
5%
0%
26%
16%
*
2013
*VPV started in October 2013
*Data as of April 2014
#
2014
Accessibility status – a persistent
challenge
• 27 districts completely not
accessible for mass immunization
activities
• 12 districts partially accessible
(SIAs possible in major towns but
not rural areas)
No of
No. of partially
Inaccessible
inaccessible
Total Inaccessible
Regions
districts
district
children (<5 years)
Bakool
3
1
45331
Bay
1
4
82796
Galgadud
3
1
22561
Gedo
2
2
30670
Hiran
3
0
32769
Lower Juba
3
0
51935
Lower Shabelle
4
3
203656
Middle Juba
4
0
55379
Middle Shabelle
4
0
47393
Grand total
27
11
572490
Anticipated accessibility
• As the result of ongoing military
operations on the ground (Somali
forces backed by AMISOM) 7 new
districts with ≈ 110,000 children
are expected to open up for SIAs
• 6 of these districts were totally
inaccessible while 1 was partially
accessible
Location and population of potentially newly
accessible districts
Region
Bakool
Gedo
Hiran
Bay
Total
Updated accessibility map
once the 7 districts become
accessible
Anticipated newly accessible
districts
District
Rabdure
Hudur
Wajid
Burdubo
Bardera
Bulo Burti
Dinsor
Target pop <5 Years
3,453
16,365
9,986
7,793
22,876
15,706
33,524
109,703
Conclusion
Conclusion
• The country program continue to demonstrate its ability
to implement effective outbreak response activities
despite persistent challenges
• The current outbreak dynamic translates an overall
positive impact of outbreak response activities
• Risks to outbreak control persist, notably in the form of
persistent accessibility issues and poor routine
immunization
• Complacency in outbreak response activities should not
settle in
Thank you