Nigeria experience on the use of polio assets for the 2017/18 measles vaccination campaign follow-up

Background: The global polio eradication initiative has made giant stride by achieving a 99% reduction in Wild poliovirus (WPV) cases, with Nigeria on the verge of being declared polio-free following over 36 months without a WPV. The initiative has provided multiple resources, assets and lessons learnt that could be transitioned to other public health challenges, including improving the quality and vaccination coverage of measles campaigns in order to reduce the incidences of measles in Nigeria. We documented the polio legacy and assets used to support the national measles campaign in 2017/2018. Methods: We documented the integration of the measles campaign coordination with the Polio Emergency Operation Centre (EOC) at national and state levels for planning and implementing the measles SIA. Speciﬁc polio strategies and assets, such as the EOC incident command framework and facilities, human resource surge capacity, polio GIS resource These strategies were adapted and adopted for the MVC implementation overcome challenges and improve vaccination coverage. We evaluated the performance through a set process and outcome indicators. Results: All the 36 states and Federal Capital Territory used the structure and resources in Nigeria and provided


Introduction
Nigeria is on the verge of being declared polio-free following over 36 months without a wild poliovirus (WPV).As part of the efforts to achieve polio eradication, as committed by the World health assembly in 1988, countries through the Global polio eradication Initiatives, have achieved a 99% reduction in wild poliovirus (WPV) cases through the Polio Eradication Initiative (PEI) programme [1].This programme has provided multiple resources and assets to ensure that immunity against the WPV is achieved and sustained to prevent paralytic polio [2].
The goal to achieve polio eradication has faced and overcome several challenges to get to this stage.These challenges have been well documented across low and middle-income countries (LMIC) [3][4][5].Lessons learned from the programme may remain handy tools in addressing other health programme challenges [6,7].The broader public health efforts of the polio programme and its economic impact have been well documented [8,9].
Nigeria has made tremendous progress in its efforts to interruption and has remained polio-free for over 36 months in 2020 [10].
As progress is made towards this goal, the GPEI and its partners have put in place a strategy to ensure that assets made available through the PEI programme are not lost but made available to help countries achieved identified health goals [11].This strategic approach is outlined in the Polio Eradication End Game Strategic Plan 2013-2018 [12].The requirements for this plan are also highlighted in the Polio Post Certification Strategy (PCS) [13].
Nigeria, like other countries, has been at the forefront of transition planning and continues to make available the polio resources to support other programmes [14 -16].Asset mapping of polio personnel has also documented the use of Polio assets spending 54% of their time on other activities including routine immunisation (RI), measles and rubella control efforts, new vaccine introductions, outbreak response etc. [17].
Majority of the assets available to the polio programme in Nigeria include human resources at various levels of >2500 personnel, small and extensive assets as well as intangible assets documented as best practices/lessons learned from the polio programme [18].These include microplanning, use of geographic information system (GIS) technology for mapping, vaccination team tracking, activation of the emergency operation centres and use of mobile phones for tracking team supervision using open data kit (ODK) [19,20].
Efforts continue, in Africa and other parts of the globe, to address high levels of morbidity and mortality from vaccinepreventable diseases (VPDs).The suboptimal routine vaccination reported in parts of the continent, continue to predisposed children missed with required vaccinations to these diseases [21].This is despite the global vaccine action plan (GVAP) and the support of the Gavi alliance to achieve optimal immunisation goals [22].
Supplemental immunisation activities (SIAs) continue to be implemented based on risk assessments to bridge these gaps to ensure achievement of measles elimination and control efforts [23].These SIAs are planned across various countries with technical guidance by the WHO and the Measles-Rubella Initiative (MRI) [24].
The Government of Nigeria with partners, with Gavi support, planned and implemented a follow up national measles vaccination campaign (MVC) targeting children aged 9-59 months in 2017/2018.To enhance the quality of the 2017/2018 MVC and ensure the achievement of the programme target of 95% vaccination coverage, the National Measles Technical Coordinating Committee (NMTCC) was set up by the National Primary Health Care Development Agency (NPHCDA) [25].
There is no report which has systematically documented the use of polio assets in supporting previous Measles vaccination campaigns in Nigeria before 2017.
This report aims to document the polio legacy and assets used to support the national measles campaign in 2017/2018, its efforts in improving the quality of the campaign and measles elimination and control goals in Nigeria.

Methods
Coordination and integration of the NMTCC with the Polio EOC at National and State levels for planning and implementing the measles SIA were identified.How specific polio strategies and assets (e.g., EOC incident command framework and facilities, human resource surge capacity, polio GIS resource etc.) were adapted to MVC implementation to overcome challenges and improve vaccination coverage are described.The Post Campaign Coverage Survey (PCCS) methods have been described in detail elsewhere [26].
We reviewed the leverage of the listed polio assets and their utilization to support the measles follow up campaign conducted in 2017/20018 in Nigeria.

Polio emergency operation centres (EOCs)
Established in Nigeria in 2012, the Polio EOC is a governmentled structure and process in which key government and polio eradication partners' staff work together in the same facility, with the aim of improving information sharing as well as joint programming (planning, implementation, monitoring and evaluation) and avoiding distractions, with the full responsibility of achieving the targeted goals and objectives.The EOC promotes a framework for joint problem identification and solving and enhancing a more coordinated response to evolving issues.
The EOC structure falls under the PEI Coordinating Mechanisms (Fig. 1), in which the Presidential Task Force on Polio Eradication and Routine Immunisation (PTFoPE) provides oversight to the PEI program, and thereby, the polio EOC, in Nigeria.The PTFoPE monitors progress at the State and Local Government Areas (LGA) levels through quarterly meetings, with the following objectives and activities: 1. Set and enforce national targets and milestones for polio eradication within 24 months.2. Report to Mr President monthly on the progress, challenges and corrective actions being taken to stop polio in Nigeria and request the President's direct engagement as necessary.3. Focus attention and action in the most vulnerable and highest risk wards, LGAs and states and monitor their progress monthly through an LGA and State accountability framework.4. Lead routine reviews on polio eradication, direct and take corrective actions. 5. Advocate for the leadership of LGA Chairmen and state Governors in the polio eradication effort.6. Mobilise specific States, LGAs, partners, traditional and religious leaders, international partners, civil society, the media and the general public as required to ensure high quality, funded polio eradication activities.

NMTCC mission and integration into the polio EOC
The structure and coordination of the NMTCC were adapted from that of the polio EOC.The NMTCC is led by Chairman and The NMTCC members adopted the polio EOC structure in dedicating 100% of their working time to the committee, meeting daily at the EOC premises, and instilling a sense of emergency in MVC operations.Based on their areas of expertise, NMTCC members and partners were assigned specific thematic areas to support and monitor and were assigned to work within related working groups (WGs), including Advocacy, Communication, and Social Mobilisation (ACSM); Training; Logistics and Cold Chain; Adverse Events Following Immunization (AEFI) Monitoring and Reporting; and Monitoring and Evaluation (M&E), similar to those of the polio EOC.The organizational structure of NMTCC and the MVC is demonstrated in Fig. 2.
This structure and coordination of NMTCC were replicated in all states, with the support of Polio EOCs.State-level coordination of the MVC was chaired by the respective Executive Secretaries of the State Primary Health Care Development Agency (SPHCDA).The state MTCC (SMTCC) members were pooled from the SPHCDA and immunization partners.Due to various challenging issues identified by the NMTCC, management support teams (MSTs) and measles consultants (MCs) pooled from NPHCDA, WHO, AFENET/NSTOP and UNICEF were assigned to states to oversee clusters of LGAs in all the states from planning through implementation.

Measles Core Working Group
The coordination and function of the PTFoPE of the PEI coordinating mechanism were adapted to form of the Measles Core Working Group.The Core Working Group operated under the oversight of the Executive Director (ED) of NPHCDA and comprised NMTCC members and all partners supporting the MVC.

Collaboration between polio EOC and NMTCC
The collaboration between polio EOC and NMTCC, and specific polio EOC assets and approaches applied used by the NMTCC for the MVC are illustrated in the following specific examples: 1.The National polio EOC facility accommodated the NMTCC, providing a secure, dedicated workspace with consistent power, internet access and communication capability.2. At the national level, the NMTCC established separate working groups for Operations, (planning and microplanning); training; advocacy/communication and social mobilization (ACSM); logistics, monitoring and evaluation/data management, which paralleled those of the polio EOC teams.3. The Polio EOC working groups provided some mentoring and support to the measles teams, but later, the work was done by the measles teams independently to avoid distracting the polio teams from their mission.For example, polio EOC data teams supported the NMTCC teams in microplanning, monitoring the implementation of the campaign, and reviewing the end-process data.4. The NMTCC had its Chairman (a director), separate from the polio Incident Manager.Frequent communication between these two executives was fostered by their being housed in the same facility.Additionally, they occasionally attended cross-mission meetings.5. MVC timing in specific states was carefully coordinated with polio EOC to avoid programme overlaps with ongoing polio campaigns.The polio agenda was given top priority and precedence.6.The EOC structures in seven states (e.g., Bauchi, Borno, Kano, Kaduna, Katsina, Sokoto and Yobe) were deployed to coordinate the measles campaigns at the states' levels, and these EOCs served as command and control centres for the MVC in these states.7.At the state level, polio staff and teams performed most of the MVC command and control functions, and separate measles teams were not established.8. State polio incident managers took the lead in managing and coordinating the MVC in their respective states.9. Polio immunisation strategies such as those designed to reach hard to reach/security compromised areas (HTR), voluntary community mobiliser (VCM) networks (a focused initiative that recruits and train local women from the community as social mobilizers and vaccination workers), and house to house (H2H) mobilisation were utilised for the MVC.Jigawa state used this effective strategy to achieve a PCCS result of 95.2%.

NMTCC mission and integration into the polio EOC
NMTCC provided oversight and coordinated all activities of the working groups, the responsibilities and activities of which included: 1.All working Groups: Updating the field guidelines and standard operating procedure (SOPs).Members of the NMTCC have dedicated zonal technical officers (ZTOs) for measles, liaising with their state counterparts.Each NMTCC member was also assigned as liaison officer to specific states.During the campaign planning and implementation for each campaign stream, daily interactions were held with each state in the stream, led by the liaison officer assigned to the state.The NMTCC analysed pre-implementation data and presented to the team every Thursday for monitoring and evaluation.

Measles Core Working Group
The Core Working Group established national MVC targets and reported weekly to the ED on the progress, challenges and corrective actions being taken to achieve the goals of the MVC in Nigeria, and to request the direct engagement of the ED with state governors, as necessary.The strategic advocacy of high government officials at national and sub-national levels, including the engagement of the Nigeria Governors' Forum with a signed agreement to support the MVC, had led to the ownership of the program and participation by government officials.

Addressing challenges of previous SIAs and MVC innovations
The adoption of polio EOC structure and strategies for this MVC helped to overcome numerous challenges of previous measles SIAs,  such as lack of high-level political commitment and poor planning.In addition to applying lessons learned from polio EOC, the MVC built on these lessons to develop innovative methods to improve and enhance planning and implementation monitoring to address these challenges.Examples of the innovation were the use of GIS technology for vaccine team planning and distribution, and ODK for real-time data collection from independent monitoring and supervision, which allowed for improved distribution of supervisors; introduction of state counterpart funding as a requirement for participation in the MVC.Campaigns were postponed in states which delayed funds release and use of Intelligence officers in tracking the use of funds in the field.The staff of the Department The value added by the adoption of these strategies is reported in Table 1, and Table 2, which presents key challenges of previous campaigns, the polio EOC strategy or MVC innovation applied to overcome them, and the related outcome from the 2017-2018 MVC.
As shown in Table 3, all 36 states + FCT (100%) in the country provided a counterpart fund for the MVC 2017/ 2018.All the polio high-risk states deployed the use of GIS for microplanning process and deployment of vaccination posts daily implementation plans.Furthermore, all the 774 LGAs in Nigeria were tracked using standardised daily call-in data template and 70,846 reports were received in real-time by the supervisor using ODK.

Post campaign coverage survey
The post-campaign coverage survey results of the 2015/2016 measles SIAs have shown that measles coverage results were below the set targets of 95.0% at 84.5% (95%CI:84.0-85.0).The proportion of children aged 9 months to 59 months who received measles vaccine during the 2017/2018 MVC was 87.5% (95%CI: 86.2-88.7)(Table 4).Twenty-four states plus FCT (65%) of subnational/states reports following the post campaign surveys had higher validated coverage in 2018 compared to 2015 ranging from <1% in Benue to 22% in Bayelsa state.In 2017/2018, five states out of 36 states and FCT-Abuja achieved more than the target 95% coverage during the campaign while only one state achieved this target in 2015(Table 4a).

Discussion
We documented the use of PEI governance and operational structure enhanced the implementation of the measles SIAs through the political and counterpart financial support of all the state Governors.We found that while national coverage in 2017/2018 was higher, 24(64%) out of the 36 states plus FCT had higher coverages in 2017/2018 compared to 2015.We also reported that 75% of the sub national levels reported a campaign readiness dashboard of 90% one week before the campaign.Leveraging on the engagement with the governor's forum and the implementation of the Abuja commitment for polio and routine immunization was also extended to measles SIAs planning and coordination.Similarly, monitoring of the Abuja commitment was found to improve polio SIAs performance [27].
We equally found that to improve the quality of the measles microplanning process, all the states with a lot of polio used GIS.This finding is similar to the result of the vaccination tracking and household-based microplanning in 2014, in Kano, where GIS was used to complement the household-based micro planning to improve polio SIAs tracking and improved coverages [28,29].
The monitoring of campaign readiness through regular assessment and the deployment of supervisors to the field does not only support the process but also ensure the timely identification of impediments to effective SIAs implementation.The MVC was coordinated and monitored through the application of periodic campaign readiness and provision of real-time supervisory, both pre and intra campaign.This conforms with the application of the PEI dashboard and accountability framework used for ensuring high-quality SIAs outcomes as reported by Tegegne et al. in 2014 [28].
The leverage of the polio structure contributed to a success of achieving 87.5% national post-campaign coverage, based on the post-campaign evaluation survey, which was higher than the 2015/ 2016 coverage of 84.5%.Similar leveraging of the polio programme infrastructure in Nigeria was documented to support response to the Ebola Virus Disease outbreak in Nigeria 2014 as reported by Vaz et al. [29].
One of the limitations of this study is the differences in the postcampaign coverage survey (PCCs) designs.The 2018 PCCS was conducted according to the revised 2018 WHO survey guidelines while the 2015 surveys were done using the outdated 30 by 7 approach.While the two surveys provided National and State level estimates, it is essential to note that there may be some slight variations as a result of differences in survey designs.However, the methods used were the recommended protocols by WHO at the time of the campaign.Another limitation is the timing of the SIAs implementation.When campaign planning coincides with the national election, as occurred in the 2015 campaign, the preparation and the contribution by the political leaders, usually diminishes.
Many polio eradication assets and lessons learned have already been applied to measles elimination efforts as the eradication, and elimination efforts have similar strategies and program implementation infrastructure needs as stated by Goodson et al. in 2017 [30].Therefore, polio eradication activities are easily integrated with measles immunization activities.The strategies and resources used by Nigeria's polio EOC for polio eradication are similar to those needed to mount effective measles SIAs, i.e.Communication and social mobilization networks, monitoring campaign planning partnership, coordination, advocacy, resource mobilization activities and using accountability frameworks.
The MVC relied on GPEI strategies, structure and assets, including the staff and physical infrastructure that are used to support the program.Polio EOC staff provided technical and operational support for the MVC, such as support for national planning, techni-cal assistance and training, and GIS technology and mapping for target population estimation and progress tracking.However, the MVC adopted other strategies, such as linking state release of counterpart funding to the participation in the campaign, engagement of State Intelligence machinery in tracking fund misuse in the field, using GIS data for expanded microplanning, and using ODK data for real-time tracking supervision and rapid convenience monitoring (RCM) data.

Conclusion
Although the 2017/2018 MVC fell short of achieving the national 95% coverage targets, leveraging on the Polio assets and lessons learned to support MVC planning and implementation may have contributed to planning, accountability and availability of human and fiscal resources required for the measles campaign.This also included high-level advocacy, improved collaboration and coordination between national, state and LGA levels.In leveraging the polio assets and best practices, NMTCC has demonstrated the use of polio assets in planning, implementing and evaluating a measles vaccination campaign in Nigeria.Our study has shown that with integration and collaboration with other programmes, polio assets can be leveraged on and contribute to the achievement of expected programme targets for measles elimination and control.
Deputy Chairman (equivalent to the EOC Incident Manager and Deputy Incident Manager) and is composed of technical staff from various departments of NPHCDA (including the Departments of Disease Control and Immunization, Community Health Services, Advocacy and Communications, and Logistics), with expertise in data management, logistics, monitoring and evaluation, communications, and training.Additionally, staff from key partner organizations, including WHO, UNICEF, Bill and Melinda Gates Foundation (BMGF), Clinton Health Access Initiative (CHAI), US Centers for Disease Control and Prevention (CDC), and African Field Epidemiology Network (AFENET), worked alongside NMTCC, providing technical assistance and operational and logistical support throughout the campaign.There was also an established collaboration between the NMTCC and several line ministries, including the Ministries of Education, Defense, Interior, Environment, Women affairs, and Finance.

5 .
Adverse event following immunization (AEFI) Monitoring and Reporting: Identifying and designating referral hospitals for AEFI management; procuring and distributing AEFI kits; planning AEFI case management; monitoring and auditing all AEFI.6.Data Management: restructuring data management tools, developing architecture for data collection and reporting and conducting all data management, analysis and presentation activities during the campaign.7. Monitoring and Evaluation: Restructuring microplanning, implementation, monitoring and supervision tools, reviewing and verifying microplans, and providing oversight to monitoring and supervision activities, patterned after the polio EOC model.

Fig. 2 .
Fig. 2. The organisational structure of the National Measles Technical Coordinating Committee and the Measles Vaccination Campaign.

Table 1
Summary of polio assets and best practices used in the 2017/2018 MCV in Nigeria.

Table 2
Key Challenges Overcome, Strategies Applied and Improvements of MVC -Nigeria, 2017-18.Special effort to reach HTR and security compromised areas, e.g.cooperation with the army Challenges in tracking the use of funds at the subnational levels MVC Innovation in using State intelligence infrastructure to identify and address funds misuse issues DSS identified and addressed issues with funds misuse in 16 states.Some staff were required to refund monies.
C8of State Services (DSS), were engaged at the subnational level to track use of funds in the field.They were able to identify and arrest funds misuse in 16 out of 36 states plus the Federal Capital Territory (FCT).

Table 3
The outcome of strategies and innovations applied during the Measles vaccination campaign 2017/2018, Nigeria.