Impact of Engaging Security Personnel on Access and Polio Immunization Outcomes in Security-Inaccessible Areas in Borno State, Nigeria

"The engagement of security personnel in immunization activities led to an improved access and improvement in postcampaign evaluation indicators in security-compromised areas of a Nigerian state."

Nigeria was polio free for almost 2 years but, with the liberation of areas under the captivity of insurgents, there has been a resurgence of polio cases. For several years, these inaccessible areas did not have access to vaccination due to activities of Bokoharam. This article describes the processes of engagement of security personnel in 33 outbreak response campaigns in security-compromised local government areas (LGAs) in Borno state and highlights the impact on immunisation outcomes between May 2016 and July 2016.

During the outbreak response to a circulating vaccine-derived poliovirus (cVPDV) from an environmental sample taken on March 23 2016, it was discovered that Maiduguri Metropolitan Council (MMC), Jere LGA, and some wards in Mafa and Konduga LGAs (all in Borno state) had many eligible children outside households that could be reached using directly observed polio vaccination (DOPV), but the challenge was dealing with the huge crowds associated with DOPV in an environment that was vulnerable bombings with improvised explosive devices. The authors and the state emergency operation centre (SEOC) reasoned that engaging the civilian joint task force (CJTF) could be central for a successful implementation of DOPV. Made up of energetic young men who may not have had any formal security training, the CJTF is a community-initiated security network that is supporting the Nigerian military in Borno state.

The authors developed PowerPoint presentations highlighting to the SEOC the benefits of DOPV and outlining a strategy for reaching the underserved. An advocacy kit that emphasised the benefits and dangers of reaching the isolated populations led to a joint decision to obtain CJTF security cover for the implementation of a DOPV strategy on May 13 2016. To facilitate the CJTF's acceptance, the authors used the influence of the state government to market the draft strategy to the CJTF. They also studied the operational processes and effectiveness of the CJTF and, given this understanding, worked out a feasible strategy.

The authors organised an orientation for the CJTF participants on their possible roles in the DOPV approach for security-compromised areas of the state. They deployed CJTF members to work in areas they were more familiar with and where they had some level of authority. A day was used to conduct dress rehearsals of the activities expected from the CJTF. A member of the CJTF was attached to a DOPV team in their domain, and they worked from the beginning to the end with their respective team members for the 2 days during which DOPV was conducted. A total of 611 persons were engaged in the June 2016 outbreak response, while 874 persons were engaged in the July 2016 outbreak response.

In addition, the authors conducted advocacy visits to the top military hierarchy in Borno state to obtain their support. The outcome of the meetings was the designation of their logistic focal points to coordinate the vaccination team's movements. This included the agreement on routes and the level of security required and type of military hardware to be deployed. The engagement with the military created a delivery corridor for the movement of vaccines, sachets of milk, detergents, and sugar to the state. Data were collected and transmitted daily through text messages in areas with a cellular phone network, while areas with no network were collated when the teams returned.

As a sequel to the security-enhanced vaccination activities in these high-risk areas, the authors evaluated the impact of the reach using qualitative and quantitative methods. They learned that, from 15 LGAs accessible to vaccination teams in January 2016, there was a 47% increase in July 2016. The number of wards increased from 131 in January to 162 in July 2016, while the settlement numbers increased from 6,050 in January to 6,548 in July 2016. The average percentage of missed children decreased from 8% in January to 3% in July 2016, while the number of LGAs with greater than 80% coverage increased from 85% in January to 100% in July 2016.

In short, the systematic engagement of security personnel improved access to security-compromised settlements, and the number of children vaccinated increased. Granted, many other interventions were concurrently happening along with the engagement of security personnel, and hence the improved outcome seen may also be attributed to some of these other interventions. However, these other interventions were ongoing before the engagement of the security personnel but the outcome did not show the improvement seen.

The authors recommend that the lessons learned from this approach should be applied in improving routine immunisation in security-compromised areas in conflict-prone areas of Africa.