We found an improved annualized non-polio AFP rate (ANPAFPR) in 21 LGAs of Kaduna state, Nigeria, in 2016, likely due to the implementation of different initiatives to intensify AFP surveillance. This improvement is largely due to increased AFP reporting by LGAs, a reduction in silent and under-reporting LGAs, an increase in the percentage of LGAs meeting the key AFP performance indicators, and increased numbers of AFP cases reported by special populations. The annualized non-polio AFP rate equals the detection rate since Kaduna state reported no WPV, cVDPV, or polio compatibles between January and June 2016. The improved AFP detection was accompanied by improved surveillance report submissions, with > 80% of the LGAs achieving > 90% completeness and > 80% timeliness.
The Zaria LGA recorded the highest improvement in the annualized non-polio AFP rate, while Giwa and Kubau LGAs declined in performance. The 23 LGAs in Kaduna state met the minimum annualized non-polio AFP rate (2/100,000 < 15 years old) and stool adequacy of > 80%. Two LGAs, Igabi and Kachia, reported more AFP cases than other LGAs from their special populations.
Training and sensitization to AFP surveillance was intensified across the 23 LGAs of Kaduna state. WHO, working with the state Ministry of Health and the state primary health care agency, organized training for DSNOs, assistants DSNOs, surveillance focal persons, clinicians, and community informants. The interactions provided by the training increased the capacity of trainees and made the surveillance network more robust and sensitive.
There was increased funding for AFP surveillance documentation, which greatly assisted the state in meeting the required standards of documentation for polio certification. The funds were utilized for procurement of shelves, display boards, stationery, and archiving of surveillance reports.
The expansion of the AFP surveillance network greatly improved AFP detection and reporting. There was a 20% increase in reporting of focal sites, which are health facilities that are routinely prioritized for active case searches for AFP and other epidemic-prone diseases. All General and Teaching Hospitals and some selected Primary Health Centers, based on client flow, the population of the settlement, and geography, were included in the AFP surveillance network. The engagement of additional community informants was another boost to the sensitivity of the AFP surveillance network. The community informants included nomadic contact persons, patent medicine vendors, traditional healers, bone-setters, and community leaders.
The inclusion of financial reward for all reported AFP cases greatly encouraged DSNOs, surveillance focal persons, clinicians, and community informants to detect and report AFP. There was a remarkable increase in AFP reporting after the introduction of the financial reward, which was further strengthened by the prompt redemption of 1000 Naira (3 USD) once the AFP was verified as “true” AFP.
Our findings are consistent with a previous study by Hamisu et al. in security-compromised northeastern states of Nigeria which showed that regular training and sensitization of health workers, community informants, caregivers, and expansion of the AFP surveillance network improved AFP surveillance indicators in security-compromised settlements [23]. Furthermore, our study also showed that other interventions worked. The implementation of a monetary reward for all reported AFP cases, engagement of contact persons in special populations (i.e., nomadic, hard-to-reach, and border settlements), and material and financial support for documentation and archiving may have contributed to the improvement in AFP performance indicators.
Our findings may be relevant in strengthening AFP surveillance systems in LGAs or states with suboptimal AFP performance indicators so that the march to Nigerian certification as polio-free is realized. It may also be useful to public health physicians, epidemiologists, and clinicians in the control and prevention of emerging and other priority diseases targeted for eradication or elimination. Other countries that are yet to interrupt poliovirus transmission, especially Pakistan and Afghanistan, may benefit from our findings.
We recognize limitations in our work. Our greatest limitation was suboptimal surveillance activities in the security-compromised settlements of Birnin Gwari, Chikun, Giwa, Igabi, and Kachia LGAs of Kaduna state. These security-compromised settlements were silent for AFP reporting, have no community informants, lack functional routine immunization structure, and were largely inaccessible during SIA campaigns. These settlements were not prioritized for AFP surveillance, owing mainly to insecurity and the fact that supervisors cannot access them for active searching for AFP cases. The re-emergence of Nigeria as a polio-endemic country, following the reporting of two WPVs in Gwoza and Jere LGAs of Borno state, has shown the need for a resilient structure against the re-emergence of poliovirus [12]. However, we believe that intensifying current initiatives, implementing the recommendations of the 13th GPEI IMB report, improving AFP surveillance in security-compromised settlements, and firming up waning government commitment to polio eradication will guarantee a resilient structure against the re-emergence of poliovirus in Nigeria [12]. The sustainability of monetary rewards for all AFP reports is a limitation of this study, but ownership of the program by the government and the availability of a budget for surveillance at the state and LGA levels will ensure the program is sustained. Our study cannot infer causality, and the improvement in AFP surveillance indicators documented in Kaduna state in 2016 may be due to other factors, such as contributions of ministries of education, agriculture, and budgets not considered by the authors. However, we strongly believe the initiatives we implemented have greatly contributed to the success recorded in AFP surveillance.
