www.ijsernet.org Page 182
EFFECTIVENESS OF MASS POLIO CAMPAIGNS IN THE GLOBAL
RESPONSE TO POLIO ERADICATION/ELIMINATION IN AFRICA.
Victor Emali Mukaka
Masinde Muliro University of Science and Technology | P.O Box 190 - 50100, Kakamega, Kenya
ABSTRACT Background
Globally, the World Health Organization has recommended mass polio campaigns as the key towards eradication of poliomyelitis, however many countries in Africa have adopted delivery of immunization services from fixed sites. This approach seem to cater majorly for those who seek care in the health facilities and thus this approach has been faulted for not being effective towards realization of a free polio generation. Although mass campaigns provide high immunization coverage, many African nations have been slow to use this approach. This systematic review has assessed the effectiveness of mass polio campaigns in Africa by providing an overview of the barriers and facilitators to mass immunization campaigns.
Methods
A systematic review using PRISMA statement (Preferred reporting items for systematic reviews and meta-analysis has been conducted in English. Published articles on Medline, CINAHL, Embase and Scopus by searching key words such as vaccinations, poliomyelitis eradication, campaigns and Africa were accessed. Articles with different study designs were included in the final analysis based on quality assessment by adopting the Down and Black Checklist. This systematic review has been approved by Queensland University of Technology.
Results
www.ijsernet.org Page 183 Conclusions
From the review it can be concluded that mass polio campaigns complement routine polio immunization in the fight against global eradication of polio. The frequency and quality of these campaigns will be instrumental in determining how long it takes for this reality to be met
Keywords: Mass campaigns; polio eradication; supplementary polio immunizations activities; African countries; acute flaccid paralysis surveillance.
Acronyms and Abbreviations
OPV Oral Polio Vaccine
MOPV Monovalent Oral Polio Vaccine
bOPV Bivalent Oral Polio Vaccine
tOPV Trivalent Oral Polio Vaccine
IPV Injectable Polio Vaccine
SIAs Supplementary Immunization Activities
SNIDs Sub National Immunization Days
WHO World Health Organization NIDs National Immunization Days
AFP Acute Flaccid paralysis
INTRODUCTION
Poliomyelitis is still a serious disease which causes substantial disability through motor-neuron Paralysis. Further to state importation of Wild polio virus into non endemic African regions will remain a risk as long as the transmission is still rampant in nations considered to be endemic (Kretsinger, 2014)
www.ijsernet.org Page 184 government in 2003 whilst in Pakistan 26 polio workers were killed during the national polio campaigns (Baron and Claire Magone, 2014). According to WHO bulletin (n.d) worldwide more than ten billion doses of polio vaccine have been administered during mass campaigns at an estimated cost of 4.5 billion US dollars following the World Health Assembly resolution of 1988.Despite all these interventions pockets of Wild polio virus tend to be a cause of concern for the experts worldwide.
Mass polio immunization to all children below the age of 5 years has been adopted as one of the global strategies in place in the eradication of polio since It has been established to be more effective than routine immunization (Miyamura, 2012).In Latin America , mass polio campaigns has been successful in the eradication of polio. However the specific reason behind this achievement is yet to be stablished (Linkins et al, 1995). However it has been postulated that children in nations that implement this approach of mass immunization get more than 14 doses of Oral polio vaccine through mass campaigns and routine immunizations hence boosting their immunity against Polio. (Reichler, 1997).
Trends in Routine immunization reveal that no more than 80% of the newborns worldwide get three doses of Oral polio vaccine and achievement in immunization outcomes is lowest in Africa as evidenced by merely half of all the children receiving doses of Oral Polio Vaccine in their first year of life (Hull & Aylward, 2001). Current coverage in routine immunization makes the polio eradication reality more worrisome. Evidenced by the trends in coverage whereby, in 2010 the African region only managed to attain 74% coverage in OPV type 3 which even
dropped further to 71% in 2011 compared to the WHO target of >80% coverage (Okeibunor, 2014).
www.ijsernet.org Page 185 It is estimated that over 2 million paralysis were prevented in China, USSR, the USA, Europe, and Oceania 20 years since introduction of Mass immunization with polio vaccine (Sabin, 1984). Moreover the number of polio endemic countries worldwide reduced to 3 in the year 2013 compared to 1998 where we had 125 countries, nevertheless the number infected countries following importation of Wild polio virus was at 5 in the year 2013 (Global Immunization data, 2014).
Polio and its Epidemiologic characteristics
Polio is disease that often invades the nervous system and most often is caused by the polio virus (WHO, 2015). The main mode of spread is through faecal-route and less often may be spread through contaminated water or food (WHO, 2015).It affects children aged below 5 years but at times may also affect adults with chances of death more likely as one ages(Robin & McFee,2013). As stated by (Miyamura, 2012, Robin & McFee, 2013) the following characteristics are associated with Poliomyelitis
1. Polio is a fatal communicable disease that causes paralysis especially in children and currently has no cure, with focus being supportive for those afflicted and vaccination being a preventive strategy
2. The main distinguishing feature of the paralysis caused due to polio is the Asymmetric flaccid (AFP) paralysis which makes its distinct from other neurologic illnesses resulting in the weakness of the arm or leg.
3. Out of every 200 cases 1 will suffer from likely irreversible paralysis that often occurs within hours of infection and amongst those paralysed, the fatality rate is estimated to be approximately 5 to 10%
4. Most poliovirus infections are asymptomatic and thus difficult to diagnose by signs and symptoms alone, virological diagnosis is also difficult especially when differentiating vaccine type from wild type polio strains
5. 4 to 8% show signs and symptoms and will present with fever, listlessness, vomiting , headache, flu-like symptoms, stiff neck and back, and painful limbs
www.ijsernet.org Page 186 poliovirus circulation in the developing nations (Dowdle eta al,2003).Furthermore in 2002 ,polio was found to be endemic only in 7 countries(WHO,2002).
Strategies for eradication
Eradication of polio aims at ensuring all wild polio virus transmission cease, and the measures in place to achieve this goal as per World Health Organization are enhancing National Immunisation Days (NIDs), Acute Flaccid Paralysis (AFP) surveillance, routine immunization, and Mop-up Immunization activities ( Hull et al 1994).
Aims and objectives
This systematic review will focus on assessing the effectiveness of mass polio campaigns in Africa by providing an overview of the barriers and facilitators to mass immunization campaigns towards polio eradication in Africa and eventually provide alternative approaches to mass polio campaigns recommended in the literatures.
Definition of Terms
National Immunization Days (NIDs)-is a strategy for delivering OPV to all children aged less than 5 years also referred to mass campaigns. NIDs act by rapidly raising population immunity, especially intestinal secretory immunity, and by doing so interrupt the circulation of wild polioviruses responsible for polio outbreaks. Generally, two doses are given approximately 1 month apart. And all children are immunized regardless of prior immunization status. To be successful, NIDs must reach all children (Hull & Aylward, 2001).
Routine immunization- a cornerstone of polio eradication strategy, as per WHO recommendation is that all children are expected to receive a minimum of three doses of oral polio vaccine in the first year of life scheduled as from birth and at 6, 10, and 14 weeks of age and an additional fourth dose in polio endemic countries, a coverage of more than 90% is recommended for routine immunizations (Hull & Aylward, 2001).
www.ijsernet.org Page 187 Mop-up campaigns-are door to door immunization sessions undertaken in specific areas or regions where the wild polio virus is known or suspected to be still circulating, other criteria for identifying this areas include areas with high population densities, high population mobility, poor hygiene measures and areas of low coverage in routine immunization where access to health care is difficult (Hull et al, 1997).
Oral Polio Vaccine (OPV) - is also referred to as “trivalent oral polio vaccine” or Sabin vaccine”, it contains a mixture three live attenuated poliovirus strains; it Produces antibodies in the blood to all these strains, identified as type I, type II and type III. It also produces a local mucosal immune response in the mucous membrane of the intestines (Shuaibu, 2015) different types of oral polio vaccines are used during campaigns in order to eradicate polio and they are abbreviated as tOPV which contains all the three strains of the polio virus, type I, II and III, this vaccine is most often used in routine immunizations. bOPV, contains two strains of polio virus most commonly used in mass campaigns depending on the wild strain polio virus isolated and mOPV, not so commonly used but is often used in campaigns depending on the type of polio virus strain isolated, it only contains one strain of the polio virus.
2. MATERIAL AND METHODS
2.1 Search strategy
A systematic review was conducted by accessing bibliographic databases, volumes of specialist journal, reference lists from retrieved articles, research registers (Cochrane library).The search key words are mentioned in Table 1 below which were accessed through Medline (Via EBSCOhost), CINAHL (Via EBSCOhost), Embase (via Embase.com) and SCOPUS from January 1995 to November 2015. Database search was conducted in November 2015.
2.1a Inclusion criteria:
- All relevant studies regardless of the study design
-Articles published in English
-Peer reviewed articles
-Those that addressed mass polio vaccination or routine polio immunization in under five year olds in African countries.
b Exclusion criteria:
www.ijsernet.org Page 188 -Articles addressing polio eradication in over 5 year olds
-Articles published more than 20 years ago
Table -1: Search strategy
Vaccination or immunization AND polio or poliomyelitis or acute flaccid paralysis AND elimination or eradication AND campaigns AND Africa AND children
Quality assessment
Quality assessment of accessed studies was done by using a checklist adopted from Downs and Black (1998). The feasibility of creating a checklist for the assessment of the methodological quality both of Randomised and non-randomised studies of healthcare interventions. This systematic review is reported using the PRISMA statement (“preferred reporting items for systematic reviews and meta-analyses”) by Moher D et al (2009) as highlighted in figure 1 below. A score of 2 was awarded if the journal met the criteria, a score of 1 if limited information was supplied and a 0 if no information was provided.
Checklist for measuring study quality
1. Is the hypothesis/aim/objective of the study clearly described?
2. Are the main outcomes to be measured clearly described in the introduction or methods section?
3. Are the interventions of interest clearly described?
4. Are the main findings of the study clearly described?
5. Were the study participants’ representative of the entire population from which they were recruited?
6. Were the limitations of the study addressed?
7. Did the studies report coverage in both routine and campaign polio activities
8. Did they report on Acute Flaccid paralysis surveillance
www.ijsernet.org Page 189 PRISMA flowchart for identifying studies
During this systematic review, 1288 papers were accessed initially and finally 14 papers met the review criteria and were included in this study, 7 studies were excluded because they did not include minimum outcome criteria to include acute flaccid paralysis surveillance data, no data on polio routine coverage and data on supplementary polio immunization activities, some reported incomplete results. These studies had been conducted in children below age of 5 years in Africa as highlighted in figure 1 below.
Figure 1. Systematic review flow diagram: effectiveness of mass Polio campaigns in the global response to polio eradication.
Full-text articles excluded, with reasons
(n = 7) Studies included in qualitative synthesis
(n =14 ) Records identified through
database searching (n = 1,288)
Records after duplicates removed
(n = 342)
Additional records identified through other sources
(n = 5)
301 excluded after reading abstract and checking selection criteria
Id
ent
ifi
ca
ti
on
Scr
ee
n
in
g
Records screened
(n = 41) reading whole article and Records excluded after
checking selection criteria (n = 20)
El
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www.ijsernet.org Page 190 Systematic literature appraisal results
Among the key objectives assessed were whether an article reported both on routine polio coverage and mass polio campaign, and acute flaccid paralysis surveillance. Among the included studies, two studies were classified as high quality studies with a score of 16 and 15 respectively , 11 as medium quality with a score ranging from 13 to 12and only one study being rated as low quality with a score of 11 as highlighted in table 2 below.
Table 2: Systematic literature appraisal results
No. Author Reference/item Score(16)
1 2 3 4 5 6 7 8
1 Shuaibu et al,2015 2 2 2 2 2 2 1 0 13 2 Ado et al,2014 2 2 2 2 0 2 1 2 13 3 Kretsinger et al, 2014 2 2 2 2 2 2 2 2 16 4 Mbaeyi et al,2014 2 2 2 2 0 0 2 2 12 5 Sheik et al, 2014 2 2 2 2 2 2 1 0 13 6 Okeibunor et al, 2013 2 2 2 2 2 2 1 0 13 7 Helleringer et al,2012 2 2 2 2 2 2 1 0 13 8 Arevshatian et al,2007 2 2 2 2 2 2 1 2 15 9 U.S .Centres for Disease
Control, 2003
2 2 2 2 1 0 2 2 13
10 U.S .Centres for Disease Control, 2001
2 2 2 2 1 0 2 2 13
11 U.S .Centres for Disease Control, 2000
2 2 2 2 1 0 2 2 13
12 U.S .Centres for Disease Control, 1997
2 2 2 2 1 0 2 2 13
www.ijsernet.org Page 191 Reference Country/
continent
Study design Population focus Methods Main outcome measures
Findings Qu alit y sco re Shuaibu et al, 2015
Nigeria Cross sectional -Children aged 0-59 months In North eastern Nigeria
-Two parallel
campaigns [OPV target age 0-59 Months, and IPV target age-14 weeks-59 Months]
-Immunization coverage in IPV and OPV
-OPV coverage for Borno and Yabe was 105% and 103%. -IPV coverage for Borno and Yabe was 102% and 99%. -Use of IPV is viable in mass campaigns.
13
Ado et al,2014
Nigeria retrospective cross- sectional
-children<5 years in Nigeria
-Review of SIAs and type of vaccines used.
-Vaccination activities
-cases of polio reported was 53 in 2013 and 122 in 2012
-LQAs results at the ≥90% threshold
increased from 7% -42%,80-
89% threshold increased from 9% to 30%
13
Kretsinger etal (2014)
Africa Retrospective cohort study
-Under 5 year olds in Africa
Review of polio performance African region(AFR) of the
Coverage of routine and mass campaign (SIA’s) -Routine coverage with 16 World Health Organization
in AFR region. WPV
surveillance
OPV increased from 72% -74%.
-OPV for SIA use increased from 335 Million in 2008 to 548 million in 2012. -bOPV increasingly replaced tOPV in SIA’s to provide improved immunogenicit y against WPV1 and WPV3. -Nigeria had 53 confirmed polio cases due to WPV
infection, a 57 % decrease compared to previous year, and no confirmed case of WP3 infection since November 2012.
www.ijsernet.org Page 192 countries- Angola, the DRC, and Chad- nor from the countries in the West Africa importation belt. Mbaeyi et al (2014)
Somalia Retrospective Cohort study
-Under 5 year olds, in Somalia.
Supplementary Immunization activities, routine immunization and surveillance.
Progress made by Somalia’s polio eradication program over the past 15 years
-OPV coverage was <50% from 1998- 2012[expected ≥90% in routine immunization services. -During 1998– 2012 SIAs, mean coverage estimates Ranged from 73% (in 1999) to 106% (in 2011). In the Northeast zone.
-86% (in 2002) to 105% (in 1999) in the Northwest zone.
-88% (in 2010)
12
to 125% (in 1998) in South Central Somalia. -Vaccine refusals were consistently <1%.Data from these campaigns suggest high administrative coverage >90%
The number of reported WPV cases increased over the surveillance period, from 12
in 1998 to 96 in
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Somalia subsequently remained free of polio until April
2013,when WPV led to 173 additional cases.
Sheikh et al,2014
Kenya Randomized controlled trial
-Under 5 year olds, in refugee camps and surrounding communities
- mass campaign using IPV and OPV in refugee camps and surrounding communities -increasing population immunity levels to ensure interruption of any residual WPV transmission and prevent spread from potential new importations. -OPV &IPV coverage in December, 92.8% in refugee camps, 95.8% in surrounding communities. -OPV in the November campaign 97.2% in the refugee camps and 97.3% in the surrounding communities. 13 Okeibunor et al(2014)
Africa retrospective cross- sectional
-Under 5 year olds, in Africa.
-6 localities were randomly selected and in each locality, 2 villages were
selected, where 10 and 15
Proportion of children missed during the SIA’s
-There was a decrease in the number of children missed during SIA’s in the region, from 7.94% in 2010
13
households randomly selected in a district. -Monitors visited at least 60 households a day.
to 5.95% in 2012, mainly in Central and West African blocks. -The East and Southern African bloc had countries with as much as 25% missed children. Helleringe r et al(2012) Non polio- endemic sub- Saharan African countries Retrospective cross-sectional
-Under 5 year olds, in Sub Saharan Africa.
-Data review from Demographic and Health Surveys (DHSs), Multiple Indicator Cluster Surveys(MICSs) and the 2010 Mobile Technology for Community Health (Mo-TeCH) survey To determine participation rates in polio supplementary immunization activities (SIAs) -Overall participation in SIA ranged from 70.2% to 96.1%
and > 85% for routine
immunization users.
-Prior use of routine immunization and compliance with the routine OPV schedule showed a strong positive association with SIA participation. 13 Arevshatia n et al ,2007
Africa Retrospective cross
sectional
-Under 5 year olds, in Africa.
-Data review and analysis of existing data sources. -Routine immunization coverage estimates -Polio endemic countries declined from 11 in 2000 to 2 in 2002
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-Reported incidence of polio declined by 89%, from 1863 cases to 208 cases in 2002. -polio was endemic in Nigeria, Niger and Chad. -In 2003-2004 resurgence of wild polio transmission was attributed to low immunization coverage of < 50%.in some countries. U.S .Centres for Disease Control, 2003
Nigeria Retrospective cross
sectional
-Under 5 year olds, in Nigeria.
Review of reports -Routine immunization, -Supplementary immunization.
-Coverage for OPV 3, was 38% in 2000, 25% in 2001
13
-AFP surveillance
-Coverage for SNIDs was less than 80% in some areas. -Confirmed polio cases were 2001(56),2002 (2 02),2003(31) U.S .Centres for Disease Control, 2001
Africa Retrospective cross
sectional
Under 5 year olds, in Africa.
Review of reports -Routine immunization, -Supplementary immunization. -AFP surveillance -low coverage in routine OPV3 coverage.42% in DR Congo,42% in Ethiopia,38% in Nigeria,33% in Angola. -SNID coverage was >90% in the four countries. -Number of AFP cases were: -Angola(217) -DR Congo(1078) -Ethiopia(345) -Nigeria(978) 13 U.S .Centres for Disease
Ethiopia Retrospective cross
sectional
-Under 5 year olds, in Ethiopia.
Review of reports -Routine immunization,
-Coverage for OPV 3 ranged between 20%- 90% from 1990- 13 reported from the 46 countries in the African Region of WHO. Linkins et al(1995)
Egypt Retrospective Cross
sectional
Under 5 year olds, in Egypt
-Mass immunization campaign
To quantify the cost effectiveness of both strategies
-Personnel and total costs were higher in house
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–to-house delivery (38% and 13% higher, respectively). -High
coverage levels achieved in house-to house delivery 100% versus 86% in fixed sites with reduced vaccine wastage rates(41% fixed
sites,23.5% in house to house). Richardso
n et al(1995)
Morocco Randomised controlled trial
Under 5 year olds, in Morocco
Administration of OPV in routine versus in mass campaigns
To investigate the immunogenicity of oral poliovirus vaccine
administered in mass campaigns compared with that used in routine
Mass campaigns appear to be highly effective in raising the dose-related poliovirus type- specific immunity achieved routine
13
immunization programmes.
immunization programme. There was improved immunogenicit y of OPV when
administered in mass campaigns. Although there was inability to identify the direct cause of this
www.ijsernet.org Page 196 3. RESULTS
This appraisal was undertaken to examine the quality and amount of research that has been undertaken on the effectiveness of mass polio campaigns in the global response to polio eradication and identification of gaps in the literature. Application of the inclusion criteria to the results of searches identified 14 empirical papers for inclusion in this systematic review. Furthermore executing of the search approach and supplementation of the search findings of the electronic search and scrutiny of reference lists of included articles allows confidence in the conclusion that all relevant articles were included in this review and that findings from this systematic review can be based on combination of all available documentation. The systematic appraisal results overall support previous research in other social settings by highlighting that mass polio campaigns are necessary towards global eradication of polio. Table 3 above shows summarised findings of the extracted data.
Four articles investigated the association in Routine immunization, supplementary immunization activities and progress towards poliomyelitis eradication and found that an association exists. U.S Centres for disease control 2003, 2001, 2000 and 1997 examined coverage in routine immunization activities, supplementary immunization activities and AFP Surveillance which are key in monitoring progress towards polio eradication. In 1997, 16 countries reported not more than 50% of children as having gotten three dosages of oral polio vaccine, coverage during SIAs was greater than 80%, cases of polio reported were 2192.in Ethiopia coverage for OPV 3 improved tremendously ranging from 20% in 1990 to 90% in the year 1999, in the year 2000 it declined and was estimated to be at 35%. Coverage for SNIDs was above 90% between 1997-2000, confirmed cases of polio also declined from 131 cases in the year 1999 to 55 in 2000. In a similar report by CDC(20001) evidence from Democratic Republic of Congo, Angola, Nigeria and Ethiopia showed low coverage in routine OPV3 with Democratic Republic of Congo and Ethiopia reporting a coverage of 42 %,Ethiopia,38%,Nigeria at 33% and Angola 33%,Sub National immunization days in the four countries was greater than 90% coverage, and the number of AFP reported was at 1078 in Democratic republic of Congo, Nigeria 978,Ethiopia 345 and Angola 217. In a related report by CDC in Nigeria in 2003, coverage for OPV3 was 38% in 2000, 25% in 2001 with some areas reporting a coverage of less than 80% in SNIDS, which further relates to the high rates of confirmed cases of polio in the year 2002 at 202 cases down from 56 cases in 2001.
Mbaeyi et al (2014) assessed the headway made by Somalia’s Polio elimination program over the previous 15 years and in his findings OPV coverage was at 50% from 1998 to 2012 which
www.ijsernet.org Page 197 reported was 228, thereafter Somalia remained polio free till April 2013 when 173 cases were reported attributed to the Wild Polio virus.
Three articles that were reviewed investigated the effectiveness of Injectable Polio Vaccine(IPV) and the OPV used in mass campaigns, in a study by Shuaibu etal 2015,OPV coverage in the two districts of Borno and Yabe was found to be at 105% and 103% respectively whilst IPV coverage was at 102% and 99% respectively, this showed that IPV is viable and can effectively be used during mass polio campaigns due to its ability to remain potent/stable compared to the OPV .In another related study by sheik et al(2014) within refugee camps and surrounding communities revealed that IPV coverage was higher at 95% compared to 92.8% coverage with OPV in December and 97.2% OPV coverage, and 97.3% coverage for IPV in the month of November. A similar study by Richardson et al (1995) to examine the Immunogenicity of Oral polio vaccine administered in mass campaigns compared with that used in routine immunization programmes, it was found that there was improved immunogenicity of OPV when administered in mass campaigns, although there was inability to identify the direct cause of this effectiveness.
Two articles focused on proportion of children reached during mass campaigns. In a study by Okeibunor et al(2014) in The Sub regional blocks of Central, West, East and South Africa, There was a reduction in the number of children left out during SIA’s in the region, from 7.94% in 2010 to 5.95% in 2012 with countries in the Eastern and Sothern African block reporting as much as 25% of missed children during the campaigns, according to Helleringer et al(2012) polio free Sub- Saharan African countries showed overall participation in SIA ranging from 70.2% to 96.1% and less than 85% for routine immunization users. Similarly previous use of routine immunization and conformity with the routine OPV Schedule showed a strong positive connection with SIA participation.
One article assessed the cost effectiveness of both strategies used in polio eradication, in his study Linkin’s et al (1995) looked at the cost effectiveness of fixed versus house to house vaccine delivery strategies in Egypt and in his findings human resource and total costs were
greater in house to house approach at 38% and 13 % higher compared to fixed sites delivery strategy. However in terms of polio immunization coverage, higher coverage levels were attained in house to house approach at 100% against 86% in fixed sites, Similarly there was reduced vaccine wastage rates at 23.5% in house to house strategy compared to 41% in fixed sites.
In a study by Arevshatian et al (2007) on routine immunization coverage estimates in Africa. Polio prevalent countries reduced from 11 in 2000 to 2 in 2002, the incidence of polio declined by 89% from 1863 cases to 208 cases in 2002 with Nigeria, Niger and Chad being reported as polio endemic, with the resurgence of polio virus being attributed to low immunization coverage of less than 20% in some countries.
www.ijsernet.org Page 198 Challenges towards realization of a polio free continent in Africa has partly been attributed to unpopular Government decisions as evidenced by Government ban in immunization in Somalia in 2009 that resulted in approximately 1million children less than 10 years of age not being immunised against polio. A similar incidence also occurred in Nigeria when the Government banned all immunization activities due to religious uproar claiming that the vaccines were laced with family planning components (Mbaeyi et al, 2013, Ado et al, 2013).
Even though several studies have shown that mass polio campaigns are effective (C.D.C, 2003; Linkins et al, 1995; Kretsinger et al, 2014). Overall trend reveals, approximately 10% of the children are missed each year which may be responsible for persistent outbreaks in Africa (Okeibunor et al, 2014). Emphasis is enhancing alternate measures like compulsory vaccination to all eligible children. Best practice can be borrowed from Australia, where in a bid to enhance 100% immunization coverage, certain benefits are pegged to immunization status of a child, with those having incomplete immunization profile being denied crucial benefits like the centre link childcare benefits, under the famous slogan ‘No Jab, No pay”( Australian Government, n.d)
Poor planning and high staff turnover has been linked to low coverage for mass campaigns in Africa (Okeibunor et al,2014 ).To address this, there needs to be a shift in the management of these campaigns, either through a change in professional roles and responsibilities and addressing staff turnover rates.
Several studies have revealed a 99% reduction in Polio worldwide since 1988, but the progress decreased as from the year 2005 attributed to the persistence of endemicity in Sudan, Nigeria and Democratic republic of Congo, which was further compounded by repeated reinfection of Polio free countries (WHO, 2010; Ado et al, 2014; Shuaibu et al, 2015).
In 2010, five issues were identified as an impediment towards realization of successful polio campaigns in Africa in a study by WHO. Firstly complacency in some parts of Africa leading to low immunity levels below the threshold needed to ensure disruption of wild polio virus and avert its re-emergence. Secondly repeated SIAs are making some communities exhibit fatigue as a result leading to refusals and thus compromising the successes of SIAs .Thirdly lack of political goodwill from the politicians and their non-engagement approach has made polio campaign in some areas to be suboptimal. Fourthly increased number of planned SIAs threaten vaccine supply, which most often are donor supported and thus not sustainable to most African countries. Finally, insufficient international and domestic funding has made some of polio eradication strategies not to be implemented or realized.
Critics of mass campaigns argue that, SIAs interfere with delivery of other health services as a result of staff shortages. SIAs also affect routine services and above all mass immunizations divert resources from other activities especially in the developing Nations (Verguet et al, 2013; Cutts et al, 1997; Loevinsohn, 2002).
www.ijsernet.org Page 199 large sums of money towards preventive medicine in contrast to most African countries that most often than not rely on support the developed Nations hence raising the big question on program sustainability partly due to lack of funds. Furthermore, low income countries naturally give preference to problems like diarrhoeal diseases, Malaria, Pneumonia and Malnutrition which has also had a negative impact on polio eradication in Africa where citizens reasonably contrast the benefits of polio elimination with benefits of alternate services for their children. Lack of political goodwill in most African nations has led to little or no funding of polio eradication activities unlike in the developed nations where Governments invest in these activities. A good example is the United States of America that spends 230 Million dollars annually on National polio control program which can be equated to 76% of USAID donation to child survival program internationally (Taylor et al, 1997).
Proponents of fixed immunization delivery strategy of polio immunization argue that mobile polio campaigns also referred to as mass campaigns are more costly and logistically difficult and that is the reason many African countries have been reluctant to embrace it despite its proven successes elsewhere in the world (Linkins,1995).
Regional reappearance of wild polio virus transmission in 2003-2004 was attributed to low coverage in routine polio vaccine compared to the developed nations where coverage is a non- issue (Arevshatian et al). Similarly interrupting remaining WPV in Africa requires capitalizing on recent progress. In America, Europe and Western Pacific which are considered as polio free regions, there has been effective AFP surveillance and efficient sample collection which can be adopted in Africa (WHO, 2010).
Intensification in ongoing health programmes by national immunisation days has been crucial in the successful eradication of poliomyelitis from the region of the Americas (Richardson, 1995) which can be incorporated into the African context. Keen to note erratic supply of the polio vaccine especially for routine immunization can have a greater impact on polio eradication goal which often has been a key issue in most developing nations that depend on UNICEF,WHO for logistical support which most often than not has never been sufficient(CDC,2001).
Limitation of the studies
www.ijsernet.org Page 200 cost effectiveness of both SIA and routine immunization approaches. Similarly no study has been undertaken to address the quality of these campaigns.
Limitations of the Review
This review comprised studies in English language only, different languages study results could possibly have impacted on the reported outcomes. Interpretation of identified research in other languages was not possible due to time limitation and financial implications. Publication bias and heterogeneity bias can occur by not including studies from the grey’s literature. Similarly the socioeconomic situation in most African countries has made limited number of studies in this area to be undertaken with a majority of these studies focusing only few selected countries thus making generalization of this review to be narrow in scope. Being a project the time allocated was not sufficient enough to undertake a more comprehensive and rigorous systematic review.
What are the implications for public health practice?
Although substantial progress towards polio eradication has occurred in many African countries, many are still at risk for Wild Polio Virus outbreaks as long as WPV circulation continues within Africa. To reach eradication, governments will need to remain politically committed, there will be need to improve Acute Flaccid Paralysis surveillance and proper implementation of immunization services as needed and readiness to undertake other measures so as to be able to lower the risks of transmission and thus enhance Polio eradication in the content as a whole.
5.0 CONCLUSION.
This review has important implications for polio eradication. Firstly, from the review of the literature both routine immunization and supplementary immunizations complement each other in the eradication of polio by increasing immunization coverage in the developing nations in Africa. Secondly studies have shown that Wild Polio Virus can be eradicated through sustained high coverage in both routine immunization programs and well organized SIA’s that reach every child (Kretsinger et al 2014).Since Initial studies have shown the quality of SIAs in many African countries to be poor due to lack of proper planning, supervision and coordination (Andre, 2014). Furthermore this highlights the need to empower all the stakeholders involved so as to be able to undertake quality campaigns with reduced incidences of missed opportunities.
The frequency and quality of the campaigns will impact on how long it takes to eradicate polio, however there is optimism in the realization of this goal as evidenced by the number of countries still endemic with Polio compared with the trends in the late 80’s and early 90’s, currently only three countries are considered to be endemic of polio, this includes Sudan,
www.ijsernet.org Page 201 RECOMMENDATIONS
From this systematic review, the following recommendations have been identified
1. There is need to strengthen routine immunization programmes, since it has been established through studies that parents who participate in routine immunization programmes are likely to embrace mass polio campaign activities thus helping towards increasing coverage and reducing likelihood of outbreaks.
2. The effectiveness of mass campaigns can be shown to be greater if they are undertaken according to the established WHO guidelines that embrace the administration of two doses of OPV to all children aged below 5 years regardless of their previous vaccination status with polio vaccine.
3. Improving AFP surveillance is critical in enhancing detection of the wild polio virus responsible for outbreaks, especially facility based active AFP surveillance.
4. There is need to coordinate cross-border vaccination and surveillance activities this will aid in detection of possible importation of Wild poliovirus from neighbouring countries.
5. Improving basic infrastructure for the expanded program on immunization
6. There is need to foster strong community engagement and social mobilization so as to be able to attain high coverage during campaigns.
7. There is need for sustained advocacy at the highest political level to enable achievement of polio eradication in Africa.
8. The role of volunteers should be embraced, since they are the gate keepers of their respective communities and studies have shown the success attained by incorporating them in any community driven program.
9. The use of IPV in mass campaigns should be embraced, since it has been found to prevent vaccine derived paralytic polio since routine use of OPV has been found to be ultimately incompatible with the eradication of polio.
10. There is need to embrace the use of teleconference during mass campaigns, this has been proven to be cost effective and efficient.
11. Implementing high quality SIAs that consistently reach every child should be embraced.
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