1 Report of the Three-Month Wild Polio Virus Outbreak Response Assessment Kenya 18 to 26 August 2013 9 September 2013 2 Introduction On 9 May 2013, the Somalia Ministry of Health reported the first confirmed case of type 1 wild poliovirus (WPV1) in a 32-month old girl from Mogadishu with onset of acute flaccid paralysis (AFP) on 18 April 2013. A week later, on 16 May 2013, Kenya confirmed a case of WPV1 in a 4- month old girl from the Dadaab refugee camp in North Eastern Province of Kenya with date of onset 30 April 2013. Three months following the detection of the outbreak in Somalia, on 14 August 2013 the Kenya Medical Research Institute (KEMRI) issued an advanced notification of a case of WPV1 from a child living in Ethiopia with date of onset 10 July 2013. As of 30 August 2013, Kenya has confirmed 13 cases of WPV-1 whereas Somalia has confirmed 152 cases of WPV1 cases in 33 districts. The latest date of onset for Kenya’s polio outbreak is 14 July 2013. The 13 confirmed cases in Kenya are from the Garissa County in North Eastern Region and all Kenya’s cases are concentrated within the axis of the Dadaab refugee camp with proximity to the border with Somalia. Of the 13 WPV1 cases, 7 (54%) cases are from the refugee camps whereas 6 (46%) are from the host community. In the refugee camp, 4 (57%) are from Hagadera, 2 (29%) from IFO1 and 1 (14%) from Kambios camps. Among those from the host community, 3 (23%) are from Damanjale, 1 (8%) each from Mathegesi and Hamay, and Hulugho areas. Regarding the age distribution, 10 (77%) out of the 13 cases are <5 years (range of 4-60 months), while 3 (23%) are adults, two aged 19 and one aged 23 years. Nine (69%) of the 13 cases are female. Only 4 (31%) out of the 13 cases had received at least 4-doses of OPV, 2 (16%) had received 1-dose of OPV each and 7 (54%) had never received oral polio vaccine (OPV) before. Six (46%) of the cases occurred during the month of May (1-18 th ), 2 (15%) in the month of June (3 rd & 14 th ) and 5 (39%) in July (2 nd -14 th ), 2013. Although 7 (54%) of the cases had no travel history, 6 (46%) were from nomadic families and only one case had a travel history to Somalia. Two cases were related and had family contact before the onset of paralysis. The population dynamics in this area are complex. Many are nomadic pastoralists who are always on the move between Kenya and Somalia for trade, grazing and meeting relatives. There are strong links to clans or tribes rather than nationality. The host communities and the refugee camps interact with each other freely, creating a favorable environment for disease transmission. Even though the Kenya- Somalia border is officially closed, there are multiple informal border crossing points. Since January 2013, Kenya has detected 373 AFP cases, giving an annualized national non-polio (NP- AFP) detection rate of 2.64/100,000 children aged <15 years. Of the 373 AFP cases, 66 (18%) 3 cases are from North Eastern Province. Twenty percent (13) of the AFP cases in North Eastern were detected during the polio SIAs. This report summarizes the findings from a 3-month outbreak assessment conducted by an inter-agency team of experts (see annex 1) between 18 and 26 August 2013 Objectives The objectives of the 3-month assessment were to: 1. Assess the quality and adequacy of polio outbreak response activities to evaluate if the response is on track to interrupt polio transmission within six months of detection of the first case, as per WHA-established standards 2. To provide additional technical recommendations to assist the country meet this goal Methods The draft guidelines developed for the 3-month assessment of the polio outbreak response were followed. The assessment was comprised the following activities: 1. Field visits to the areas at risk or affected by the outbreak including evaluating the planning process and implementation of an SIA and/or assessing response activities. 2. A desk review and field assessments of the quality of AFP surveillance and routine immunization activities 3. Interviews with national and sub-national officials, NGOs and other partner organizations involved in polio eradication activities in Kenya. 4. Provision of feedback to the government authorities and national partner teams assisting the government with the response. Assessment Teams and areas visited Four teams were constituted covering the following areas: 1. Nairobi (central level assessment and field assessment of high risk districts in Nairobi) 2. Rift Valley Province (Turkana Central, Turkana West, Loima sub-counties and Kakuma refugee camp) 4 3. North Eastern Province (Garissa County, Dadaab District and Dadaab refugee camps) 4. Coast Province (Mombasa County) Assessments The assessments focussed on: 1. Speed and appropriateness of immediate outbreak response activities in line with WHA Resolution, 2006 (WHA59.1) 2. Effectiveness of government leadership and partner coordination during outbreak response 3. Quality of SIAs – planning, delivery, monitoring and communications 4. AFP surveillance quality 5. Routine immunization performance 6. Adequacy of human resources to carry out effective response activities Summary of findings Central level The central level assessment focussed on adherence to the recommended guidelines regarding the speed and quality of response, and partner coordination and collaboration. Meetings were held with representatives of Ministry of Health (MOH), Nairobi County Health Office, Kenya Red Cross, UNHCR/Kenya, UNICEF/Kenya, WHO/Kenya, Kenya Medical Research Institute (KEMRI), and Polio Plus, Rotary International. The following were the key findings: A. Speed and appropriateness of immediate outbreak response The country met the requirements of speed and appropriateness. MOH conducted four large- scale, house-to-house vaccination rounds using bOPV and tOPV, with the first round within four weeks of confirmation of the index case, and an interval of approximately four weeks between subsequent rounds. The outbreak response comprised the following supplementary immunization activities: Round 1: 27-31 May 2013 . Targeted a population of 512,610 <5 year 5 old children in all districts in Garissa County, except refugee camps and 3 host districts where children <15 years of age were vaccinated. bOPV was used in Dadaab refugee camp and 3 host districts; tOPV was used in the rest of Garissa. Independent monitoring of <5 year old children verified by finger-marking showed vaccination coverage was 86%. Round 2: 17-21 June 2013 . Targeted 1.35 million individuals, including: the entire population in Dadaab all refugee camps, <15 year olds in 3 host districts, and <5 year olds in 22 other districts in North Eastern Province, neighboring districts in Coast Province, and selected districts in Nairobi. Independent monitoring coverage of finger-marked <5 year old children was 91%. Round 3: 1-10 July 2013. Implemented in phases targeting 4,661,881 persons, including: Dadaab refugee camp (July 1-6) covering <15 year olds, four districts (Dadaab, Fafi, Lagdera, Wajir South) bordering Dadaab Camp (3-7 July) covering <5 year old children, all other districts including those on Coast, Turkana, and Nairobi. Independent monitoring coverage of finger-marked <5 year old children was 93%. Round 4: 17- 21 August 2013 : The round targeted 4.9 million individuals in 127 districts. This round was observed by the assessment teams in their areas of deployment and formed part of the field component of this outbreak response assessment. B. Effectiveness of government leadership and partner coordination during outbreak response The following were key findings: 1. Regular calls between the global partners took place to coordinate the outbreak response. 2. Joint visits were undertaken to North Eastern Province (Garissa and Dadaab) by high level representatives of MOPH, UNICEF, and WHO for advocacy, assessment of preparedness, and monitoring of the SIA rounds. 3. In the initial phase of the outbreak, there were reports of lack of coordination between WHO/AFRO and WHO/EMRO and little/no sharing of lessons learned from SIA implementation. Coordination improved in subsequent campaigns. 4. There was excellent collaboration and support between the laboratory (KEMRI) with WHO/AFRO, WHO/EMRO, WHO/IST, and the Centers for Disease Control Prevention (CDC). However, it was reported that human resources and laboratory equipment were initially inadequate to cope with the increased number of stool specimens. 6 5. Kenya Red Cross volunteers supported rounds 1 and 2 of SIAs. Funding was inadequate to support all the volunteers needed for round 3 and 4 of the SIAS. 6. Community health workers cover only 30% of Kenya, and they tend to be working in Nairobi and other places where they are not critically needed. Funding is not available to support a community health worker network covering all priority areas (52% of Kenya), including high risk pastoralist communities. C. Recommendations for the central level assessment 1. Increase partner involvement: a. Ensure that robust advocacy and resource mobilization plans are developed and implemented and that all partners have a stake and a voice in decision-making. b. Strengthen partnership with Kenya Red Cross; explore ways their volunteers can support immunization at informal and formal Somalia border crossings, and in high risk, hard to reach communities. c. Strengthen focus on cross-border activities, including increasing the frequency of cross-border meetings and monitoring the completion of recommendations/action points from the meetings. Hold partners accountable for progress. d. Assess the feasibility of fixed immunization posts at border crossings and at priority transit sites within the country. Develop a staffing and resource plan to ensure continuity of care. e. When possible, synchronize campaigns with neighbors.