Conducting public health surveillance in areas of armed conflict and restricted population access: a qualitative case study of polio surveillance in conflict-affected areas of Borno State, Nigeria

Abstract

This study examined the impact of armed conflict on public health surveillance systems, the limitations of traditional surveillance in this context, and innovative strategies to overcome these limitations. A qualitative case study was conducted to examine the factors affecting the functioning of poliovirus surveillance in conflict-affected areas of Borno state, Nigeria using semi-structured interviews of a purposeful sample of participants. The main inhibitors of surveillance were inaccessibility, the destroyed health infrastructure, and the destroyed communication network. These three challenges created a situation in which the traditional polio surveillance system could not function. Three strategies to overcome these challenges were viewed by respondents as the most impactful. First, local community informants were recruited to conduct surveillance for acute flaccid paralysis in children in the inaccessible areas. Second, the informants engaged in local-level negotiation with the insurgency groups to bring children with paralysis to accessible areas for investigation and sample collection. Third, GIS technology was used to track the places reached for surveillance and vaccination and to estimate the size and location of the inaccessible population. A modified monitoring system tracked tailored indicators including the number of places reached for surveillance and the number of acute flaccid paralysis cases detected and investigated, and utilized GIS technology to map the reach of the program. The surveillance strategies used in Borno were successful in increasing surveillance sensitivity in an area of protracted conflict and inaccessibility. This approach and some of the specific strategies may be useful in other areas of armed conflict.

What are the barriers and facilitators to polio vaccination and eradication programs? A systematic review

“…Lack of access to general and health infrastructure, including healthcare, health facilities, and financial, organizational, and logistical constraints, served as key barriers to the vaccination interventions, highlighting the need for implementers to take health system capacity into account when considering vulnerable groups at the design stage of interventions [14,18,20,23,24,26]. Similarly, newer studies support these findings, as they attempt to highlight the need for surveillance capacity and health service delivery across many contexts, including: remote and conflict-affected areas [39][40][41]. For instance, common implementation barriers in regions of the Democratic Republic of Congo and Ethiopia include inaccessibility issues caused by gaps in human resources, supply chain, and finance [39].…”

Historical reconstruction of inaccessibility status in Local Government Areas (LGAs) of Borno and Yobe States, Nigeria, 2010-2020

“…Inaccessabillty is similarly implicated in the current persistent transmission and confinement of WPV1 in major portions of Pakistan and Afghanistan [ 2 , 14 , 15 , 23 ]. Active surveillance was limited to accessible portions of Borno and Yobe LGAs but was unlikely to be optimal given population displacement; in security-compromised areas, it was not feasible to conduct AFP surveillance as evident by undetected WPV transmission until discovery in 2016 [ 2 , 3 , 4 , 12 , 18 ].…”

“…Heatmaps using a system of color-coding was used to graphically represent the different extent of inaccessibility of settlements within LGAs over the years. Inaccessibility was defined as the inability of civilians like health workers and vaccination teams to safely move in and out of a given area due to the risk of attack by insurgents [ 18 ].…”