University of Groningen
Internal displacement; an impediment to the successful implementation of planned measles
supplemental activities in Nigeria, a case study of Benue State
Korave, Joseph; Bawa, Samuel; Ageda, Bem; Ucho, Aondoaver; Bem-Bura, Doris Mwuese;
Onimisi, Anthony; Dieng, Boubacar; Nsubuga, Peter; Oteri, Joseph; Fiona, Braka
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Vaccine
DOI:
10.1016/j.vaccine.2020.12.064
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Korave, J., Bawa, S., Ageda, B., Ucho, A., Bem-Bura, D. M., Onimisi, A., Dieng, B., Nsubuga, P., Oteri, J.,
Fiona, B., & Shuaib, F. (2021). Internal displacement; an impediment to the successful implementation of
planned measles supplemental activities in Nigeria, a case study of Benue State. Vaccine.
https://doi.org/10.1016/j.vaccine.2020.12.064
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Internal displacement; an impediment to the successful implementation
of planned measles supplemental activities in Nigeria, a case study of
Benue State
Joseph Korave
a, Samuel Bawa
b,⇑, Bem Ageda
a, Aondoaver Ucho
c, Doris Mwuese Bem-Bura
c,
Anthony Onimisi
b, Boubacar Dieng
d, Peter Nsubuga
e, Joseph Oteri
f, Braka Fiona
b, Faisal Shuaib
f aPrimary Health Care Development Board, Benue State, Nigeriab
World Health Organization, Country Office, Abuja, Nigeria c
Benue State University, Makurdi, Nigeria d
Technical Assistance Consultant, Global Alliance for Vaccines and Immunizations, United States e
Global Public Health Solutions, Atlanta, United States f
National Primary Health Care Development Agency, Abuja, Nigeria
a r t i c l e i n f o
Article history: Available online xxxx Keywords:
Measles vaccination campaign Internally displaced persons Measles outbreak
a b s t r a c t
Background: Measles is a highly infectious disease with great burden and implication on a displaced pop-ulation with low immunity status. The disease can cause up to 140,000 deaths annually. Internal dis-placement during supplemental immunization activities often affects optimal reach and coverage of the campaign as people move and implementation and logistic plans are usually disrupted with atten-dant missed children. This study documented the process of extension of the measles vaccination cam-paign (MVC) 2018 for five internally displaced persons (IDPs) camps in Benue state, not previously in the microplan, to increase population herd immunity.
Methods: We obtained population figures and disease surveillance data for five IDPs camps and used it to conduct detailed microplanning to determine the requirement for the conduct of additional days of measles vaccination. Vaccination teams used fixed posts in the camps and temporary posts strategy in designated locations in the host communities.
Results: The estimated total population of the IDPs was 170,000 with MVC target population of 9374 which was not earlier planned for. There was reported measles outbreaks in IDP camps in both Guma and Makurdi Local Government areas (LGAs) during period of displacement. Microplans requirement determined 10,421 bundled measles vaccine, 30 health workers, 5 vehicles and 15 motorcycles. A total of 7679 out of 9374 (81.9%) of the eligible children aged 9–59 months were vaccinated during the 3 days of the campaign.
Conclusion: Non-inclusion of plans on internally displaced population in supplemental immunization activities (SIAs) microplans have a potential risk of vaccine preventable diseases (VPDs) outbreak. Future Measles Vaccination campaigns should take cognizance of internal displacement due to insecurity and other humanitarian emergencies.
Ó 2021 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
1. Introduction
Measles is a highly contagious, severe disease caused by a virus
[1]. A suspected measles case is any person with generalized mac-ulopapular rash and fever plus one of the following: cough, coryza (runny nose) or conjunctivitis or in any person in whom a physi-cian suspect measles[1,2,3].
Globally, measles ranks top among the burden of vaccine-preventable diseases. In Africa, measles is still the leading cause of mortality and morbidity in children under the age of 5 years. Though there has been a substantial decline in global measles deaths, Nigeria still tops the chart of the number of children not vaccinated against measles, as it is among the 45 countries that account for 94% of the global deaths due to measles[4].
Public health interventions in refugee camp settings aim to meet the basic health needs of refugees[5]. Military conflict has been an ongoing determinant of inequitable immunization
cover-https://doi.org/10.1016/j.vaccine.2020.12.064
0264-410X/Ó 2021 The Authors. Published by Elsevier Ltd.
This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
⇑Corresponding author.
E-mail address:bawasa@who.int(S. Bawa).
Contents lists available atScienceDirect
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Please cite this article as: J. Korave, S. Bawa, B. Ageda et al., Internal displacement; an impediment to the successful implementation of planned measles supplemental activities in Nigeria, a case study of Benue State, Vaccine,https://doi.org/10.1016/j.vaccine.2020.12.064
age in many low- and middle-income countries, yet the impact of conflict on the attainment of global health goals has not been fully addressed[6]. Those displaced face immense challenges in meeting their basic needs[7].
Measles outbreaks can be particularly deadly in countries expe-riencing or recovering from a natural disaster or conflict[2]. Camp conditions are common risk factors for measles transmission, movement between camp and host populations also contributes to measles outbreaks. Most of these outbreaks affect children < 5 years old and occurred in the first quarter of the year
[9–10]. Internal displacement has significant effects on public health and the well-being of the affected populations[11].
During crises, children face specific life-threatening risks, including malnutrition, separation from their families, trafficking, recruitment into armed groups, and physical or sexual violence and abuse, all of which require immediate action[12]. Vaccination strategies among displaced populations should not be an after-thought and must be part of the vaccine-preventable disease erad-ication and elimination initiatives from the start[13]. Interrupting transmission of measles requires an effort to achieve population immunity of at least 95%[14].
The post-campaign coverage survey result for the measles vac-cination campaign (MVC) 2017/18 for Benue state was 83.2% while the national average coverage was 87.5%[23]. Although the coun-try’s MVC 2017/18 proposal made provision for insecure, insurgent and hard to reach areas, the main prioritized states were in the northeast and south south of Nigeria. Benue was not prioritized even though the armed conflict between the herdsmen and farm-ers on the land and grazing paths in has been a protracted issue since 2013. However, as from January 2018, Benue experienced a high level of violent armed attacks between herdsmen and farmers at the border LGAs of Benue and Nasarawa states resulting in about 170,000 internally displaced persons (IDPs). The conflict also dis-rupted health services and plan for the SIAs in the affected LGAs. The Benue State Emergency Management Agency (SEMA) estab-lished three IDP camps in Guma and two in Makurdi.
The conflict erupted before and during the implementation phase of the 2018 MVC in Benue after the microplans and logistics arrangements were already concluded; with no provision for such large-scale internal displacement and disruption of health services. The overcrowded IDPs and host communities coupled with under vaccination resulted in measles outbreak among the IDPs.
Accurate and timely information about various domains of pub-lic health underpins the effectiveness of humanitarian pubpub-lic health interventions in crisis[15]. As such the National Primary Health Care Development Agency (NPHCDA) in collaboration with the state and WHO reassessed the situation, revised and developed plans for additional days of vaccination campaign for IDPs.
We documented the activities aimed at targeting the IDPs and host communities, especially after the conclusion of microplans and the implication of population displacement during the measles vaccination campaign in Benue state.
2. Methods
Setting: Benue is a state in north-central Nigeria with 23 Local Government Authorities (LGAs) comprising 277 wards. It has a total population of 6,015,633 projected from the 2006 national census. The target population 2018 MVC was 972,371 children aged 9– 59 months.
Study population: We planned and targeted eligible children in five IDPs camps (Three in Guma LGA, and two in Makurdi LGA) which were situated in the following communities; The three in Guma LGA are; Gbajimba, Tse-Aginde and Daudu settlements, while the two in Makurdi LGA are Abagana and Agan settlements
(Fig. 1). We obtained the population of the IDPs from the Benue State Emergency Management Agency (SEMA.).
Implementation of the measles supplemental activities in the IDP camps and host communities
We reviewed existing data from 2018 MVC microplanning and coverage data, surveillance information from Integrated Disease Surveillance Response (IDSR) to ascertain the extent of the measles outbreak and population immunity gaps in the camps. We implemented the activities through the following processes:
-Identifying the vaccination post strategy and team members. We used the existing five health posts located in the camps as fixed vaccination posts to implement the measles vaccination cam-paign. Seven temporary vaccination posts were also located in Churches, Markets, schools and Traditional Leaders residences to cover eligible children in the host communities. The number of teams was determined by the population targeted, the surrounding host communities of the IDP camps and the security risk assess-ment of the area. Catchassess-ment areas were delineated each with seven team members. The team comprised one supervisor/vaccina-tor, one vaccinator (who were health workers), two recorders, one crowd controller, one town announcer and one house to house mobilizer. Vaccination was provided at these sites for either the duration of the campaign or partially depending on the population density. Only 14 health workers were recruited instead of 30 required due to inadequate logistics provision. We provided addi-tional motorcycles for team members and supervisors to ensure a better implementation process. There was difficulty in mobilising funds to pay for extra requirements after the main 2018 MVC. Determination of logistic requirement
We mobilised additional cold chain equipment, bundled vacci-nes based on estimates and daily consumption as implementation continued. Accountability of the vaccines was supervised by Local Government Cold Chain Officers (LCCOs). Conditioned icepacks were produced at state cold room and distributed daily to all vac-cination points by the ward focal persons. WHO recommends con-ditioned icepacks to avoid freezing of vaccines (i.e., frozen icepacks that are warmed under room temperature and melted enough to allow the ice to move inside the pack). Marker pens and vaccina-tion cards were provided to teams adequately. We conducted emergency training for the health workers engaged and orientation of additional supervisors to get them acquainted with interper-sonal communication skills to work in a humanitarian situation. Additional data tools were also printed.
Community engagement
Additional community mobilizers were engaged in supporting the mobilization of IDPs to vaccination posts. We also conducted five community dialogues (CD) with Traditional Leaders (TL) and other relevant stakeholders to engage them as part of critical stakeholders to support in resolving non-compliance cases. Accelerated control of other vaccine preventable diseases
The campaign in IDP camps was conducted from 19 to 21 April 2018 to increase coverage and reach to all eligible children in the camps thereby improving herd immunity and limit outbreak. How-ever, there was acceleration of other routine immunization anti-gens (Bacilli Calmette Guerin (BCG), Oral polio vaccine (OPV), Hepatitis B vaccines (HBV), Pentavalent vaccine (Penta), Yellow fever vaccine, Inactivated Polio Vaccines (IPV) and Pneumococcal conjugate vaccines (PCV) were also administered to avoid further
J. Korave, S. Bawa, B. Ageda et al. Vaccine xxx (xxxx) xxx
outbreaks of measles and control other VPDs and health conditions like diarrhoea and malnutrition.
Data collection, collation and analysis: We established an operation room for daily data collation and feedback. There was a daily evening review meeting at Local Government and state level and regular review of plans and progress of implementation by state team on daily basis. Simple statistical analysis was done using percentages and proportions for results presentations. Results
The population estimate from SEMA showed that children aged 0–15 years constituted 45% of the population of IDPs in the five camps. The total number of eligible children 9–59 months for measles vaccination was 9,374 as of April 2018 (Table 1). Surveil-lance information showed four reported cases of suspected measles from IDPs camp in Makurdi LGA in epidemiologic week six, increasing trend to 57 in week 14. Similarly, for Guma LGA, cases were reported in week seven, with an increasing trend to 20 in week 13. There was a decline in the number of cases from week 17 in both LGAs.
Regarding the microplan for measles vaccines and other logis-tics required for the campaign, Guma LGA with three camps had 5223 estimated eligible children (9–59 months old), and Makurdi had 4151 eligible children. A total of 10,421 bundled vaccines doses was required for the 3 days vaccination based on the esti-mated target population with Abagena having the highest require-ment of 3441, and Agan lowest requirerequire-ment of 1170. The breakdown of the microplan by settlement indicated that Daudu required 2290 and Tse-Aginde 1630 of the vaccine doses. Abagana had the highest number of teams of 10 needed for the campaign while Daudu had 8. Gbajimba, Tse-Aginde and Agan had 4 teams each.
Gbajimba ward had the highest workload of 85 children to be covered by a team per day, with an average of 63 children for the five IDP camps. Abagena had the highest requirement of Measles vaccination cards with 3441 and Agan lowest of 1170. Similarly, Abagena had the highest requirement of Giostyles vac-cine carriers (10), while Agan had the least requirement of four vaccine carriers (Table 2).
The required community sensitization and mobilization materi-als in form of Information Education and Communication (IEC) materials; Community mobilizers; traditional leaders; banners; megaphones and posters. Community mobilizers, traditional and religious leaders were adequately engaged (Table 3).
Thirty health workers were required for the exercise but only 14 were recruited (47%). Only 47% of required state and LGA supervi-sors supervised the exercise. One vehicle was required per camp for transportation of team members, daily supply of vaccines, ice-packs and submitted a daily report to Makurdi, only 50% of the requirement were available. Fifteen motorcycles were planned, but only seven (38%) were hired. Gbajimba team was allocated one motorcycle; Tse-Agindi, one; Agan, one; Daudu two and Aba-gena two (Table 4).
The administrative campaign coverage was suboptimal with Abagena having the highest coverage of 85%, Tse-Agindi 84%,
Daudu 83%, Agan 77% and Gbajimba 77%. No team reached the expected 100% coverage (Fig. 1). Overall, the total number of chil-dren immunized for 2018 MVC was 7679 as against the target pop-ulation of 9374 children aged 9–59 months giving the administrative coverage of 81.9% (seeFig. 2).
Discussion
We found that it is essential to make provision for the internally displaced and special population while developing micro plans and planning for SIAs, especially for States frequently experiencing a crisis. The review also found that the crisis at the time of the 2018 MVC implementation resulted in a high number of unvacci-nated children in Guma and Makurdi LGAs, which needed to be vaccinated. This is similar to studies from northeastern Nigeria by Sato, R, 2019, where conflict affected the vaccination of children leading to the risk of VPDs outbreak[16]. Complex humanitarian emergencies affect 40–60 million people annually and are a grow-ing public health concern worldwide[17].
Only 81.9% of the targeted population was vaccinated. However, the population in IDP camps are highly unstable and this could account for this low coverage. Furthermore, there could be issues with the denominator which may have a high tendency of infla-tion. Conflict and disaster often cause large-scale displacement of people due to the destruction of homes and environment, religious or political persecution or economic necessity[11].
The conflict in Benue extended to February during the peak per-iod of measles transmission leading to measles outbreak among displaced population. This finding conforms with the report in a descriptive analysis of measles cases seen in a tertiary health facil-ity in Sokoto, north-west, Nigeria that measles transmission in Nigeria occurs through all months of the year, but peaks in the dry season (February, March and April)[8].
There was a delay in implementation of the vaccination cam-paign in the five camps due to the challenge of funding the extra logistics to vaccinate > 9000 children which were not budgeted for in the 2018 MVC. As with other interventions, financing of any vaccination programme must be assured before implementa-tion[18]. The study revealed that planning is crucial for optimal response outcomes[12]. We highlighted the fact that the delay in finding a partner to support the process increased the risk of measles outbreak and spread including other vaccines preventable diseases and underscored the need for the mobilization of local resources to avoid escalation of the outbreaks. As the crises became protracted, more health workers continued vaccination up to 2 months as the IDPs continued to increase every day and routine immunization service was established to continue vaccinating the birth cohort of children in IDPs camps and host communities. Inte-grating routine primary-care services in special population resulted in increased coverage routine immunization and child health interventions as found by Bawa et al in 2019[19].
The inability to recruit required health workers for the cam-paign did not hinder implementation. This finding is similar to study from the Royal Tropical Institute final report on measles campaigns and their effects on the overall immunization system. Though there were complaints of excessively heavy workload in
Table 1
Population distribution of Internally Displaced Persons Camp, Guma and Makurdi LGAs, April 2018.
LGA IDP camp Total population Children (0–15 yrs) Children (9–59 months)
Guma Daudu 24,044 10,871 1700
Tse-Agindi 20,928 10,021 2061
Gbajimba 24,019 9,393 1462
Makurdi Abagena/Agan 34,986 16,583 4151
Table 2
Distribution of requirement from developed micro plans, implementation of 2018 measles vaccination campaign in Five IDPs camps in Guma and Makurdi LGAs.
LGAs Ward IDP
Camp Target population (9– 59 months) Number of teams Workload/ team/day Measles Vaccine doses Vaccination Card Giostyles vaccine carrier Tally sheets AEFI forms Cotton wool Pen marker Safety boxes
Guma Nzorov Gbajimba 1700 4 85 1890 1890 4 5 5 4 9 19
Mbawa Daudu 2061 8 52 2290 2290 8 9 9 8 18 23
Mbawa Tse-Agindi
1462 4 73 1630 1630 4 5 5 4 9 17
Makurdi Agan Abagena 3100 10 62 3441 3441 10 12 12 10 23 35
Agan 1051 4 53 1170 1170 4 5 5 4 9 12
Total 4 5 9374 30 63 10,421 10,421 30 36 36 30 68 106
Table 3
Distribution of Social mobilization and communication materials required for mobilization of IDPs and host communities, Guma and Makurdi LGAs, 2018.
LGAs IDPs Camps Teams Megaphones Posters Banners Community Mobilisers
Guma Gbajimba 4 2 4 2 2 Daudu 8 4 8 4 4 Tse-Agindi 4 2 4 2 2 Makurdi Abagena 10 5 10 5 5 Agan 4 2 4 2 2 Total 30 15 30 15 15 Table 4
Health workers and transport logistics required and available for 2018 vaccination campaign in five Internally displaced persons’ camp in Guma and Makurdi LGAs.
LGA Wards Teams Health Workers Vehicles Motorcycles
Required Used Required Used Required Used
Guma Gbajimba 2 4 2 1 1 2 1 Daudu 4 8 4 1 0 4 2 Tse-Agindi 2 4 2 1 1 2 1 Makurdi Abagena 5 10 4 1 0 5 2 Agan 2 4 2 1 0 2 1 Total 15 30 14 5 2 15 7
Fig. 1. Showing number and locations of IDPs camps in Guma and Makurdi LGAs of Benue state in 2018.
J. Korave, S. Bawa, B. Ageda et al. Vaccine xxx (xxxx) xxx
some cases, there was no evidence that the Human Resource for Health (HRH) shortage hindered implementation of the campaigns
[20].
Similarly, there was no opportunity to verify the micro plans as required by MVC 2018 guidelines before implementation as it was an emergency. Involvement of Traditional and Religious leaders in supplemental immunization activities has become an essential component of social mobilization to increase community aware-ness and uptake of immunization. The review showed that full involvement of traditional and religious leaders in this process was instrumental to acceptance of vaccination by IDPs and sup-ported the resolution of Non-compliance cases.
We demonstrated the importance of establishing routine immunization in IDPs camps for eligible children to complete their immunization schedules, especially the second measles dose. This underscores the need for vulnerable populations affected by humanitarian emergencies to require unique strategies to ensure access to life-saving vaccines and attain sufficiently high popula-tion immunity to interrupt virus circulapopula-tion[10]. Vaccination cam-paigns remain a quick and effective approach to increase vaccination coverage in crisis-affected areas[22].
The study had some limitations; first, though it is possible to consider unforeseen conflict during the microplan development process, it is difficult to estimate logistics requirement without knowing the magnitude of the expected crisis and level of displace-ment. Secondly, SIAs are time-bound in terms of the number of implementing days so it was challenging to produce new micro-plans to meet the exact needs for an unknown period of crisis. Thirdly, there was no post-campaign coverage survey for the IDPs camps activity. as a requirement to validate SIA administrative coverage, a post-campaign coverage survey should be conducted after measles SIAs[21].
Conclusion
The planning for immunization campaigns should take cog-nizance of the effects of internal displacement and make provision for the strategy for IDP camps. Supplementary budget for mop ups should be comprehensive enough to avoid gaps between planned funds/logistics and what is available for the campaigns.
To sustain the gains from the implementation of supplemental MVC 2018 in the five IDPs camps, it is necessary to establish and maintain routine immunisation in all IDPs camps for the cohort of eligible children. This will maintain high population herd immu-nity desired to achieve measles elimination goals.
Permission to conduct this work was obtained from Benue State Primary Health Care Board.
Credit authorship contribution statement
Joseph Korave: Conceptualization, Methodology, Writing -review & editing. Samuel Bawa: Conceptualization, Methodology, Formal analysis, Writing - original draft, Writing - review & editing, Visualization. Bem Ageda: Writing - review & editing. Aondoaver Ucho: Writing - review & editing, Visualization. Doris Mwuese Bem-Bura: Writing - review & editing. Anthony Onimisi: Writing - review & editing. Boubacar Dieng: Writing - review & editing, Validation. Peter Nsubuga: Conceptualization, Methodology, For-mal analysis, Writing - review & editing, Visualization. Joseph Oteri: Writing - review & editing, Validation. Braka Fiona: Concep-tualization, Methodology, Formal analysis, Writing - original draft, Writing review & editing, Visualization. Faisal Shuaib: Writing -review & editing, Validation.
Declaration of Competing Interest
The authors declare that they have no known competing finan-cial interests or personal relationships that could have appeared to influence the work reported in this paper.
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