Cross Border Initiative for Polio
Eradication in the Horn of Africa:
Operationalizing and Strengthening
CORE Group Polio Project (CGPP)
APHA 2015
Chicago, USA
Bal Ram Bhui, CGPP HOA
Filimona Bisrat, CGPP Ethiopia
Anthony Kisanga, CGPP South Sudan
Mercy Lutukai, CGPP HOA
Presentation Objectives
• To provide an overview of process of Cross
Border Initiative for Polio Eradication in Horn
of Africa
• Share achievements of cross border initiative
for polio eradication.
• Challenges and lesson learnt
WPV & cVDPV: HOA, 2013-14
2013:
• Ethiopia: 9
• Somalia: 194
• Kenya: 14 (14th July)
• Total: 217
2014:
• Ethiopia: 1 (5th Jan)
• Somalia: 5 (11 August)
• Kenya: 0
• Total: 6
cVDPV in South Sudan: 2
(9th & 12th Sep 2014 Onset)
Polio outbreaks in HOA
Border Population at Risk
• Border communities share
ecology, epidemiology,
culture, and values
• Border communities are
likely to be: Hard to reach,
Left outs, Socioeconomically disadvantaged
• Borders are porous, free
movement
• People move for trade,
pastures, health care,
education, cultural reasons,
recreation, migration,
conflict and security
Cross border meetings for polio
evolution
• 2012 Cross border meetings of Ethiopia, Somalia,
South Sudan, Sudan and Kenya in 4 operational sites
organized by MOH Ethiopia
• 2013 Cross border meeting in Kisumu between South
Sudan, Uganda and Kenya organized by WHO
• African Region cross border meetings- Kampala,
Uganda (2004), Abuja, Nigeria (2010), Lusaka, Zambia
(2011) and Natitingou, Benin (2013) supported by
WHO
• Cross border meetings by CORE Group South Sudan
with Ethiopia, Kenya, DRC, Uganda
Recommendations from past Cross
Border Meeting
• Agree on criteria to define at-risk border districts
• Agree on need for early warning and response system and harmonization
of activities with IDRS implementation and surveillance training
• Agree on sharing of technical expertise and disease information and
improve coordination of disease control activities
• Identify need for community based surveillance system to supplement
data obtained from health facility
• Engage community in solving public health issues
• Strengthen partner commitment
• Increase local resources in cross border initiatives
• Integrate cross border activities in annual health planning process
• Involve other sectors (Water, Infrastructure, Traders) and stakeholders
(immigration and border security)
Operationalizing and Strengthening
Cross-Border Initiative
• WHO AFRO Guidance for Cross Border
Initiative for public health issues
• EAC Institutional Framework for Cross border
Integrated Disease Surveillance and Response
in East Africa Region
• CORE Group CBI Model building on above two
CORE Group in HoA
• HOA regional secretariat in
Nairobi
• CGPP Project in Ethiopia
since 2001
• CGPP Project in South
Sudan since 2010
• CGPP in Kenya and Somalia
since 2014
• CGPP Management Model
– Secretariats – global, country
– Implementing partners –
CORE Group NGOs, National
NGOS
Coordinative partnership to joint
working relationship
• Country is responsible for resource mobilization
for implementation of cross border activities
• Monitoring of implementation of activities done
separately by each border health authority
• But activities are well aligned and strategic and
operational information is shared regularly with
all partners
• Partner organizations – CORE Group, WHO
extends technical and financial supports to each
country health authority
Goal and Objectives of CGPP CBI
• Goal: Contribute to global eradication by
improving the population immunity in cross
border communities and population with an
effective AFP surveillance
• Objectives: To promote cross border
collaboration between health, administrative
authority of border regions and the partners
for polio eradication efforts
Scope of CGPP Cross Border Initiative
• Advocacy to border county/district health authority
for cross border initiative
• Interventions to improve mass polio vaccination
• Institute cross border surveillance
• Interventions to improve routine immunization
• Country and joint planning
• Institute governance system – Cross Border Health
Committee
• Establish mechanism for communications
• Involve stakeholders
Scope of CGPP CBI
• Implementation
–
–
–
–
–
Each country implements its plan of action
Training – planning, surveillance, immunization
In county monthly review/shared with counterparts
Quarterly joint review meeting
Annual review and planning meeting inclusive of border
health facilities
– Supporting partner supports implementation
• Monitoring and Evaluation
– Monitoring of workplan implementation
– Monitoring of performance indicators
• Inputs, process, outputs, outcome
Results
• Cross border Initiative Operation Guide developed
• Cross border initiative functional with cross border health
committee in
– 3 sites in Kenya with Somalia, Ethiopia, South Sudan and Uganda and
– 3 sites in South Sudan with Kenya, Uganda, DR Congo
• Mapped and profiled cross border villages, border crossing points,
border health facilities using standard tools
– 3 border sub county, Turkana county, Kenya poses 30 border crossing
points, about 700 cross everyday, 35 border villages with about 10
thousand under 5 population
• High level of commitment and support from MOH, County Health
Office, Immigration and Security offices
• High level of commitment from polio Partners – WHO and UNICEF
and NGOs
Results
• Vaccination of children in crossing points with polio
during campaign
– Kenya vaccinated 3816 (1%) of in 5 border counties in Aug
2015
– South Sudan vaccinated 8,864 in Nov and Dec 2014 and
12,225 in Feb and Mar 2015 in 5 counties
• South Sudan vaccinated 6,514 children in 7 permanent
cross border vaccination points from August 2014
• Moyale Somali region of Ethiopia established
permanent vaccination sites on 14 crossing points that
is vaccinating children's for polio
Results
• AFP Surveillance
– Increased rate of AFP case detections
– Community based surveillance instituted
– Sharing of surveillance data with border
counterparts
– Joint case investigation
• Cross border committee meetings – monthly
in country, quarterly and annual between
countries
Challenges and Recommendations
– Country capacity varies – technical, health infrastructure,
resource leveraging
– Need for priority commitment from National and Local
government and MOH institutions
– Need for continued operationalization and strengthening
of process and activities
– Need for improved accountability, documentation,
reporting and monitoring
– Potential for integrating other diseases and cross border
health issues
– Need for adequate resource mobilization for border health
facilities and communities
– Border security
Extras
Cross Border Initiative Framework – WHO AFRO
Inputs and activities
WHO AFRO Guidance for Cross Border
Initiative for public health issues
• Three type of joint working relationships
– Cooperation, Coordination, Collaboration
• Attributes of Successful Joint Working
Relationship
– Purpose, Process and structure, Resources, Strategic
and operational communications
• Operationalization of joint working relationship
– Strategic planning, Defining the scope, identifying
stakeholders, Governance, Operational Plan,
Monitoring and Evaluation, Advocacy, Communication
EAC Institutional Framework for Cross border
Integrated Disease Surveillance and Response in East
Africa Region
• Operational procedures
– Identification of priority animal and human diseases
– Establishment of Cross Border Disease Surveillance and Response
Team
• Regional Rapid Response Team (RRT), District RRT
–
–
–
–
–
–
–
–
Cross border DSR Committee
Mechanism for sharing epidemiological information
Community based disease surveillance in the cross-border zones
Joint planning for Epidemic Preparedness, Investigation and
Synchronized Response
Training
Joint designation of ground crossing points for implementation of IHR
(2005)
Workplan template and suggested activities
Monitoring for Implementation
Scope of CGPP CBI
• Advocacy to border county/district health authority
for cross border initiative
– Discuss on goals, objectives, cross border health
committee and ToR
• Initiation meeting – Border county/district health
office come together to initiate the initiative
– Formation of cross border health committee
– Agree on plan for Cross border health situation
assessment
• Country ownership and resource mobilization
Scope of CGPP CBI
• SIA
– Improve quality of mass polio campaigns in border communities and
population
– Improve synchronization of polio campaigns in cross border points
– Establish permanent vaccination points at major crossing points
– Improve PEI efforts in transit hubs and routes
• AFP surveillance
– Establish cross border surveillance for AFP and selected disease and conditions
in cross border facilities
– Joint case investigation and response
– Establish mechanism for sharing of AFP surveillance data
– Establish a community based surveillance
• Routine Immunization
– Improve routine immunization services to border villages with
outreach/mobile clinics
Scope of CGPP CBI
• Planning
– Identification and profiling of border crossing points, border communities and transit
hubs and routes
– Joint mapping of border crossing points and border communities
– Improve micro planning
– Country specific cross border initiative plan
– Joint country cross border plan
• Governance
– Develop a cross border health committee with designated co-sharing positions
– Representation of county and sub county health offices and relevant technical programs
– Representation of stakeholder – immigration, security, non-health sectors, business
community
– Manual for planning, governance, implementation, reporting ad monitoring
– Periodic in-country and joint review and planning meetings
– Designated focal persons for communication
Scope of CGPP CBI
• Communication between partners
– Vertical and horizontal communication between health authorities and
facilities
– Immediate, weekly, and monthly frequency
– Sharing of surveillance, polio campaign data, routine immunization
data
– Sharing of meeting minutes
• Stakeholders
–
–
–
–
–
National, County, Sub county and health facility authorities
Surveillance staff, Immunization Staff
County governments
County border security agency
County immigration agency
Scope of CGPP CBI
• Implementation
–
–
–
–
–
Each country implements its plan of action
Training – planning, surveillance, immunization
In county monthly review and shared with counterpart
Quarterly joint review meeting
Annual review and planning meeting inclusive of border
health facilities
– Supporting partner supports implementation
• Monitoring and Evaluation
– Monitoring of workplan implementation
– Monitoring of performance indicators
• Inputs, process, outputs, outcome
Progress – Kenya – Cross border
initiative sites
Cross border
initiative place
Border region of
Kenya
Between –
county health
office and
countries
Achievements
Lokichhogio,
Turkana, Kenya
Turkana West,
Kibish, Loima –
Turkana, Kenya
Kapoeta East3 meetings done
South Sudan
Gaabong-Uganda
Moyale,
Marsabit, Kenya
Moyale, North
Horr – Marsabit
Wajir North –
Wajir - Kenya
Moyale - Ethiopia 3 meetings done
Garissa, Garissa,
Kenya
Dadaab, Fafi,
Hulugo – Garissa
East, Garissa
South- Kenya
Gedo, Lower Juba One meeting
region - Somalia done
Mapping border crossing points,
border villages and population sizes
Kenya counties
Turkana
Sub counties
Kibish
Kibish
Loima
Turkana West
Turkana West
Total - Turkana 3 border sub
counties
Wajir North
Wajir
Wajir South
2 border sub
Total - Wajir
counties
Dabaab
Garissa
# crossing
points
Estimated U
Average in a # border
5 pop
villages
day
479
5
386
7
1,119
15
38
7
1,143
4
87
4
7,085
10
200
11
120
1
10
1
30
24
3
721
77
117
35
25
4
9,946
4,695
6,735
27
8
194
47
29
8
11,430
1,089
Border
country
Ethiopia
South Sudan
Uganda
South Sudan
Uganda
Ethiopia,
South Sudan
and Uganda
Ethiopia
Somalia
Ethiopia,
Somalia
Somalia
August 2015 Kenya SIA Results in four cross border
counties- Turkana, Marsabit, Wajir, Garissa
Data
Total vaccinated in the campaign
Number vaccinated in area outside household play ground,
street etc.
Number vaccinated in Bus Station
Number vaccinated in Border Crossing point
Number vaccinated in Water Points
Number vaccinated in Nomadic Settlement
Number
Percent
560207
64567
1634
3916
6041
7777
11.5%
0.3%
0.7%
1.1%
1.4%
South Sudan cross border initiative
sites
Cross border initiative place With neighbour border
in South Sudan
region and country
Year of establishment
Morobo-South Sudan
Koboko-Uganda
2012
Adi-DR Congo
2012
Moyo-Uganda
2013
Yumbe-Uganda
2013
Amuru-Uganda
2013
Lamwo-Uganda
2013
Adjumani-Uganda
2013
Turkana West- Kenya
2013
Kajo-Keji-South Sudan
Magwi-South Sudan
Kapoeta East-South Sudan
South Sudan Cross border collaboration meetings
• Quarterly Review Meetings:
• The project supported a cross border committee meeting between
Uganda and South Sudan on the 6th Feb. 2015, with 24 people in
attendance.
• Another meeting supported by the project at the county level and brought
together DR Congo, Uganda and South Sudan, this was held in Aru DRC
Congo from 30-31 /4/2015 with total attendance of 43 participant
• The quarterly review meetings were to discuss activities and plans on
cross border special vaccination posts, upcoming NIDs and information on
surveillance
• Annual Review meeting:
• Core Group South Sudan organized together an annual review meeting in
Arua-Uganda to discuss progress so far made, share information on
immunization, surveillance, challenges and way forward in 30-31 July
2015. This meeting brought along 44 participants from Uganda, DRC and
South Sudan.
South Sudan – Children vaccinated at border
crossing points with Kenya, Uganda and DR
Congo
Cross border counties
Number of children immunized during
campaign
Counties
2014 (Nov, Dec)
2015 (Feb, Mar)
Magwi
1,475
2,091
Kapoeta East
471
110
Kajo-Keji
1,349
1,345
Nzara
1,481
1,438
Morobo
4,088
7,241
Total
8,864
12,225
South Sudan – Children vaccinated at border permanent
vaccination post with Kenya, Uganda and DR Congo
Special vaccination posts set up throughout the week along busy routes
connecting countries . Children 0-15 years passing the border vaccinated with
OPV. Core Group started this initiative in August 2014.
County
# of vaccination post
Bordering country
Total # of children
vaccinated
# of zero
dose
Kajo-Keji
4
Uganda
1,216
6
Magwi
1
Uganda
1,052
1
Kapoeta
East
1
Kenya
3,120
38
Morobo
1
Uganda/DRC
1,126
0
Total
7
3
6,514
45
Progress – South Sudan – AFP
surveillance
•
•
•
•
•
•
•
Community based surveillance in place
Kajo-Keji- 6 AFP cases-Oct 2014- Sept 2015
Magwi- 5/10 AFP cases- Oct 2014- Sept 2015
Morobo- 2 AFP cases Oct 2014- Sept 2015
Kapoeta East- 2 AFP cases- Oct 2014-Sept 2015
Reporting of other diseases beside polio
2 Measles cases identified in Morobo county which was
traced back to a village in DR Congo
• Joint case investigation initiated within the border districts as
a results of the collaboration & coordination.
• Cholera notification outbreaks in South Sudan and Uganda by
the cross border committees
Social mobilization and communication – South Sudan
• 5 – Joint radio talk shows were conducted, 1 in
Kitgum – Uganda at Mighty Fire FM and 2 in
Adjumani – Amani FM, Trans Nile broadcasting in
Moyo- Uganda and Koboko FM.
• Translation of IEC materials in local language used
along the border this was between Koboko-Uganda,
Adi-DR Congo and Morobo-South Sudan
Ethiopia – Cross border initiative place
Cross border
initiative place
Between – county
health office and
countries
Established
when?
Moyale Somali and
Oromia
Mersabit county of Kenya
October 2014
Dollo Ado Somali Mandera county of
kenya
On progress
Aysha Somali
On progress
Adjacent districts of
Djibouti
Progress - Ethiopia
• CGPP started cross border initiatives in 2012. Involved in country
level CBM held in four different places with bordering countries
(Kenya, Somalia, S. Sudan, Sudan and Djibouti )
• Following the Horn of Africa polio outbreak in 2013, CBM
collaborative meetings were conducted in Djibouti and Jigjiga
Ethiopia to discuss immunization, surveillance, and coordination for
outbreak control.
• The Horn of Africa TAG understood country level cross border
coordination has limitations in monitoring the implementation of
planned activities. Recommended local level cross border
coordination among bordering districts of countries.
• CORE Group Horn of Africa Regional Coordination Office and CGPP
Ethiopia Secretariat started cross border coordination at local level
in Moyale and Marsabit counties in October 2014.
Progress – Ethiopia (Contd.)
• Since then, cross border communities, health facilities and crossing points
along the border have been mapped with mapping tool
• Cross border health committee was established
• Follow up cross border health committee meeting conducted at Moyale
etc.
• Cross border implementation manual was developed by HOA CORE Group
and is being adapted to other countries
• Other partners and stakeholders committed to sustaining the initiative
• Permanent vaccination sites at 14 crossing points in Moyale now
vaccinating children against polio
• During polio immunization campaigns vaccination posts will be established
at crossing points
• Information sharing on immunization and surveillance is ongoing
Progress – Ethiopia – AFP surveillance
• Community based surveillance in place
• 3 AFP cases reported by CVs in Moyale
Woreda out of reported 4 cases 2014/2015
according to week 31 WHO report
• CVs are providing health education and case
searching in all districts
Summary of AFP Surveillance indicators by Region , Ethiopia
Jan 01 – July 24, 2015
Region
Expecte
d Cases
(2015)
Reporte
d (this
period
2015)
Reporte
d (same
period
2014)
Reported
this
Week
NP-AFP
Rate
(annualiz
ed)
Stool
Adequacy
(%)
Stool
Cond.
(%)
NPEN
T (%)
Compati
bles
VDPV
Cases
WPV
Cases
A ABABA
14
11
14
0
2.8
82
100
0.0
0
0
0
AFAR
12
17
15
1
5.1
100
83
3.1
0
0
0
AMHARA
170
174
115
11
3.7
93
79
4.3
0
0
0
B/GUMUZ
9
8
11
1
3.2
88
75
0.0
0
0
0
D/DAWA
2
1
2
0
1.8
100
100
0.0
0
0
0
GAMBELLA
3
7
8
1
2.0
100
43
0.0
0
0
0
HARERI
2
2
3
0
3.6
100
100
0.0
0
0
OROMIA
315
263
231
15
3.0
92
80
1.8
0
0
0
0
SNNPR
165
128
136
9
2.8
97
87
6.0
0
0
0
SOMALI
46
67
81
3
5.1
94
88
4.1
0
1
0
TIGRAY
39
20
25
2
1.8
85
89
0.0
0
0
0
NATIONAL
777
698
641
43
3.2
93
82
3.3
0
1
0