Immunizing nomadic children and livestock – Experience in North East Zone of Somalia

Abstract

Nomads and pastoralists represent around 30% of the population of North East zone of Somalia (Puntland) and have very limited access to basic health including immunization. During the 2013–2014 polio outbreak in Somalia, an increase number of polio cases notified health services among these underserved communities highlighted the urgent need to devise innovative strategies to reach them. Harnessing the high demand for veterinary services among pastoralist communities, the Ministry of Health and the Ministry of Livestock, with support from UNICEF, WHO and FAO launched an integrated human and animal vaccination campaign on 19 October 2014. Over 30 days, 20 social mobilizers conducted shelter to shelter social mobilization and interpersonal communication for nomadic/pastoralist hamlets, 20 human vaccination teams, accompanied by local community elders, traveled with animal vaccination teams to administer polio and measles vaccination to pastoralist communities in the 5 regions of Puntland. 26,393 children (0 to 10 years) received Oral Polio Vaccine (OPV) out of which 34% for the first time ever; 23,099 were vaccinated against measles. and 12,556 Vitamin A. Despite various operational challenges and a significantly higher operational cost of $6.2 per child reached with OPV, the integrated human and animal vaccination campaign was effective in reaching the unvaccinated children from nomadic and pastoralist communities of Somalia.

Introduction

In 2013 194 polio cases (46.8% of global polio case-count) due to Wild Polio Virus (WPV), were reported from Somalia.¹ Originating in the urban area of Mogadishu, the outbreak rapidly spread to surrounding districts of South and Central Somalia, and ultimately into North Eastern Kenya and Eastern Ethiopia.² Despite access challenges and the banning of immunization activities by non-state actors in some areas of the country, WHO, UNICEF, the Government of Somalia and local polio partners were able to mount a strong and effective response to the polio outbreak. In 2014, only 5 cases of polio were reported and all of these cases were detected among nomadic and pastoralist communities in the North East zone (Puntland). As the country was battling with polio, measles outbreaks were also reported from various districts of Somalia, including Puntland.

The spread of polio and the risk of measles outbreak in remote, nomadic and pastoralist communities of Puntland prompted the Technical Advisory Group (TAG) on polio eradication in the Horn of Africa to recommend devising new, innovative and appropriate strategies to reach these populations. Nomads and pastoralists represent around 30% of the population of Puntland, are constantly on the move and as such difficult to reach, and have very limited access to basic health and social services.

Harnessing the high demand for veterinary services among pastoralist communities, and building on the success of joint human and animal vaccination activities in other countries,³ the Ministry of Health (MOH) and the Ministry of Livestock (MOL), with support from UNICEF, WHO and FAO launched an integrated human and animal vaccination campaign on 19 October 2014. The goal of the vaccination campaign was to interrupt circulation of WPV, and to minimize the risk of measles outbreaks among the nomadic and pastoralist communities of Puntland.

Results

Over the 30 days of the campaign, 20 human vaccination teams (1 in each district) traveled with animal vaccination team to administer polio and measles vaccination to pastoralist communities of the 5 regions of Puntland. In total, 26,293 children (0 to 10 years) received OPV, 23,099 were vaccinated against measles and 12,556 Vitamin A. For many children, this was the first time they had received either polio or measles vaccine (zero-doses). Overall 31% of all children vaccinated were zero-doses with the highest proportion of zero-doses reported from Bari region (46%). In the remote districts of Qandala, Iskushuban, Xudun and Jariban, 93%, 67%, 82% and 37% of children vaccinated, respectively, were zero-doses (Table 1). The high proportion of zero doses among children from remote districts highlights the ability of the program to reach population previously not reach by health services.

Table 1.

Number of children reached with polio and measles vaccine and number of ORS packets distributed during the 30-day join animal human vaccination in Puntland (October 2014, Somalia)

		Oral Polio Vaccine
Region	District	Number vaccinated (0 – 10 years	Number vaccinated for the first time (Zero-doses)	% zero-doses	Total vaccinated against measles (9 months – 10 years)
Mudug	Galkaio	1901	166	9%	1818
	Jariiban	2325	855	37%	2212
	Goldogob	791	5	1%	665
	Total	5017	1026	20%	4695
Nugal	Burtinle	425	95	22%	406
	Dangoroyo	715	265	37%	698
	Eyl	938	264	28%	880
	Garowe	1105	261	24%	1053
	Total	3183	885	28%	3037
Bari	Qandala	1405	1300	93%	1296
	Iskushuban	3233	2155	67%	2839
	Alula	2045	481	24%	1518
	Bandar bayla	524	25	5%	468
	Qardho	1404	4	0%	1331
	Total	8611	3965	46%	7452
Sool	Boocame	868	126	15%	816
	Xudun	496	406	82%	640
	Taleh	890	57	6%	855
	Total	2254	589	26%	2311
Sanag	Badhan	1965	525	27%	1037
	Laasqorey	1235	995	81%	796
	Dhahar	2429	7	0%	2479
	Xingalool	1599	151	9%	1292
	Total	7228	1678	23%	5604
Grand Total		26293	8143	31%	23099

The target age group for polio vaccination was 0 to 10 years. The zero-dose were children vaccinated for the first time, irrespective of the age.

No vaccine refusal was recorded during the campaign, translating a high level of acceptance of polio and measles vaccination among nomadic and pastoralist caregivers. House to house social mobilization and interpersonal communication by social mobilizers, combined with local media engagement were conducted to increase community awareness about the importance of polio vaccination, and in regard to the critical importance of routine immunization as a means to prevent disease.

Discussion

Ensuring that every child receives polio vaccine is the central aim of the Polio Eradication Initiative. Achieving this aim however remains a challenges in underserved remote and mobile communities where access to basic health services including immunization is rare. Consequently these communities are at high risk of disease and should be targeted for health interventions through special strategies. The linkage of vaccination services with other health interventions is recommended by WHO and UNICEF to achieve equitable, sustainable and high immunization coverage. The linkage of human and animal health interventions to advance polio eradication agenda is not new; experience from various countries^3-6 has demonstrated the ability of join campaign to reach remote communities with a package of life-saving intervention including immunization. The current report shows that provision of immunization services to pastoralist communities through a join animal/human vaccination campaign is feasible albeit few challenges.

Challenges

The campaign didn't go without challenges: a) pastoralist and nomadic population data are unreliable in Somalia which presents challenges in relation to micro-planning and resources allocation; b) some settlements are very remote and could not be reached by cars - this resulted in vaccination teams having to walk very long distances to access remote and isolated houses; c)the remuneration scale for vaccinators was not harmonized and animal vaccinators (from FAO) received a higher level of incentives, compared to the human vaccinators. However, these challenges were quickly resolved through dialog and communication with all vaccinators; d) the operational costs per child (including social mobilization costs) was about $6.20 per pastoralist child reached with OPV and measles vaccine, compared to $0.60 per child in other areas where children are vaccinated for polio alone. However, costs would have been significantly higher had it not been for the savings that resulted from joint planning and implementation with the FAO.

Lessons learned and way forward

Despite a significantly higher operational cost, the integrated human and animal vaccination campaign was effective in reaching previously unvaccinated children from nomadic and pastoralist communities of Somalia. The campaign increased opportunities for collaboration between ministries, UN agencies, local partners and communities. Joint planning and implementation allowed identification of synergies to reach the unreached, as well as opportunities to optimize the use of limited logistical and financial resources (economy of scale). Join planning, monitoring and oversight by both the Ministry of Health, Ministry of Livestock and UN agencies strengthened collaboration, and has paved the way for future collaboration.

The campaign has helped establish a multi-agency partnership that can be leverage to improve access to underserved pastoralist communities. As a way forward, the polio program will continue to explore areas of collaboration with partners to maximize opportunities to reach remote and marginalized communities. The opportunities revealed through the join campaign will be used to establish lasting links with nomadic and pastoralist communities, and to mobilize community leaders and influencers to promote future health interventions. Adapted communication for development (C4D) strategies will be devise while appropriate communication will be explored to increase awareness of pastoralist communities about the value of immunization. For future animal/human campaigns, it will make sense to expand the package delivered to include and promote additional health interventions including, for example, hygiene promotion, the delivery of TT vaccine, nutritional screening and micronutrients supplementation.

Methods

Joint animal/human vaccination strategies were able to build upon veterinary campaigns conducted by FAO twice a year to protect the livestock so essential to the livelihood of Somali pastoralist and nomadic communities. The joint integrated campaign was designed to combine resources and hitch interventions on popular veterinary services thereby allowing partners to deliver vaccination services at a decreased cost.

Organization of the campaign

The campaign was planned through a series of join meetings between WHO, UNICEF, FAO and MOH/MOL zonal and regional technical officers.

Animal vaccination campaigns are conducted during the short rainy season lasting from October to December when nomadic communities and their cattle are settled on the vast green plains and around water points. The 2014 campaign, conducted from October to November 2014, targeted 4 million animals in all areas of Puntland, including animals from remote and nomadic settlements. While the animal vaccination campaign ran for 55 days, human vaccination teams – composed of 2 vaccinators, one social mobilizer and local guide – were deployed by UNICEF and WHO to work alongside animal vaccination teams for 30 days. The primary objective of the human vaccination teams was to reach 24,000 children <10 years old from nomadic and pastoralist communities with a basic health package consisting of oral polio vaccine, measles vaccine, ORS and Vitamin A.

The joint human/animal vaccination teams travel between settlements by cars and local guides help the vaccination teams to locate nomadic and pastoralist settlements. At the settlements, social mobilizers used IEC materials and visual aids to engage in dialog with caregivers and to share messages on polio and measles, routine immunization, breastfeeding, hand washing and other key child health messages.

Disclosure of Potential Conflicts of Interest

No potential conflicts of interest were disclosed.

Acknowledgments

We would like to acknowledge vaccinator, community leaders and local authorities for their support in making this activity possible.

Funding

Funding for the human vaccination was provided by the Global Polio Eradication Initiative.