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Vaccination is an important and cost-effective disease prevention and control strategy. Despite progress in vaccine development and immunization delivery systems worldwide, populations in areas of conflict (hereafter, "conflict settings") often have limited or no access to lifesaving vaccines, leaving them at increased risk for morbidity and mortality related to vaccine-preventable disease. Without developing and refining approaches to reach and vaccinate children and other vulnerable populations in conflict settings, outbreaks of vaccine-preventable disease in these settings may persist and spread across subnational and international borders. Understanding and refining current approaches to vaccinating populations in conflict and humanitarian emergency settings may save lives. Despite major setbacks, the Global Polio Eradication Initiative has made substantial progress in vaccinating millions of children worldwide, including those living in communities affected by conflicts and other humanitarian emergencies. In this article, we examine key strategic and operational tactics that have led to increased polio vaccination coverage among populations living in diverse conflict settings, including Nigeria, Somalia, and Pakistan, and how these could be applied to reach and vaccinate populations in other settings across the world.

Introduction In Kaduna State of Nigeria, the high influx of people from neighboring states with eligible children for polio vaccination represents a significant proportion of the target population. Many of these children are often missed by the vaccination team. The purpose of the study was to determine the contribution of targeted stakeholders in transit polio vaccination. Methods We used the trends of vaccinated children at transit points, motor parks and markets, well as total children vaccinated by transit teams in Chikun, Igabi and Sabon Gari Local Government Areas (LGAs) of Kaduna State, Nigeria, four rounds before and after the introduction of transit polio vaccination with targeted stakeholders in Kaduna State. Results A total of 87,502 under-5 children were vaccinated by the various transit teams in the three LGAs, which accounted for 3.2% of the total 2,781,162 children vaccinated by the three LGAs. For transit point vaccination, the number of vaccinated children increased from 1026 to 19,289 (302%), while motor park vaccination increased from 1289 to 4106 (318%) and market vaccination increased from 10,488 to 14,511 (138%), four rounds after the introduction of transit polio vaccination with targeted stakeholders. Conclusion Engagement of targeted stakeholders significantly enhanced transit polio vaccination in Kaduna State, Nigeria.

In September 2015, more than 1 year after reporting its last wild poliovirus (WPV) case in July 2014 (1), Nigeria was removed from the list of countries with endemic poliovirus transmission,* leaving Afghanistan and Pakistan as the only remaining countries with endemic WPV. However, on April 29, 2016, a laboratory-confirmed, circulating vaccine-derived poliovirus type 2 (cVDPV2) isolate was reported from an environmental sample collected in March from a sewage effluent site in Maiduguri Municipal Council, Borno State, a security-compromised area in northeastern Nigeria. VDPVs are genetic variants of the vaccine viruses with the potential to cause paralysis and can circulate in areas with low population immunity. The Nigeria National Polio Emergency Operations Center initiated emergency response activities, including administration of at least 2 doses of oral poliovirus vaccine (OPV) to all children aged

The 41st World Health Assembly in 1988 resolved to launch the Global Polio Eradication Initiative aimed at achieving a polio-free world by the year 2000 [1, 2]. Remarkable progress has been made, with a reduction from 350 000 cases in 125 countries in 1988 to 223 cases in 5 countries by the end of 2012 [3, 4]. In May 2012, the 65th World Health Assembly declared the completion of polio eradication a programmatic emergency for global public health [5–7]. At that time endemic wild poliovirus (WPV) transmission in 3 countries—Nigeria, Pakistan, and Afghanistan—constituted a risk factor for WPV reintroduction to polio-free countries and an obstacle to global polio eradication [8, 9]. Nigeria reported 122 cases of WPV in 2012, of which 28 (23%) were from Kano State in northern Nigeria [3, 10]. Kano State has traditionally been regarded as the epicenter of polio transmission in Nigeria and was the origin of the boycott of polio vaccination campaigns in 2003 [11]. Poliovirus of Nigerian and Kano State origin has been implicated as the source of reinfection to 25 polio-free countries since 2003 [6, 12]. The 2012 Nigeria National Polio Eradication Emergency Plan (NPEEP) included in its priorities the need to significantly reduce the numbers of chronically missed children by strengthening microplanning [13]. The Sixth Independent Monitoring Board of the Global Polio Eradication Initiative report in June 2012 identified poor microplanning as a major impediment to achieving the implementation of quality polio supplemental immunization activities (SIAs) [8]. Microplanning for polio SIAs is a process of estimation of the target populations and resource requirements for conduct of good-quality implementation in a specified location. The guidelines for microplanning for polio SIAs in Nigeria were revised to focus on the target number of households rather than the target number of children per vaccination team in August 2012. The revised guidelines were piloted in 87 very high-risk (VHR) local government areas (LGAs) in the 11 VHR states that were identified based on their risk categorization using the combined US Centers for Disease Control and Prevention–Global Goods Criteria [14]. The 24th Expert Review Committee on Polio Eradication in Nigeria in September 2012 recommended the expansion of implementation to all the LGAs in the 11 VHR states and the intensification of oversight of the 2012 NPEEP [13]. This resulted in the establishment of the National Emergency Operations Center (EOC) by the presidential task force and subsequent establishment of EOCs in 5 states. In August 2013, the Kano State EOC identified inflation of target population estimates with its consequent increase in requests for vaccines and high number of missed settlements as areas of serious concern in the available microplans; and with orientation, guidance and support from the country team organized a revised household-based microplanning exercise including microcensus (a process of estimating the numbers of households and eligible children in a given area by physical count, enumeration, and revalidation) was initiated. This process was aimed at collecting reliable demographic information on the target numbers of households and children in the communities. This article describes the process of implementing revised household-based microplanning intervention in Kano State between September 2013 and April 2014 and highlights the contributions of revised microplanning to improved outcomes of polio SIAs.

Poliomyelitis has remained endemic in 3 countries in 2 regions of the World Health Organization (WHO), resulting in continued shifting of the target date for global eradication. By the end of 2011, polio remained a global threat despite the availability of oral polio vaccine (OPV), widely acclaimed as one of public health triumphs, given its success in reducing the health burden of the paralyzing disease. Because of the difficulty in eradicating polio, in May 2012 the World Health Assembly declared polio eradication as a programmatic public health emergency of global significance [1, 2]. In Nigeria, some children continued to miss the opportunity to be fully vaccinated because, for various reasons (eg, religious and sociocultural beliefs), parents and caregivers do not allow them to be fully vaccinated. In some instances, vaccination programs miss children because of compromised security and population mobility. These missed opportunities conflict with the Convention on the Rights of the Child and the principles of social justice, which demand that all children should have equal access to effective childhood vaccines, given the potential of vaccines to save lives and to give all children a chance in life [3, 4]. Some factors responsible for the suboptimal vaccination coverage in areas with ongoing poliovirus circulation in Nigeria are suboptimal OPV acceptance due to unmet health needs, low uptake of vaccination in security-compromised and underserved areas, due to threats and inaccessibility to OPV, challenges reaching the underserved communities, and poor program visibility. Indeed, the epidemiology of polio transmission in Nigeria has continuously shown a pattern of isolation in noncompliant, hard-to-reach, and security-compromised areas of 11 states in northern Nigeria where the risk of polio is very high [5–7]. Although children were chronically missed in Nigeria over successive rounds of supplementary immunization activities (SIAs), not much was done on the part of the program to systematically generate sufficient demand for immunization of this group, especially in areas of traditional polio endemicity in the north. Put differently, despite the desire to vaccinate all children and meet the Global Polio Eradication Initiative targets, the effectiveness of recommended strategies for creating a genuine demand for immunization was limited. Demand-side interventions have been shown by the World Health Organization and others to lead to significant gains in child vaccination coverage in low- and middle-income countries [8–11]. To stimulate the population to request for OPV, demand creation interventions were introduced during the September 2013 polio vaccination campaign following successive recommendations by the Independent Monitoring Board and the Expert Review Committee, which oversee polio eradication activities in Nigeria. The demand creation activities included the provision of attractive benefits (hereafter, “pluses”) during immunization activities, the establishment of health camps, implementation of the nomadic Ardo (ie, Fulani community leader) intervention, the Qur'anic schoolteacher package, and increasing media visibility at the state level. We describe the implementation and evaluation of several activities to create demand for polio vaccination in persistently poor performing areas of northern Nigeria. These demand creation activities were designed to specifically target children in these communities by providing attractive packages that best respond to caregivers concerns and provide easy access to vaccines among eligible children.

The 41st World Health Assembly's resolution in 1988 for the worldwide eradication of polio marked the launch of the Global Polio Eradication Initiative (GPEI), spearheaded by national governments, the World Health Organization (WHO), Rotary International, the Centers for Disease Control and Prevention, and the United Nations Children's Fund and supported by key partners [1]. The GPEI was based on 4 strategies: high coverage with oral polio vaccine in routine immunization, surveillance for acute flaccid paralysis, supplemental immunization activities (SIAs), and mop-up immunizations. Nigeria made significant efforts but remained endemic for wild poliovirus (WPV) as a result of several factors but mainly because of poor quality and coverage of the SIAs. Another hindrance was the inability to identify areas that were missed by timely intervention with vaccination to provide the required herd immunity to break the polio transmission. The government of Nigeria, through the national and state emergency polio operations centers (EOCs), in collaboration with the WHO and partners, deployed geographic information system (GIS) technology to track vaccination teams during polio campaigns. These innovations are now increasingly used by public health professionals to visualize and explore disease patterns [2–5]. Similar tools were also used in India to monitor population migration through railroads, and Google Earth was used to track the poliovirus down the Congo River [6, 7]. These studies have demonstrated that GIS is an essential tool for making informed decisions on health, social, and environmental issues. In Nigeria, global positioning system (GPS) and GIS solutions were deployed in 2010 and piloted in the tracking of vaccination teams and for supporting the microplanning process for SIAs [8, 9]. Since 2010, GIS has been part of an intense package of interventions in Nigeria and has contributed to the successes so far recorded. The quality of the immunization campaigns has significantly improved, and the country has recorded a significant decline in the number of confirmed cases of WPV infection between 2012 and 2015, from 122 cases to 0. This article describes the innovative use of GIS in tracking vaccination teams during SIAs.

The use of Inactivated Polio Vaccine (IPV) in routine immunization to replace Oral Polio Vaccine (OPV) is crucial in eradicating polio. In June 2014, Nigeria launched an IPV campaign in the conflict-affected states of Borno and Yobe, the largest ever implemented in Africa. We present the initiatives and lessons learned. The 8-day event involved two parallel campaigns. OPV target age was 0-59 months, while IPV targeted all children aged 14 weeks to 59 months. The Borno state primary health care agency set up temporary health camps for the exercise and treated minor ailments for all. The target population for the OPV campaign was 685,674 children in Borno and 113,774 in Yobe. The IPV target population for Borno was 608,964 and for Yobe 111,570. OPV coverage was 105.1 per cent for Borno and 103.3 per cent for Yobe. IPV coverage was 102.9 per cent for Borno and 99.1 per cent for Yobe. (Where we describe coverage as greater than 100 per cent, this reflects original underestimates of the target populations.) A successful campaign and IPV immunization is viable in conflict areas.

Transmission of wild poliovirus (WPV) has never been interrupted in Afghanistan, Pakistan, and Nigeria, and since 2003, Nigeria has been a reservoir for WPV reintroduction to 25 polio-free countries. In 2012, the Nigerian government activated an emergency operations center and implemented a national emergency action plan to eradicate polio. The 2013 revision of this plan prioritized 1) improving quality of supplemental immunization activities (SIAs), 2) implementing strategies to reach underserved populations, 3) adopting special approaches in security-compromised areas, 4) improving outbreak response, 5) enhancing routine immunization and activities implemented between SIAs, and 6) strengthening surveillance. This report summarizes polio eradication activities in Nigeria during January 2012-September 2013 and updates previous reports. During January-September 2013, 49 polio cases were reported from 26 local government areas (LGAs) in nine states in Nigeria, compared with 101 cases reported from 70 LGAs in 13 states during the same period in 2012. For all of 2012, a total of 122 cases were reported. No WPV type 3 (WPV3) cases have been reported since November 2012. For the first time ever, in 2013, no polio cases of any type have been detected in the northwest of Nigeria; however, transmission continues in Kano and states in the northeast. Despite considerable progress, 24 LGAs in 2012 and seven LGAs in 2013 reported two or more cases; WPV continues to circulate in eight LGAs that had cases in 2012. Efforts to interrupt transmission remain impeded by insecurity, anti-polio-vaccine sentiment, and chronically poor SIA implementation in selected areas. Improvement of SIA quality and effective outbreak response will be needed to interrupt WPV transmission in 2014.

Background. Cases of paralysis caused by poliovirus have decreased by >99% since the 1988 World Health Assembly's resolution to eradicate polio. The World Health Organization identified environmental surveillance (ES) of poliovirus in the poliomyelitis eradication strategic plan as an activity that can complement acute flaccid paralysis (AFP) surveillance. This article summarizes key public health interventions that followed the isolation of polioviruses from ES between 2012 and 2015. Methods. The grap method was used to collect 1.75 L of raw flowing sewage every 2–4 weeks. Once collected, samples were shipped at 4°C to a polio laboratory for concentration. ES data were then used to guide program implementation. Results. From 2012 to 2015, ES reported 97 circulating vaccine-derived polioviruses (cVDPV2) and 14 wild polioviruses. In 2014 alone, 54 cVDPV type 2 cases and 1 WPV type 1 case were reported. In Sokoto State, 58 cases of AFP were found from a search of 9426 households. A total of 2 252 059 inactivated polio vaccine and 2 460 124 oral polio vaccine doses were administered to children aged

Since the 1988 launch of global poliomyelitis eradication efforts, four of the six World Health Organization (WHO) regions have been certified polio-free. Nigeria is one of only three countries, along with Afghanistan and Pakistan, where transmission of wild poliovirus (WPV) has never been interrupted. During 2003-2013, northern Nigeria served as a reservoir for WPV reintroduction into 26 previously polio-free countries. In 2012, the Nigerian government launched a national polio eradication emergency plan to intensify efforts to interrupt WPV transmission. This report describes polio eradication activities and progress in Nigeria during January 2014-July 2015 and updates previous reports. No WPV cases have been reported to date in 2015, compared with a total of six cases reported during 2014. Onset of paralysis in the latest reported WPV type 1 (WPV1) case was July 24, 2014. Only one case of circulating vaccine-derived poliovirus type 2 (cVDPV2) has been reported to date in 2015, compared with 20 cVDPV2 cases during the same period in 2014. Pending final laboratory testing of 218 remaining specimens of 16,617 specimens collected since January 2015, Nigeria could be removed from the WHO list of polio-endemic countries in September 2015. Major remaining challenges to the national polio eradication program include sustaining political support and program funding in the absence of active WPV transmission, maintaining high levels of population immunity in hard-to-reach areas, and accessing children in security-compromised areas of the northeastern states.

The polio eradication journey in Nigeria has been long, with a mix of good and not so good news over the years. Nigeria was very close to interrupting transmission of polio and then experienced an upsurge of transmission, owing to an interaction of several factors. At one point, Nigeria became a net exporter of poliovirus to polio-free countries, but at the end of 2013 there was clear evidence that the hard work and numerous innovations that the government and its partners had implemented were beginning to pay off: the number of cases of wild poliovirus (WPV) type 1 infection had decreased by 58%, compared with 2012; there had not been any cases of WPV type 3 infection detected since November 2012; and there had also been a reduction in the genetic diversity (clusters) of WPV1, from 8 in 2012 to 2 in 2013. In 2014, there were 6 cases of WPV1 infection, compared with 53 in 2013, and the number of genetic clusters had decreased to 1. Poliovirus transmission in Nigeria has been driven by reservoirs in northern Nigeria, where several states are considered to be at very high risk of poliovirus transmission. Additionally, 3 states in the northeast region have suffered from insecurity, and this added another facet to the struggle to control polio; several health workers gave the ultimate sacrifice to polio eradication, when they were killed as they conducted their work. All public health programs rely on effective surveillance and prompt response guided by the best information available. Polio eradication, like other infectious diseases surveillance and response programs, relies on prompt detection, registration, and laboratory and epidemiologic confirmation of suspected polio cases; reporting, analysis, use, and feedback of data; and preparedness and response (eg, outbreak investigations, contact tracing, and public health interventions). Like other programs, polio eradication needs managerial and support functions, which include coordination, supervision or performance evaluation, training, and resource provision for infrastructure, including communication. In Nigeria, each of these core activities and support functions were needed for the polio eradication program to produce the remarkable results that it has achieved, given the situation that it is in. New innovations also had to be tried and perfected to solve complex problems that revolved around the community accepting incessant rounds of oral polio vaccination. This supplement presents some of the public health programmatic innovations that the Nigerian government and its polio partners, with the support of the World Health Organization, tried and implemented to interrupt the transmission of polio. The programmatic interventions that are described here include efforts to create demand for polio vaccination; strategies to detect every case of suspected WPV, including those in the environment; methods to determine the underlying population immunity; strategies to effectively plan for, implement, and track vaccination activities, using the latest technologies; and approaches to widen the polio partnership in noncompliant and security-compromised communities. These interventions were enabled by a focused effort to obtain the necessary resources, use them effectively and transparently, provide the needed public health workforce, and ensure accountability for results. In 2014, Nigeria was one of the countries that was affected by the Ebola virus disease outbreak in West Africa. This supplement reviews how the polio partnership demonstrated remarkable flexibility by addressing and quickly overcoming this major public health challenge, using lessons and experiences obtained from polio eradication without compromising the gains that had been won for polio eradication. At the time this supplement was prepared, Nigeria had gone 12 months with no report of WPV and had started using inactivated polio vaccine. We believe that these public health interventions and other activities will help Nigeria enter a poliovirus-free environment. We also believe that these lessons can be adapted to improve routine immunization in Nigeria. We hope you will enjoy learning about these interventions.

In 1988, the World Health Assembly resolved to interrupt wild poliovirus (WPV) transmission worldwide. By 2013, only three countries remained that had never interrupted WPV transmission: Afghanistan, Nigeria, and Pakistan. Since 2003, northern Nigeria has been a reservoir for WPV reintroduction into 26 previously polio-free countries. In May 2014, the World Health Organization declared the international spread of polio a Public Health Emergency of International Concern. Nigeria's main strategic goal is to interrupt WPV type 1 (WPV1) transmission by the end of 2014, which is also a main objective of the Global Polio Eradication Initiative's Polio Eradication and Endgame Strategic Plan for 2013-2018. This report updates previous reports (4-6) and describes polio eradication activities and progress in Nigeria during January 2013-September 30, 2014. Only six WPV cases had been reported in 2014 through September 30 compared with 49 reported cases during the same period in 2013. The quality of supplemental immunization activities (SIAs) improved during this period; the proportion of local government areas (LGAs) within 11 high-risk states with estimated oral poliovirus vaccine (OPV) campaign coverage at or above the 90% threshold increased from 36% to 67%. However, the number of reported circulating vaccine-derived poliovirus type 2 (cVDPV2) cases increased from four in 2013 to 21 to date in 2014, and surveillance gaps are suggested by genomic sequence analysis and continued detection of WPV1 by environmental surveillance. Interrupting all poliovirus circulation in Nigeria is achievable with continued attention to stopping cVDPV2 transmission, improving the quality of acute flaccid paralysis (AFP) surveillance, increasing vaccination coverage by strengthened routine immunization services, continuing support from all levels of government, and undertaking special initiatives to provide vaccination to children in conflict-affected areas in northeastern Nigeria.

Background Transmission of wild poliovirus (WPV) has never been interrupted in Afghanistan, Pakistan, and Nigeria. Since 2003, infections with WPV of Nigerian origin have been detected in 25 polio-free countries. In 2012, the Nigerian government created an emergency operations center and implemented a national emergency action plan to eradicate polio. The 2013 revision of this plan prioritized (1) improving the quality of supplemental immunization activities (SIAs), (2) implementing strategies to reach underserved populations, (3) adopting special approaches in security-compromised areas, (4) improving outbreak response, (5) enhancing routine immunization and activities implemented between SIAs, and (6) strengthening surveillance. This report summarizes implementation of these activities during a period of unprecedented insecurity and violence, including the killing of health workers and the onset of a state of emergency in the northeast zone. Methods This report reviews management strategies, innovations, trends in case counts, vaccination and social mobilization activities, and surveillance and monitoring data to assess progress in polio eradication in Nigeria. Results Nigeria has made significant improvements in the management of polio eradication initiative (pei) activities with marked improvement in the quality of SIAs, as measured by lot quality assurance sampling (LQAS). Comparing results from February 2012 with results from December 2013, the proportion of local government areas (LGAs) conducting LQAS in the 11 high-risk states at the ≥90% pass/fail threshold increased from 7% to 42%, and the proportion at the 80%-89% threshold increased from 9% to 30%. During January-December 2013, 53 polio cases were reported from 26 LGAs in 9 states in Nigeria, compared with 122 cases reported from 13 states in 2012. No cases of WPV type 3 infection have been reported since November 2012. In 2013, no polio cases due to any poliovirus type were detected in the northwest sanctuaries of Nigeria. In the second half of 2013, WPV transmission was restricted to Kano, Borno, Bauchi, and Taraba states. Despite considerable progress, 24 LGAs in 2012 and 7 LGAs in 2013 reported ≥2 cases, and WPV continued to circulate in 8 LGAs that had cases in 2012. Campaign activities were negatively impacted by insecurity and violence in Borno and Kano states. Conclusions Efforts to interrupt transmission remain impeded by poor SIA implementation in localized areas, anti-polio vaccine sentiment, and limited access to vaccinate children because of insecurity. Sustained improvement in SIA quality, surveillance, and outbreak response and special strategies in security-compromised areas are needed to interrupt WPV transmission in 2014.