Simulation Exercises To Strengthen Polio Outbreak Preparedness in The Horn of Africa: Experiences and Lessons Learnt

"Communication teams in the different countries were more effective and knew what they needed to do."

Between 2013 and 2014, there was a series of outbreaks of wild poliovirus type 1 (WPV1) in the Horn of Africa. In response, the World Health Organization (WHO) and United Nations Children's Fund (UNICEF) held 7 tabletop polio outbreak simulation exercises (POSEs) to explore national planning and coordination in response to detection of poliovirus circulation. This paper reviews and summarises these experiences and lessons learned therein, with a focus on country readiness to respond to a polio outbreak in line with the existing plan should one occur.

The first 4 POSEs were conducted in Sudan, Ethiopia, Eritrea, and Tanzania in 2016; another 3 POSEs were conducted in Kenya, South Sudan, and Uganda in 2017. The exercises were designed to stimulate the countries to critically review and bring their national plans to be consistent with the standard operating procedures (SOPs) to responding to detection of polioviruses, to increase preparedness. The exercises addressed aspects of response, such as coordination, communication, and collaboration at international and national levels. The objectives of the exercises included assessing preparedness for a possible event of WPV importation or cVDPV circulation, identifying preparedness strengths and challenges in individual countries, strengthening capacity to respond rapidly to poliovirus detection, improving country response and use of the International Health Regulations (IHR) mechanism in case of WPV detection, and exploring the communications response, including strengthening communications planning, use of social media tools, and management of traditional media outlets.

The lead facilitators trained a team of evaluators drawn from various WHO country offices with experience of implementation of polio eradication activities at national and sub-national levels. Each POSE was country specific and engaged external facilitators. Participants received 7 progressive scenarios that mirrored what could happen during a real-life response in any country. The scenarios portrayed unfolding events to a polio outbreak response of approximately over a period of 120 days, when a circulating vaccine-derived poliovirus (cVDPV) outbreak should be interrupted once it occurs. As the simulated outbreaks developed, sessions covered: local, national, and international communications; supplementary immunisation activities (SIAs); enhanced surveillance; and local and reference laboratory activities. Participants then acted upon this information to simulate realistic response activities. The exercises encouraged interaction and communication between groups. Participants had access to the internet, national polio plans, and information sheets. At the end of the exercise, all participants on an individual basis were tasked with evaluating the exercise using a one-page questionnaire. Evaluators were provided with an integrated checklist to enable them to document whether the input and expected actions would produce the desired outcome of the POSE.

With regard to the communication and coordination mechanism of the POSEs, the evaluation found that the communication activities were efficiently discharged, with relevant stakeholders adequately informed. There was good collaboration between partners in responding to rumours. Verbal communication was efficiently conducted, clear, and moved down the line, with information shared by phone (e.g., specifying VDPV2). The national social mobilisation committee (NSC) is active and provides directions to make things move forward. Sub-committees began to work with clear guidance and follow-up from the NSC, and an emergency operations centre (EOC) was established immediately.

However, a number of gaps were observed. For example, the roles and responsibility of each partner were not clear, and internal communication in the agencies was not evident. Furthermore, formal communication between stakeholders was not evident in many of the countries. The national preparedness and response plan did not show clearly committees' terms of reference (TORs) and responsibilities and no evidence of outbreak to be declared as a public health emergency of international concern (PHEIC) by the Ministry of Health. Furthermore, in many of these countries, WHO and UNICEF representatives did not physically participate in the POSE - yet they are key to effective outbreak response.

On the whole, the external evaluators observed that the technical capability to respond to an outbreak of polio was available in the different countries, with some gaps that can be addressed while performing future POSEs. The participants' evaluation closely mirrored the findings and comments of the evaluation team. Their comments reflect the need for the countries to work on the POSE findings and recommendations, as well as to review the national response plan (among the weeknesses identified: unreliable routine immunisation coverage data, weak communications components, and lack of clarity on national vaccine policies and sources of procurement in case of an outbreak).

In conclusion: "The impact of simulation exercises to date, along with positive feedback from the participants, suggested that the POSEs have become valuable tools that are helping to respond to polio outbreaks. The exercises helped familiarize participating countries with each other's preparedness plans and practices and promoted better understanding and cooperation between countries and international organizations.... They fostered discussions, proposed realistic actions, and identified important issues and areas for development.... The experiences and lessons learned from these exercises are transferable to other vaccine-preventable disease[s.]"