Day Zero: Inside Nigeria’s response to the 2016 polio outbreak

August 10, 2016
10:30 A.M.

When Dr. Anis Siddique’s cell phone rang, he was driving to work at the Emergency Operations Center (EOC) in Abuja, Nigeria. As UNICEF’s team leader for polio, Siddique attended weekly strategy meetings alongside other organizations in the Global Polio Eradication Initiative (GPEI)—including the World Health Organization (WHO)—and its partners from Nigeria’s health department, and the National Center for Disease Control. Siddique thought, maybe the call was about the day’s top agenda item: planning the president’s announcement that Nigeria was celebrating two years without a case of wild poliovirus. As the lone polio-endemic nation in Africa, if Nigeria could go a third year then the entire AFRO region could be declared polio-free.

Answering the phone, Siddique realized the president’s announcement would have to wait. A colleague from UNICEF’s headquarters told that samples taken from two children in the northern state of Borno had tested positive for wild poliovirus type 1.

“This has to be a joke,” Siddique said. A native of Bangladesh, he worked for UNICEF and WHO during India’s fight against polio. Now working in Nigeria, Siddique had learned that false alarms were part of the job. But the sample had been analyzed at the CDC laboratory in Atlanta, Georgia. The news got worse. The lab had sequenced the virus’s genome and it matched a strain of polio not seen in Nigeria since an outbreak in 2011. That meant the wild poliovirus had been circulating all along.

In an instant, Nigeria’s track record of going 730 days polio-free was reset to zero. And it wouldn’t start counting again until they could be sure the outbreak was contained. From past experience, Siddique knew that every hour mattered in the early days of an outbreak. He stepped on the gas.

11:00 A.M.

The boardroom table in the EOC’s incident management room grew more and more crowded. The table was covered with laptop computers, projector devices, and speaker pods for conference calls. On the walls hung flat screen displays for video conferencing and screen sharing, along with dozens of maps of Nigeria.

The incident manager sat at the head of the table. He opened the weekly meeting by announcing the strategy group was now operating as an incident management team. This outbreak was, in many ways, a continuation of the 2011 outbreak. They were dealing with the same virus in roughly the same location. But much had changed in how Nigeria responded to disease outbreaks since then. The biggest game-changer was the construction of 9 EOCs around the country (a national headquarters in Abuja, and 8 regional facilities), built between 2012 and 2013, creating a framework for the Nigerian government and GPEI’s partners to work together more effectively. The EOC framework had proven a secret weapon for helping stop outbreaks of Ebola, yellow fever, monkey pox, measles, cholera, and Lassa Fever.

The room grew noisy as program leaders broke into impromptu huddles, strategizing how their organizations needed to work together. Vaccines were at the top of Siddique’s mind. Once the exact location of the outbreak was known, they’d need a significant amount of oral polio vaccines (OPVs) for a rapid immunization effort. To effectively disrupt the virus, they would then need to follow up with regional and national immunization campaigns. That would amount to tens of millions of vaccine doses.

He called Nigeria’s National Strategic Cold Store in Abuja and learned there were roughly one million doses of OPV stored in vaccine banks around the country. Siddique ordered all of them transferred to the EOC in Borno.

During past polio outbreaks, such a transfer would’ve been risky because of how many vaccines were routinely spoiled during shipment because of poor cold chain infrastructure. But thanks to a $21 million investment by Gavi, the Vaccine Alliance, Nigeria completely revamped its national inventory of cold chain refrigerators. And the group eHealth Africa had designed the innovative PUSH-Plus vaccine tracking system for assuring that vaccines were constantly “pushed” out to regional vaccine stores, rather than “pulled” from centralized stores as needed.

Of course, Siddique was now “pushing” every single dose of polio vaccine to Borno. And it was still just a fraction of the amount needed. Siddique walked around the conference table to where the WHO team sat. They could order resupplies of OPV from manufacturers in Europe, India, and Indonesia. Over the next two months, more than 90 million doses of OPV would be airlifted to Nigeria from around the world.

12:00 PM

The conference speaker crackled with the sound of Dr. Fiona Braka’s voice.

As WHO’s immunization team lead for Nigeria, Braka would’ve been sitting in the incident command room in Abuja, but the outbreak caught her on a short break in her native Uganda. She was having lunch with a friend when her phone lit up with calls and text messages from a number with Switzerland’s country code. That likely meant it was coming from WHO’s headquarters in Geneva. Excusing herself, Braka took the call and heard the devastating news about the polio outbreak. Her friend, a fellow WHO employee, told her to go and not worry about the bill.

Braka drove to the WHO office in Kampala, Uganda, to make a series of conference calls. She immediately notified the WHO country representative in Nigeria, who then conveyed the news to Nigeria’s Minister of Health. The government leader wanted a full briefing within the hour. While stuck in Kampala (she would take the next flight to Nigeria, which left the next day), Braka could easily coordinate with her team assembled at the national EOC in Abuja.

To effectively launch an immunization response, they needed to know the exact location of the outbreak. Braka assigned the WHO field office in Borno (housed at the regional EOC) to find the two cases among the thousands of cases investigated that year. They also alerted Borno state’s health officials, as well as leaders of Rotary International, because they would need all the help they could get to mount a fast and aggressive response to the polio outbreak.

Finally, investigations teams need to be sent to the locations of the outbreaks. That also meant organizing military escorts since the cases were located in an unstable region of Nigeria, which had to be reached by helicopter.

Braka’s team also needed to think big picture. During the 2011 outbreak, wild poliovirus had spread across the border between Nigeria and Chad. With help from WHO’s regional office in Borno, Braka started contacting her WHO colleagues in four nearby countries—Chad, Cameroon, Niger, and the Central African Republic—warning them about the outbreak. They, in turn, would alert the authorities in districts bordering Nigeria to heighten their surveillance at border crossings to prevent the outbreak from spreading.

August 11, 2016

Her name was Aisha, she was four-years-old, and lived in the Muna camp for internally displaced people in the state of Borno. The outbreak investigation team located her by comparing the information on her “epidemiological number” case file, with the micro-plan posted to the Vaccination Tracking System that had been used by the health workers who’d originally seen her. Now, sitting with Aisha’s family inside their camp tent, they learned her story which was as heroic as it was tragic.

In May 2016, the Nigerian military won an offensive against Boko Haram, liberating Aisha’s village of Marte from insurgent control. The family decided to flee, hoping to seek refuge in Maiduguri, the capital of Borno. They walked for two days before reaching the Muna camp. Seven weeks into their stay, Aisha’s left leg showed signs of paralysis. On July 6, the family asked a health worker assigned to their camp for help. She recognized the symptoms as a potential case of acute flaccid paralysis. The health worker collected a stool sample and sent it to the regional lab for analysis. It was then sent to the CDC lab in Atlanta where it waited in line with samples from around the world for testing.

Now, one month later, the family learned the diagnosis: Aisha had wild poliovirus type 1. A health worker on the investigation team gave her and her siblings doses of OPV, as well as a full package of routine immunizations. Nigeria’s polio program managers had realized their vaccination teams were often the first contact a child ever had with a public health worker. Polio vaccination campaigns helped drive down rates of infection for vaccine-preventable diseases like measles, hepatitis, and tetanus.

Not that any vaccine could bring back the full use of Aisha’s leg. For being such a sweet, young girl, she had potentially shed poliovirus across the length of her family’s journey. The investigation team asked detailed questions about their movements and for the names of all associates during that time. Then they moved to the next tent, asking if there were any children under the age of 5. The matter, they said, was urgent.

Meanwhile, a helicopter touched down in the town of Gwoza, located near a conflict zone with active fighting between the Nigerian army and Boko Haram insurgents. Somewhere, the investigators knew, there was a two-year-old girl named Fatima who’d developed some weakness in her right leg.

August 21, 2016

Word spread quickly around the Borno EOC that a new case of wild poliovirus had been discovered. That brought the 2016 outbreak to a total of four cases. To the immunization team, the number sounded both minuscule and insurmountable. A decade earlier, Nigeria suffered from hundreds of polio cases every year. An immunization team could confidently go into almost any community in Nigeria and be sure they were attacking the virus head-on. Paradoxically, as the number of cases grew smaller, it became harder and harder to finish the job of eradication.

The task was becoming like the search for a needle in a haystack. To make the haystack safe, you have to comb through every stalk of hay, perhaps even using a magnet to find that needle. Because if you prematurely declare the haystack safe and allow children to jump in it, it’ll be just a matter of time before one of them gets pricked.

Dr. Ndadilnasiya Endie Waziri had a knack for finding the needles. As a frontline worker, she’d paddled a canoe along the shores of Lake Chad to immunize children who’d never-before seen a health worker. In 2012, when she started working for Nigeria’s NSTOP (National Stop Transmission of Polio) program, she realized that mobile communities of nomadic Fulani people were going unvaccinated. Their seasonal migrations happened to overlap with the location of polio outbreaks. Coincidence? She didn’t think so. However, the Fulani people were reluctant to participate in immunization campaigns. Waziri had the idea of teaming up with the Ministry of Agriculture because the Fulani people would always welcome a veterinarian into their settlements to care for their animals. Waziri’s nomadic immunization project broke down cultural barriers that brought the Fulani people within the scope of Nigeria’s immunization program.

Waziri also coordinated with program partners who recruited social mobilizers, such as traditional barbers known as wanzams. In northern Nigeria, a newborn isn’t given a name until its seventh day. During a naming ceremony, the wanzam shaves the baby’s head. Realizing wanzams had eyes and ears in places vaccinators weren’t necessarily welcome, USAID launched an innovative program that recruited wanzams to work as immunization advocates. With their help, a baby could get named and their routine immunizations, including polio, on the same day.

In the coming week, Waziri was planning for the first national immunization program since the outbreak. Health workers would need every social mobilizer at their disposal to make it a success. If they could hold the outbreak’s number of cases to four, then the date “August 21, 2016” could be Day Zero of a truly polio-free Nigeria.

Three Years Later
9:30 A.M.

Dr. Siddique again found himself driving to work at the EOC in Abuja. Three years have passed since the polio outbreak of 2016. Through collaboration, innovation, and relentless work, GPEI’s partners worked with local communities to change the odds that Nigerians could live in a world free of wild polio. The milestone felt heroic to most. For Siddique, who’d battled through polio outbreaks in India and Nigeria, he’d learned that the poliovirus had a tenacious spirit of its own. It could re-emerge when you least expected. Statistically, the odds were good that wild poliovirus had finally been eliminated from the African continent, leaving Afghanistan and Pakistan as the world’s last polio-endemic nations.

The WHO wasn’t committing to making a declaration, just yet. A lot of work remains and GPEI’s partners—and all of those working to stop polio through immunizations, disease surveillance, and data analysis—will need to hold the line until polio is eradicated everywhere. But Siddique felt confident that Nigeria’s president could finally announce Nigeria as wild polio-free in the near future.