Qualitative review on type two circulating polio virus outbreak in Ethiopia: a thematic analysis approach, 2020

¹Ethiopian Public Health Institute, Center of Public Health Emergency Management, Addis Ababa, Ethiopia, ²Oromia Regional Health Bureau, Addis Ababa, Ethiopia, ³Ethiopian Civil Service University, Addis Ababa, Ethiopia

^&Corresponding author
Yonas Assefa Tufa, Ethiopian Public Health Institute, Center of Public Health Emergency Management, Addis Ababa, Ethiopia

Introduction    

Poliomyelitis is a viral disease caused by three serotypes of poliovirus, transmitted mainly through the fecal-oral route. While paralysis is its most known symptom, polio can range from asymptomatic to severe illness, including meningitis and death. There is no cure, but it is preventable by vaccination. Failure to eradicate polio poses a global risk [1].

Since the 1988 launch of the Global Polio Eradication Initiative, cases have dropped from 350,000 to just 33 by 2018, with 80% of the world now polio-free [2]. However, Africa remains vulnerable, contributing nearly 90% of global cases. Ethiopia interrupted indigenous wild poliovirus in 2001 but has since faced multiple importations [3]. Polio is a notifiable disease in Ethiopia; all suspected cases must be reported immediately for timely detection and response. Ongoing surveillance at all levels is essential [4]. On May 20, 2019, Ethiopia reported cVDPV2 cases in Somali and SNNP (Sidama zone) regions. A national team investigated the outbreak in Bokh Woreda, Somali Region, confirming four type 2 circulating poliovirus. In response, emergency measures, including vaccination, community engagement, and awareness campaigns were launched. The study was conducted to assess best practices, identify gaps, and strengthen future preparedness and response efforts [5].

Methods     

Study setting and population: the study was conducted in 2020 in Somali, SNNP regions, focusing on affected zones and woredas where the outbreak and response occurred. The index case was detected in Bokh Woreda, Dollo Zone, Somali Region. Dollo, formerly Warder, lies 1,147 km from Addis Ababa and 529 km from Jijiga. According to the 2007 CSA Census, Dollo Zone had a population of 306,488 (57% men, 43% women), with 9.4% urban dwellers and 37% pastoralists. The Somali ethnic group made up 99.57% of the population. The zone has 10 hospitals and 188 health centers, while Bokh Woreda is served by 4 health centers and 18 health posts (9 of which provide routine immunization) Figure 1.

Review design: his study used a qualitative research approach with thematic analysis and purposive sampling. It involved key stakeholders from national health institutions, partners, and two regional states Somali, and SNNP engaged in the polio outbreak response. Key informant interviews (KIIs) were conducted with representatives from EPHI, FMoH, RHBs, zonal health offices, and partner organizations, focusing on five AAR thematic areas. Additionally, participants from woredas and communities took part in group exercises following AAR steps. For the KIIs, three representatives were selected from each national and regional health sector, and one from each partner organization. Two representatives were selected from each zonal health office. At the woreda and community levels, two focus group discussions (FGDs) were conducted per site, each involving 6-8 participants.

Method and data collection: data were collected using focus group discussions (FGDs), in-depth interviews, observations, and document reviews. Interview guides and semi-structured checklists were developed to gather information from Rapid Response Team (RRT) members, health professionals, and selected community members. A total of six FGDs were conducted. KII (Key informant interview). Fourteen informants from various health sector offices, ranging from zonal to federal levels, were interviewed. These included Zonal PHEM units, RHB PHEM leads, the national PHEM unit, and purposefully selected RRT members at each level. Focus group discussion: total six FGD were conducted, from these, two community FGD per affected woreda. An FGD session contained 8-10 participants. Digital audio voice recorder was used to record conversations. Mean age was 34.3 years (SD= ±8.5). Observation: minutes of the epidemic committee at woreda and zonal level; epidemiological data analysis and report generated at each levels; guidelines at each level. Document review: the following documents were reviewed during collection of data: patient card reviews at health facilities; review of daily and weekly reports at WrHO and Zonal health department; outbreak investigation report by zonal PHEM; check list and questionnaire were prepared/adapted for data collection; required resource were mobilized With respect to data quality assurance, the tools were initially piloted in selected areas to evaluate their effectiveness across different levels, from national to community. The feedback obtained from these pilot implementations was systematically reviewed and incorporated, after which the tools were refined and finalized for use in data collection. Interviews and discussions were conducted on questions deriving from the core IHR functional areas/ indicators: surveillance; preparedness; response; coordination; and risk communications. For observation as a supportive method, the team made systematic observation of: minutes of the epidemic committee at woreda and regional level and; epidemiological data analysis and report generated at regional and national level; EPRP and VRAM documents were viewed. Finally, document review as an added data generation approach reviewed a range archives including: review of daily and weekly reports at woreda HO and Zonal health department; and, o utbreak investigation report by zonal PHEM.

Data analysis: data were recorded using a digital voice recorder and transcribed from Amharic to English. Transcripts were shared with participants for feedback or corrections. Analysis was conducted using Atlas.ti 9 software, with content coding for thematic analysis. Initial coding followed conceptual categories, and additional codes were derived from the data. The coded data were explored to identify recurring themes, relationships, and patterns. Three main themes emerged from the analysis. The following functional areas were reviewed: preparedness; coordination; surveillance and laboratory investigation; response; risk communication, community mobilization, and engagement.

Results     

Coordination

Coordination is essential during emergencies, as no organization can manage an outbreak alone. After confirming polio cases, coordination structures were activated from the national to woreda level. As one informant stated, “..for the polio coordination, we revitalized task forces from the Measles outbreak..” [KII Sidama Zonal EPI focal, 2020]. The Emergency Operation Center (EOC) served as the main hub, managing coordination, logistics, planning, and operations [KII Somali Region PHEM, 2020]. Regional efforts included Rapid Response Teams (RRTs) and task forces from multiple sectors [KII Sidama Zonal HBH, 2020].

Human resources were deployed to ensure supervision and accountability: “..we assigned a specific person for each area..“ [KII Sidama Hawasa Zuria Health Office Head, 2020]. Inter-regional coordination was strengthened, with Dire Dawa supporting polio immunization and COVID-19 testing (KII SITI Zonal PHEM officer, 2020). Coordination was supported by regular meetings, enabling quick issue resolution [KII Somali RHB Head, 2020]. At the community level, coordination involved local health committees with HEWs, WDAs, and community leaders [Hawasa Zuria Kebele FGD, 2020]. However, gaps like the absence of formal agreements at the woreda level led to direct partner communication without full coordination with health offices [Arbaminch Zuria Dore Bafaanan WHO KII, 2020].

Stakeholder mapping and involvement

Stakeholder mapping is key for outbreak management. National-level stakeholders included GAVI, UNICEF, WHO, CDC, and government sectors like Education and Women´s Affairs [KII SNNPR PHI DDG, 2020]. At regional and zonal levels, stakeholders such as WHO, UNICEF, local administrations, and security services played active roles in the polio immunization campaign [KII Arbaminch EPI focal, 2020]. Their collective efforts ensured timely and effective intervention.

Preparedness

The data reveal key gaps in polio outbreak preparedness, highlighting both strengths and areas for improvement in capacity-building. While preparedness efforts shaped the outbreak response and offered valuable lessons, they need to be more visible and better understood. In regions like SNNPR, and Somali, existing systems were leveraged effectively. As one Somali informant noted, “…Since we have an Emergency Operation Center (EOC), whenever there is a disease outbreak, we plan an emergency preparedness and response plan (EPRP) based on the EOC and act accordingly…” [KII MCH Focal, 2020]. Sidama zone prepared proactively: “…we prepared a micro plan before the campaign, assessed resources, manpower, and supplies based on our goals…” [KII Sidama Program Head, 2020]. In SNNPR, activities included vulnerability assessments, EPRPs, and capacity-building for health workers. One recommendation was: strengthen regional labs for diseases like Dengue and Yellow Fever to avoid delays from sample transport [KII SNNPR DDG, 2020].

Surveillance and laboratory

The theme highlights efforts to enhance polio case identification and reporting, drawing lessons from the 2019 outbreak. Insights from interviews and discussions are grouped into five areas: case detection, notification, early warning, lab investigation, and monitoring. While surveillance “the collection, analysis, and interpretation of public health data” is essential for early detection, it was weak at service delivery points early in the outbreak, despite Ethiopia´s immediate and weekly reporting system [6].

Case detection: case detection is crucial for effective surveillance. However, early detection of suspected Acute Flaccid Paralysis (AFP) cases was poor. As one key informant noted: “The surveillance system has been in place, but for AFP, it showed weaknesses. We reported over 100 suspected polio cases and sent 63 samples to EPHI during the campaign, indicating that the system failed to detect cases early and communities lacked awareness.”[KII SNNPR IPH DDG, 2020]. Detection rates varied across regions, with SNNPR performing better than Somali and Sidama regions.

Case notification and reporting: notification processes showed mixed results. A key informant shared: “The first case was reported from Oromia region. Health extension workers played a significant role in case notification.” (KII SNNPR IPH DDG, 2020).In Sidama, immediate notification through phone calls was common: “They notify us first through the phone until the report form arrives.” [Sidama_KII Zonal PHEM Coordinator]. Community members also confirmed grassroots reporting: “We inform our group leader, who reports it to higher levels” and, “When a child is found, we bring him to a clinic for testing.” [Sidama_Community FGD Dore Bafaana]. At the woreda level, a participant shared: “We found a 5-month-old with lower extremity weakness and informed our supervisor for notification.” (SNNPR Community FGD, 2020).

Laboratory: laboratory confirmation was essential for outbreak response, A Somali region informant explained:“Only the laboratory can confirm polio cases; early testing is crucial for swift response and disease control.” [KII Somali Region HBH, 2020]. During campaigns, Standard Operating Procedures (SOPs) guided sample handling: “A stool sample would be collected immediately upon suspicion and sent to EPHI, maintaining cold chain requirements.” [KII SNNPR Hawassa Area WHOH, 2020]. Rapid Response Teams (RRTs), including laboratory experts, supported the regions: “Laboratory experts were involved in each region during campaigns.” [KII Somali RHB ead, 2020]. However, challenges persisted. During a second-round campaign: “Eight children were reported as suspected AFP, but only two met the criteria for sampling.” [KII SNNPR Zonal EPI Focal, 2020].

Response

Vaccination campaign: the vaccination campaign was a major sub-theme under the “Response” component. This section discusses the status of the vaccination campaign, community involvement, risk communication strategies, monitoring and evaluation efforts, vaccination coverage, successes, and challenges encountered.

Vaccination campaign status: according to participants in community focus group discussions (FGDs), pre-campaign activities for the polio vaccination campaign were well executed. One participant from the SNNPR region mentioned: “…Before the campaign, we conducted social mobilization at all levels and worked in coordination with community mobilizers and vaccinators…” [SNNPR_Community_FGD_2020]. Similarly, a participant from Sidama Region explained: “…When the budget came from the federal level, it was separated for the campaign and RCC activities. We used that budget to distribute printed materials and other communication tools to the districts…” [Sidama_KII Zonal Head of Health Program, 2020].

Communication and community engagement: risk communication during the outbreak was generally effective, with early warnings, case searches, and surveillance. However, regional differences were observed.In Somali Region, strong community engagement was established: “…There is a social mobilization platform comprised of community leaders, woreda, and kebele officers…” [Somali Region MCH focal KII, 2020]. Local networks proved useful: “…Edir and Ekub were the most effective social networks…” [Somali Region Community FGD, 2020]. Media played a key role in SNNPR:“… Media outlets like South FM and South TV were engaged in social mobilization…” [SNNPR Community FGD, 2020]. Still, communication gaps were noted:“…There was no sufficient media coverage, and even among health professionals, there was limited communication about polio…” [SNNPR_WHD_KII, 2020].

Vaccination Coverage: Vaccination coverage was reported to be above the planned targets. A key informant from SNNPR reported: “Our target for children aged 0-59 months was 268,607, and we vaccinated 282,775 children, achieving 105% coverage…” [KII SNNPR Zonal EPI Focal, 2020].

Discussion     

Coordination

Coordination and synergy between public health and other critical sectors (security, humanitarian, financial mechanisms, and neighboring countries) are vital for effective outbreak response (Strategic Response Plan, 2018). Effective coordination in Public Health Emergency Management (PHEM) is achieved when a task force with all stakeholders is formed [7]. The polio immunization campaign achieved significant success, with SNNPR (Sidama zone specifically) reaching 98% coverage, Somali at 94%, and Sidama at 92%. The campaign also increased awareness about polio and COVID-19 vaccination, without disrupting routine Expanded Program on Immunization (EPI) services. However, despite improvements, the EPI program still faces challenges in further boosting coverage and reducing vaccine-preventable diseases. At all levels, stakeholders showed strong coordination. Regular meetings were held, and Rapid Response Teams (RRTs) were quickly activated after polio cases were confirmed in the Somali region, ensuring coordinated efforts across regions and sectors.

Preparedness

Findings from this study highlight that preparedness gaps stemmed from limited knowledge and perceived risk of polio within the PHEM structure, particularly at lower levels. Many believed acute flaccid paralysis (AFP) had been eradicated in Ethiopia, leading to low prioritization of preparedness efforts even among national bodies like EPHI and the Federal Ministry of Health. Consequently, risk assessments were not conducted, and preparedness activities were inadequate, despite the outbreak occurring in Bokh Woredas, Dollo Zone, Somali Regional State in 2019. Furthermore, the general weakness of the EPI program was evident, as many health centers and most hospitals were not delivering routine immunization services. Supporting evidence from Tegegne et al. (2018) and Sufa and Gerema [8,9] in Dollo Zone confirms that underserved communities, inaccessible immunization services, suboptimal surveillance, and inadequately supplemental immunization activities were critical gaps. Weak emergency preparedness contributed significantly to the outbreak [5].

Surveillance and laboratory

Surveillance is central to polio prevention, guiding risk assessment, response, and evaluation. Ethiopia classifies polio as immediately reportable [4], with AFP surveillance designed to detect even a single case. A system that detects the expected number of non-polio AFP cases signals sufficient sensitivity. The purpose of surveillance is to empower decision-makers to lead and manage more effectively by providing timely, useful evidence so effective surveillance systems are useful for targeting resources and evaluating programs [10,11]. During the outbreak, initial surveillance at service delivery points was weak. Active surveillance involving health facility case searches was the main approach. AFP cases were promptly reported and sampled per WHO guidelines, enabling early detection and confirmation. Although the VDPV2 case was not identified promptly, reporting to higher levels met the 30-minute standard set by WHO and national protocols. Escalation from community to national level (EPHI) was timely. Lab confirmation is crucial, but responses must start immediately once AFP is suspected, as a single case confirms an outbreak. While regions can report AFP, attention should focus on areas with an active case history or silent. Key challenges included centralized labs and delayed results. Informants from SNNPR stressed the need to decentralize lab services to regional levels.

Response

Managing disease outbreaks is a vital part of disaster response, requiring Rapid Response Teams (RRTs) to remain prepared for any public health threat. Public Health Emergency Rapid Response Teams (PHERRTs), as technical and multidisciplinary units, must be ready for immediate deployment [7]. Although initial surveillance failed to detect the outbreak early, timely notification and case escalation improved. Subsequent interventions were well-coordinated among stakeholders, as described in the coordination and results sections. Effective outbreak response depends on adaptable strategies, supported by strong coordination, detailed planning, timely resource allocation, community engagement, and continuous monitoring. Risk communication and social mobilization must be context-specific to enhance surveillance, vaccination campaigns, and routine immunization [12,13]. In this case, risk communication and community engagement were successful, with active involvement from community groups, political leaders, partners, and government offices at all levels. Rapid emergency response enables swift outbreak assessment, implementation of control measures, and monitoring, playing a critical role in containment and preventing further spread.

Gaps and challenges

In Ethiopia, centralized polio testing at EPHI led to delays, high costs, and weak result communication. Decentralization is essential to improve service quality [KII, SNNPR IPH DDG, 2020]. Delayed results and inadequate transport compensation further affected response efforts [Shele Woreda FGD, SNNPR, 2020]. Coordination gaps included irregular woreda-level meetings, lack of TORs, and inconsistent stakeholder involvement [KII, Sidama RHB Head, 2020]. COVID-19 disrupted house-to-house vaccination, though training improved staff readiness [KII SNNPR Zonal EPI Focal, 2020]. A key systemic issue was poor accountability, with many facilities failing to deliver routine immunization [Sidama RHB MCH Focal, 2020].

Conclusion     

The surveillance system initially failed to detect the polio case early, but the subsequent response, including early case notification and the vaccination campaign, was effective and well-organized. Coordination within the health system and the involvement of experienced outbreak management professionals were key strengths. However, coordination mechanisms were only activated during the vaccination campaign, and inter-sectoral collaboration was limited before the intervention. There was a significant gap in preparedness, as the low risk perception of polio and the belief that poliovirus had been eradicated led to inadequate preparedness efforts by the Ethiopian Public Health Institute (EPHI) and the Ministry of Health (MOH). No formal risk assessment was conducted before the 2019 outbreak in Somali Region. The outbreak was primarily attributed to poor routine immunization coverage, weak surveillance, and inadequate supplemental immunization activities. The lack of adequate preparedness and the absence of functional Technical Working Groups (TWGs) and Rapid Response Teams (RRTs) contributed to the crisis.

Competing interests     

The authors declare no competing iterests.

Authors' contributions     

Yonas Assefa Tufa, Mikiyas Alayu, Negash Abera, Ahmed Mohammed, Alemu Zenebe, Belay Makango, Shiferaw Tesfaye Tilahun, Yoseph Nigussie, Birhanu Regassa, Tsegaye Getachew, Hebron Mekonen, Assebe Feyera, Mintesnot Hawaz, Ermiyas Woldie, Yibeyin Mulualem, Senait Alemayehu, Zerihun Doda and Yarega Fufa have different experience in conducting qualitative research and participated in all part of the work, including data collection, tools development, facilitated fieldwork logistics, analyzed and interpreted the data; and assisted/contributed in translation, transcription and analysis.Yonas Assefa Tufa, Mikiyas Alayu, Ermiyas Woldie and Zerihun Doda participated in reviewing the manuscript and prepared the draft manuscript. Finally, Zerihun Doda provided special assistance and contribution in data analysis, thereby helping in the drafting process.,Aall authors read and approved the final manuscript.

Acknowledgments     

We are strongly indebted to those who engaged from the inception of this document to the final throughout the work. Without the commitment these coauthors, the accomplishment of this manuscript would have been impossible. We thank the Ethiopian Public Health Institute for facilitating the accomplishment of this research project.

Figure     

Figure 1: map of regions type two circulating polio virus outbreak a review was conducted

References