Strengthening CORE Group Polio Project Impact: Community-Based Surveillance (CBS) Activities in South Sudan - FY2018 Progress Report, The Bill and Melinda Gates Foundation

Since 2010, the Bill and Melinda Gates Foundation has supported the CORE Group Polio Project (CGPP)'s polio eradication efforts in South Sudan. With a population of 3.7 million people within the catchment areas, the project has sought to reach nearly 2 million children under the age of 15 years with the aim of halting the potential spread of wild poliovirus (WPV) and vaccine-derived polio viruses. In October 2015, the CGPP designed and implemented a new acute flaccid paralysis (AFP) surveillance system based on the use of unpaid community informants (rather than health workers) to cover all 33 counties in the conflict-affected states of Jonglei, Upper Nile, and Unity, in addition to the hard-to-reach state of Eastern Equatoria. Protracted conflict has resulted in the internal displacement of 1.96 million people and the exodus of more than 2.5 million people (UNOCHA 2018) - this, plus the recent vaccine-derived outbreaks in Kenya and Somalia, underscores the continued need for a strong community-based surveillance (CBS) network. This annual report, which covers the period from October 1 2017 through September 30 2018, describes the strategy and impact of the network.

The CGPP collaborates closely with the World Health Organization (WHO), the United Nations Children's Fund (UNICEF), and the Ministry of Health (MOH). Furthermore, in fiscal year (FY)18, CORE Group South Sudan directed the work of 6 national non-governmental organisations (NGOs): Support for Peace and Education Development Program (SPEDP), Universal Network for Knowledge and Empowerment Agency (UNKEA), Children Aid South Sudan (CASS), LiveWell, Christian Mission for Development (CMD), and Bio Aid in 37 counties. These implementing partners worked in the conflict-prone and hard-to-reach border areas that were also impacted by flooding, cattle rustling, and interclan and tribal conflicts. The report describes the efforts CGPP made to improve partner collaboration and cooperation, such as monthly meetings in Juba to discuss lessons learned, best practices, and challenges in the field, as well as to plan future actions.

The CBS strategy combines components of active facility-based AFP case surveillance and behaviour change education using community health volunteers. These informants are all well-respected community members such as birth attendants, teachers, elders, community leaders, and church officials who, in the course of their daily lives, are likely to observe or be informed of unusual health events such as a newly paralysed child. CGPP identified these key informants, trained them on the symptoms of AFP, and gave them the names and numbers of contact persons to notify in case they identified a suspected case. Strengthening support supervision is a core component for measuring the quality of CBS activities.

The CGPP South Sudan originally set out to reach 90% of 73,280 community leaders with key messages on CBS. Due to the large numbers of returning residents from other counties as security normalised in some areas, an additional 6,100 chiefs, headmen, women leaders, youth leaders, teachers, church leaders, and government local authorities were reached during quarterly health sessions.

During the reporting period, a network of 3,464 volunteer community informants worked to detect and report suspected polio cases in areas under the control of both the opposition and the government. Through CBS efforts, volunteers reported 79.1% of true AFP cases detected in the CGPP project areas and a total of 398 non-polio AFP cases (raising the levels of non-polio AFP surveillance to an average of over 4 per 100,000 children under 15). These efforts have reduced the number of silent counties from 18 to 1.

Despite successes, there have been some challenges. For example, a lack of network coverage has limited access to the internet in the states of Upper Nile, Jonglei, and Unity. This has impacted timely communication by creating prolonged delays of reporting between County Supervisors and partner NGOs on the ground. In addition, "WHO has chronically failed to provide feedback to the community on laboratory test results, leaving many community members distrustful of the system."