• South Sudan’s last case was reported in June 2009. However, sewage samples detected in Aswan, Egypt and traced back to 2009 point to continued low-level circulation of poliovirus in the region, and potentially in South Sudan.
• The influx of returning refugees and population movements into Ethiopia still pose risks for virus transmission and importation.
• Refusals are minimal, at only 2.5% of a very small proportion of missed children.
• Currently the most serious challenge for the programme is the inability of vaccinators to visit households due to insecurity and inaccessibility.

• Spotlight on missed children
• Access
• Children unavailable

Spotlight on missed children

In the world’s newest country, the proportion of missed children is less than 5%. However the volatile security and population movements that results still presents a significant threat to the Horn of Africa region. The three States bordering Northern Sudan - Unity, Warrap, Northern Bahr El Ghazal – are the most vulnerable to conflict, together with Jonglei and Upper Nile, which continue to have internal tribal clashes (see Figure SSU1).

Why are we missing children?

Access

The overall proportion of children missed in S. Sudan has been reduced following the mass movement of returnees in February. Still, internal migration and widespread population movement into neighboring Ethiopia presents an operational challenge for reaching every child with OPV. This presents a significant risk of an outbreak should a virus be detected.

Accessing the widely dispersed population in the context of conflict, flooding and poor infrastructure is now the biggest challenge. Air transport is often the only option to deliver vaccines and necessary supplies to the states, but this is not a viable option to for transporting vaccinators. This is one of the reasons why over 50% of missed children in S. Sudan are missed due to teams’ inability to reach homes (see Figure SSU2). However, many vaccinators work against the odds, for example risk their lives crossing overflowing rivers in order to reach children.

The high costs of service delivery also present a significant challenge for the new Government. Government spending for polio has been largely achieved through GAVI grants, and the country currently has no cost-sharing mechanism to support polio eradication or immunization programmes going forward. Therefore, a heavy reliance on GAVI and the technical agencies will need to continue into the foreseeable future.

Children unavailable

The reasons for missed children in South Sudan are split almost evenly between children not accessed, and children not available when vaccination teams visit. Over 45% of children missed in November were due to “child not available.”

The lack of social data available to the programme means we simply do not know where children are when they are not at home. It is also likely that children who could be easily recovered are missed due to inadequately trained health staff who may not be actively searching for them. The planned KAP study will be critical to ensuring communication plans effectively address reasons for missed children.

New population groups settling into areas that are difficult for health staff to access, together with an inadequately trained pool of health workers, means that many children are missed due to poor service delivery.

Awareness of campaigns has remained fairly consistent throughout the year, with about 85% of caregivers reporting that they were aware of campaigns before vaccinators arrived (see Figure SSU3). Only Warrap lags substantially behind the rest of the country on awareness, with declining rates and now the lowest awareness of polio campaigns in the country, at only 57%.

Lower awareness among new citizens

While refusals are almost negligible, pockets of resistance are seen in areas where awareness is lower, largely due to incoming migration (see Figure SSU4). These groups have had less time to be sensitized to polio campaigns, and have not yet been fully reached with information about polio.

Radio is the most common source of information, with 31% of parents citing it as their primary source. The communication strategy uses radio as the primary mode of mass media, through 27 radio stations spread across various states. But many areas in South Sudan still remain media dark, and in these areas, the programme must rely on health workers, vaccinators, and other interpersonal sources such as churches, to get the message about polio across.

Since vaccinators do reach the vast majority of households, partners are building their capacity to communicate more effectively with parents, providing them training on interpersonal communication. Work with churches, faith-based organizations and NGOs is also being scaled up. For all these workers, more effective communication materials need to be developed in order to equip them with tools that can make them more effective. Currently, the programme is operating with very basic materials.

Recommendations

It will be critical for South Sudan to sustain its hard-won gains this year, amidst a volatile political transition. The key priorities are as follows:

• Improve the availability of social data, through Independent Monitoring and social research, in order to focus limited resources on the most critical demand-seeking strategies. The KAP Study should be released by March 2012.
• Critically analyze social and operational data to assess the most vulnerable areas and high risk groups. High Risk Analysis does not exist in S. Sudan below the state level, and plans must be targeted at lower community levels.
• Continue to strengthen communication skills for all vaccinators, social mobilizers and NGO volunteers.
• Develop more engaging communication materials for mobilizers to use with parents. Specifically, develop more interactive radio programmes (beyond PSAs) and tools that can be used for Interpersonal Communication.