Once suspected cases of poliomyelitis, which presents as sudden paralysis of the arms or legs, are identified in the community, a race against time begins.
Emmanuel Amuri is Head of Branch at LOGISTIQUExpress, a company specializing in the transport of goods and mail in Kalemie, capital of the Tanganyika province in the Democratic Republic of Congo (DRC). He just welcomed back Jeef Adjunay Seleman, a motorcycle rider who regularly covers the Manono-Kalemie route, after he traveled more than 413 km in a day and a half to drop off 12 polio samples from Manono.
The samples are ‘triple packaged’ in containers, and Emmanuel makes sure to bring them to the provincial office of the government’s Expanded Programme on Immunization (EPI) in Kalemie, where they will be kept in cold chain conditions. The samples will then be sent on the next available cargo flight to the national laboratory in Kinshasa – the National Institute of Biomedical Research (INRB) – to test for poliovirus.
A persistent public health problem
Although the DRC was certified free of wild polio in 2015, the country has been experiencing a surge in polio outbreaks of the vaccine-derived type since 2017. Tanganyika is one of seven provinces in eastern DRC currently affected.
Despite efforts by the Ministry of Public Health, Hygiene and Prevention (MSPHP), through EPI and later the Polio Emergency Committee (COUP), over time, these outbreaks have touched almost the entire country. In 2022, more than 146 cases of circulating vaccine-derived poliovirus type 1 (cPVDV1) and 363 cases of cPVDV2 were recorded. In 2023, the outbreaks continue, with more than 24 cPVDV1 and 41 cPVDV2 cases notified.
This situation poses a great challenge to achieving the goals of the Global Polio Eradication Initiative, a global initiative established in 1988, after the successful eradication of smallpox.
An assessment leading to possible solutions
A sensitive disease surveillance system, in addition to routine immunization, mass vaccination campaigns and outbreak response, can stop polio transmission. However, in a vast country like DRC, ensuring that polio samples arrive at the national laboratory within three days remains a major challenge.
In early 2022, VillageReach carried out an assessment of the polio specimen referral system. Key recommendations led to the implementation of new approaches to tackle specific weaknesses of the system.
Drawing on its experience in optimizing the supply chain, VillageReach has proposed solutions to reduce sample transport duration, by redesigning the transport circuits, collaborating with private transporters, and introducing innovative digital solutions. Under the leadership of EPI, seven provinces were selected to implement these solutions with technical and financial assistance from VillageReach: Equateur, Haut-Lomami, Haut-Katanga, Lualaba, Mai-Ndombe, Sankuru, and Tanganyika.
VillageReach works in these seven provinces to shorten the transport time of samples from the community or health facility (where samples are initially collected) to the point of transit, usually the EPI provincial offices (from where the samples are shipped to the national laboratory in Kinshasa).
Redesigned transport circuits
In a country where only 17% of the road infrastructure is in good condition, natural barriers such as lakes and rivers, and the security situation in certain areas of Eastern DRC, are bottlenecks in the transport of any goods, including health products and lab samples.
Aware of these challenges and the particularities of each province, VillageReach met with the provincial and district health supervisors in the seven provinces to revisit and map out shorter routes that samples could take towards the national laboratory.
Haut Lomami province lacks urban roads, has dilapidated bridges and several lakes, so it has greatly benefited from the new circuit.
For the Haut Lomami provincial health director, Dr. Patrick Banza Piongo, the VillageReach approach is already bearing fruit in his province: “With the new circuit we are using, we now have at least three different routes that the samples can take to arrive in Kinshasa, including via Kamina, Kolwezi and Lubumbashi. Before, everything had to go through Kamina, which took too long for the health district teams that were more than 200-400 km away; on the other hand, some health districts are closer to towns that have more regular flights to Kinshasa. Since the route changes, we have been encouraging border districts to save time [by taking the samples to the closest transit point towards Kinshasa].”
Integration of the private sector
Additionally, using every form of transport possible is important, which means engaging local commercial transporters like Jeef and private transport companies contracted by the provincial authorities with the technical assistance and funding from VillageReach.
More than ten private transport companies, such as LOGISTIQUExpress, have been contracted across the seven provinces, based on their ability to reach remote or challenging areas of the country.
“My role as a transport manager is to bring local transporters and the provincial government together,” says Emmanuel. “We have contracts with local transporters in the health districts. And each time the health districts have samples for pick up, they call us first, and we in turn contact the local transporters. Wherever the samples are, wherever the cases are, they go to collect the samples, and we pay them.”
Jeef is one of the local transporters selected to ensure rapid transport from health facilities to the provincial towns that serve as transit points towards Kinshasa. These transporters facilitate the work of health district teams, who no longer have to travel far or worry about transport costs.
For EPI’s Chief Medical Officer in Mbandaka, Equateur, Dr Jean-Jacques Isanjola, this was a source of motivation for the health workers: “We know that a transporter will take the samples from a health center or community after so many hours or days, and that the samples will make it to the provincial office. Before, for one suspected polio case, it could cost up to $400-500 if we had to rent motor boats, buy fuel, etc. But today, we know that if there are samples to transport, the fees are reimbursed, fuel is taken care of, people are committed and give it their best.”
Because of the barriers to travel in the seven provinces, several means of transport are used, including motorcycles. In Tanganyika, some health districts are served by humanitarian planes, but the flights don’t have regular schedules. When the flights are confirmed in Manono or Ankoro, the local transporters make sure to bring the samples at the same time; that way the samples fly to Kalemie, and the local transporters don’t have to travel the long distance there themselves.
In Equateur, for years, samples only went to the national lab in Kinshasa by cargo plane. With VillageReach’s approach of including the private sector, the provincial authorities were able to work with WHO and the transport company to negotiate contracts with commercial airlines to transport the samples. Since March 2023, the province has been sending the samples at least twice a week, instead of just once a week, to Kinshasa.
Dr. Isanjola explains: “Previously, [samples] could only leave [for Kinshasa] on Saturdays, by cargo plane. So now, we contacted other [commercial] airlines, that initially had hesitations about transporting biomedical samples. Since we are a province [that has had multiple outbreaks] of Ebola…With triple-packaged containers, we minimize any chance for contamination during transport. So these companies finally agreed. Now, every Wednesday, the samples can leave; and also every Saturday.”
The assessment conducted at the beginning of 2022 showed that, in 2021, nationwide AFP samples were averaging 11 days of transport time to Kinshasa. In the seven provinces where VillageReach now works, the average was 17,3 days in the first 8 months of 2022 but in the first 9 months of the project, it has been reduced to 12.4 days.
Innovations in this program include: the use of drones in Equateur province; and Tec4Med devices in Haut-Lomami, Tanganyika and Equateur provinces, to monitor temperature during transport and track the geolocation of the lab samples in real time.
Since the end of 2020, routine drone flights have been delivering vaccines and other immunization products to 40 hard-to-reach health facilities in Equateur. However, the drones are bi-directional (they can land at the remote facility), so more recently the drones have also started picking up lab samples.
Dr. Isandjola explains: “In the health zone of Bikoro, [the village] Maanga which is on the other side of Lake [Ntumba], during the rainy season, the lake can get angry for five days, preventing anyone from crossing it. If the lake gets angry, there is no way to even use the local boats, it is complicated, otherwise you put your life in danger. So, with the drone… in a couple of hours, you can have samples going from Maanga to Bikoro, and from Bikoro to Mbandaka; and the next day they arrive in Kinshasa.”
The Tec4Med tracking devices, which are closely monitored by VillageReach, make it possible to know the whereabouts of the samples from departure from a health facility or health district all the way to the national laboratory.
Emmanuel, the transporters’ manager, explains the convenience of this device: “The devices really make our job easier. When there are samples, we ask the health facility nurses or the person who took the samples to activate the device and share the EPID number. When they share the EPID number, and send us the QR code with the screenshot, we send it to VillageReach. And sometimes [VillageReach] calls us to check if the device is on. And if the temperature rises, VillageReach calls us, we have to follow up on this sample, or this device; we have to change the ice pack.”
This ice pack change is made several times along the route to the national laboratory to maintain sample quality for analysis. Similar to most vaccines, polio samples must be kept between +2 and +8° Celsius.
In this race against time, our collaboration with private transporters, the reconfiguration of transport circuits, and the use of new technologies contribute to reducing the transport duration for polio samples.
For Emmanuel, this work brings him satisfaction, knowing that he is contributing to the efforts of the government and its partners, such as VillageReach, to eradicate polio in DRC: “[We agreed to support the province] because this is about people’s health. Our motto is ‘speed and confidence’. When we are called to transport lab samples, we get to put our motto into practice. And if [the samples] arrive [on time], despite the road conditions, we are proud.”