[afro-nets] Getting Polio Eradication Back on Track in Nigeria

[Dr Rana Jawad Asghar <jawad@alumni.washington.edu>]

Getting Polio Eradication Back on Track in Nigeria
--------------------------------------------------

Ebrahim Samba, M.D., Francis Nkrumah, M.D., M.P.H., and Rose
Leke, M.D.


The recent cancellation of polio-vaccination campaigns in sev-
eral key northern Nigerian states where poliomyelitis is endemic
[1] has focused attention on this African country, which re-
ported more cases of the disease in 2003 than any of the other
six remaining countries with transmission of indigenous wild po-
liovirus. Nigeria is currently the country that poses the great-
est risk to the achievement of the goal of eradicating poliomye-
litis globally by the end of 2004. Although the current situa-
tion in Nigeria is of great concern, the country has already
achieved remarkable progress toward eradication of the disease,
[2] demonstrating its capacity to implement high-quality eradi-
cation strategies. Standard international surveillance has been
established in all states for the reliable detection of remain-
ing chains of transmission of wild poliovirus and to monitor
progress toward eradication. Repeated polio-immunization cam-
paigns since 1996 had interrupted polio transmission throughout
southern Nigeria and, most important, in the megacity of Lagos
(population, more than 12 million) for nearly two years, from
April 2001 to June 2003, when wild poliovirus was reintroduced
from the north. Transmission was stopped in the northern state
of Kaduna for six months, between October 2002 and April 2003.

However, as of November 11, Nigeria had reported 233 cases in
2003 - for the first time, more than were reported in either In-
dia (179 cases) or Pakistan (81 cases), the two other remaining
major reservoirs of poliovirus. The increase in reported cases
is paralleled by a renewed spread of polio into the central and
southern states of Nigeria, including Lagos. Of equal concern,
wild poliovirus that has been linked by genetic viral typing to
northern Nigeria has reinfected the neighboring countries of
Burkina Faso, Ghana, Togo, and Chad (see Figure), all of which
had been polio-free for more than one and a half years, crip-
pling 14 children and prompting the implementation of urgent,
large-scale vaccination campaigns at a cost of more than $10
million. Without rapid progress, the unchecked transmission of
poliovirus in Nigeria, the largest remaining reservoir of wild
virus, will, at a minimum, delay the achievement of regional and
global goals, add substantial additional cost, and in the worst-
case scenario, put at risk all regional and global investments
in polio eradication since 1988.

What has caused the largest public health program ever conducted
in Nigeria to stumble, especially given the enormous investment
that had already been made, the progress that had already been
achieved, and the urgency of the need to catch up with other
countries in Africa and the world? A key underlying factor, as
data now demonstrate, is that many children in the northern
states of Nigeria had not in fact been immunized, because of the
low quality of the immunization campaigns since the beginning of
the initiative. The quality and coordination of campaigns con-
ducted in the first quarter of 2003 below the national level
were compromised further by the considerable demands that the
presidential and state elections placed on civil administrators.
There was also, at the time, a perceived lack of ownership of
the polio-eradication effort at the level of some state and lo-
cal governments, as well as considerable dissatisfaction among
members of the vaccination-campaign field staff in many areas,
since their payment for work in previous campaigns had been de-
layed. As a result, the spring 2003 campaigns were largely inef-
fective in increasing coverage to the level needed to curb the
resurgence of polio originating from the north during the second
and third quarters of 2003.

An additional factor contributing to the overall low levels of
immunity among young children were rumors about alleged adverse
health effects associated with oral polio vaccine, which had
emerged earlier in northern Nigeria and were further promoted in
mid-2003 by local opinion leaders, motivated in part by politi-
cal considerations or political tensions between the national
and state levels. These rumors alleged that oral polio vaccine
has a sterilizing effect or spreads AIDS because it is contami-
nated with human immunodeficiency virus. Both rumors have previ-
ously surfaced in other countries; although they are baseless
and may easily be refuted on scientific grounds, these allega-
tions have the potential to discredit and damage immunization
programs. Because of the high public awareness of the allega-
tions, important vaccination rounds planned for September 2003
in northern Nigeria - including in Kano, the state with the
highest rate of endemic polio - were suspended by state govern-
ments to allow time for special commissions set up in several
states to clarify the allegations and to restore public confi-
dence in the immunization program. The final reports of these
panels are pending.

At the same time, the Nigerian federal government has taken a
number of important steps to regain the momentum of polio eradi-
cation and bring the country back on track toward the interrup-
tion of transmission of wild virus. The new federal minister of
health has shown strong commitment, working closely with state
governments to resolve critical problems - the most important of
which is the confusion surrounding the rumors about vaccine
safety - as a basis for restoring public confidence in the vac-
cine. With testing of the vaccine now completed, the ministry of
health is providing objective information to all relevant groups
and building consensus in order to enhance the quality of the
upcoming vaccination rounds. In particular, the minister has in-
creased the dialogue with political and traditional leaders in
the north, and the president has appointed an Ambassador Extra-
ordinaire for Polio Eradication. A month-by-month plan of action
for polio eradication was established for 2004 under the direct
guidance of the minister of health, addressing key issues in the
areas of advocacy and political ownership at the national,
state, and community levels and defining activities and goals
for the improvement of the quality of campaigns, as well as lo-
gistics, communication, and social mobilization. Steps were also
taken to improve full accountability at all levels in order to
ensure the optimal use of financial and other resources.

The international polio partnership, led by the World Health Or-
ganization, Rotary International, the Centers for Disease Con-
trol and Prevention, and the United Nations Children's Fund,
continues to give broad support to Nigeria's polio-eradication
effort, providing detailed information on vaccine safety, ex-
tending considerable financial and technical assistance toward
improving the quality of vaccination campaigns at the state and
local levels, and conducting joint advocacy efforts.

Building on its previous experience and using its own resources,
Nigeria can overcome the current problems that have led to in-
adequate coverage. The previously demonstrated rapid progress in
southern Nigeria shows that the interruption of transmission of
wild poliovirus in Nigeria by the end of 2004 is technically
feasible. The key to bringing about improvement will be building
strong consensus among all groups involved, regaining public
confidence in the vaccine, especially in the northern states,
and translating this confidence into a series of high-quality,
supplementary, house-to-house immunization rounds that reach
each and every child. In view of the commitment to the children
of Nigeria and the world, and given the enormous investments al-
ready made in polio eradication at the national, regional, and
global levels, we hope that the national and global polio-
eradication goals can be reached as soon as possible.


Source Information

 From the World Health Organization Office for Africa, Brazza-
ville, Republic of Congo (E.S.); the Noguchi Memorial Institute
for Medical Research, University of Ghana Medical School, Legon,
Ghana (F.N.); and the Department of Immunology and Microbiology,
Faculty of Medicine, University of Yaoundé, Yaoundé, Cameroon
(R.L.).

References

[1] Kapp C. Surge in polio spreads alarm in northern Nigeria:
rumours about vaccine safety in Muslim-run states threaten WHO's
eradication programme. Lancet 2003;362:1631-1632. [Cross-
Ref][ISI][Medline]

[2] Progress towards poliomyelitis eradication in Nigeria, Janu-
ary 2002 to March 2003. Wkly Epidemiol Rec 2003;78:210-
215.[Medline]