Spread of polio from Pakistan leads WHO to declare public health emergency; is Nigeria next?

In recent years, the threat of polio has risen in Pakistan, where Taliban militants have targeted health workers administering the vaccine. When the Nigerian President Goodluck Jonathan, speaks about the violence in North East Nigeria, he often refers to Pakistan as a country facing a similar threat. As the violence escalates in NE Nigeria, and the campaign to #bringbackourgirls gains momentum, immunisation is not on most people’s list of priorities. The challenge the world faces is that when the goal is eradication, even one case is too many. We worry that in addition to the thousands of lives lost directly, that many more are threatened if the billion-dollar global polio eradication programme is not saved from extremist violence in Pakistan and Nigeria.

Polio is a terrible disease, which can paralyze for life or even kill. It affects mostly children under five. Just a few days ago on 5 May, the World Health Organization (WHO) declared a global health emergency in respect to polio. Nigeria Health Watch is having a closer look at the situation, and what it means for Nigeria.

Polio still was endemic in 125 countries by 1988. Today only three countries remain so: Nigeria, Pakistan and Afghanistan. The number of reported cases decreased significantly over the same time period, from about 350,000 in 1988 to only 416 cases in 2013. This progress was also observed in Nigeria. The 2014 Nigeria Polio Eradication Emergency Plan shows that the incidence of polio in Nigeria was lower in 2013 than in 2012 and more limited in geographical spread. This trend continued into 2014 as demonstrated by the only 2 confirmed cases of polio detected so far this year, in contrast  to the 14 cases for the same period in 2013 (see 10thmeeting of the Independent Monitoring Board GPEI).  This prompted the Polio Global Eradication Initiative to state that Nigeria is “making strides against the disease”. So up to last week Monday, it seemed as if we were on the right track for getting rid of polio once and for all.

Then the WHO declared a global polio emergency due to “extraordinary” circumstances. By this, the organization refers to the recent spread of the disease across three national borders, from Pakistan to Afghanistan, from Syria to Iraq and from Cameroon to Equatorial Guinea. Considering that these exports of polio took place in the low transmission period of the disease, the WHO felt that the goal of achieving complete eradication of polio was under threat. To reduce the risk of jeopardising the entire eradication programme, the WHO declared an emergency and issued stiff recommendations for affected countries, including the advice to encourage residents and long-term visitors to get vaccinated against polio before travelling abroad. It is only the second time ever that the WHO has declared an emergency, which shows that we better take this matter extremely seriously!

Nigeria has never been able to stop the transmission of polio and is listed by the WHO among the countries “posing an ongoing risk for new wild poliovirus exportations in 2014“. The BBC reports that attacks on vaccination campaigns are the reason for the recent spread of polio. Sadly in our own country too, health workers are attacked and even killed while carrying out their duties. Moreover vaccination is not always taken seriously by the government as shown by the recent (April/March 2014) “non-participation of Ebonyi State in the on-going National Immunization Plus Days”.

At Nigeria Health Watch we ask: What will be the impact of the on-going violence in the NE on the vaccination of our children and the safety of our health workers? When answering this question we have to keep in mind that the impact of a pause on vaccination activities is often not felt immediately, but in the months and years to come.

To make sure as many children as possible are vaccinated, the National Primary Health Care Development Agency (NPHCDA) continues to organise Immunization Plus Days (IPDs) and Sub-National Immunization Plus Days (SIPDs) on a repeated basis. The agency is also working towards increasing awareness in the population of how important these vaccinations are. The 2014 Nigeria Polio Eradication Emergency Plan (also by the NPHCDA) mentions additional measures to reach children in areas that have insecurity problems. This includes “Hit & Run” immunizations as well as discreetly providing training and vaccines to elderly women, who then become part of “Permanent Health Teams”. Finally, to prevent polio from spreading into neighbouring states and countries, the NPHCDA set up fixed posts at the borders and in bordering communities of states with high insecurity.

Foot soldiers of the NIDs
As much as we commend the NPHCDA for their efforts and the fruits these are yielding, we need to raise a few issues, as this cannot be left to the Ministry of Health or NPHCDA alone. We must all get involved. One, we urge all state governments to always facilitate and actively support IPDs by supporting the teams with logistics and security. Secondly, we wonder why the Nigerian army has not followed the example set by the Pakistani army, who recently promised to keep their own vaccinators safe from harm. As attacks are becoming part of everyday life in Nigeria, health workers will need protection in order to carry out their work. And they deserve it, just as much as our children deserve to be protected from crippling and killing diseases like polio.
Thirdly, not enough attention has been paid to routine immunization in Nigeria. In 2003, less than 1% of infants in Jigawa, 1.5% in Yobe, 1.6% in Zamfara and 8.3% in Katsina were fully immunized. The Programme for Reviving Routine Immunization in Northern Nigeria (PRRINN) was established in 2006 with the aim to raise routine immunization rates in the Northern states just mentioned. However we feel that, just little over a decade after the start of the PRRINN, it is unlikely that numbers will have risen from around 1% and 8% respectively to the 80% recommended by the WHO. Therefore, we need to tackle the issues that are responsible for our low routine immunization rates, which include poor quality of primary health care centres, an unawareness of the importance of immunization and insufficient supply of vaccines

We call upon all parties involved, the NPHCDA, health workers, community volunteers, families with children, activists, the army and many more, to continue the struggle against polio. We need to keep up the good work we are already doing and improve in the areas in which we are still not performing at our best. We have almost reached the finish line. So, let us not slow down now but instead succeed in beating polio. It can be done.

But most importantly, we need you. When next the vaccination teams  knock on your gate, let them in, bring out your kids, and offer them a glass of water and a word of encouragement. They are the foot soldiers of another war – the one to end polio. 

Never doubt that a small group of thoughtful committed people can change the world; indeed it is the only thing that ever has…Margaret Mead

Chikwe Ihekweazu is an epidemiologist and consultant public health physician. He is the Editor of Nigeria Health Watch, and the Managing Partner of EpiAfric (www.epiafric.com), which provides expertise in public health research and advisory services, health communication and professional development. He previously held leadership roles at the South African National Institute for Communicable Diseases and the UK's Health Protection Agency. Chikwe has undertaken several short term consultancies for the World Health Organisation, mainly in response to major outbreaks. He is a TED Fellow and co-curator of TEDxEuston.

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