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Sustaining the tempo; How Kano is succeeding in its fight against Polio

As the early morning harmattan wind blew through the crowded Fagge area of Kano, about thirty people, mostly women, gathered inside the Galadima Primary Health Centre (PHC) in Fagge C ward. In teams of three, they prepared to collect vials containing Oral Polio Vaccines (OPVs) from the PHC, as they would each morning for the next four days. Each team consists of a vaccinator, a recorder who also acts as supervisor; and a community mobiliser, representing the community leader; and they form a key part of the State-wide Immunisation Plus Days (SIPDs). These additional immunisation days were an offshoot of the National Immunisation Plus Days (NIPDs) which take at least twice every year in every settlement of every ward in Kano State’s 44 Local Government Areas (LGAs).
 
Our goal today is to enter every household in Lungun Fulasko settlement and vaccinate every eligible child,’’ vaccination Team Supervisor Fatima Auwal says as she leads her team out after collecting vaccines, tally sheets and other materials The team enter the first compound while community mobiliser Auwal Ibrahim waits outside. As they emerge after vaccinating a child there, team member Jamila Mukhtar explains: ‘’After introducing ourselves we ask five questions in every house we enter,’’ she says . The five questions (asked in Hausa) are:

  1. Is there any child in the house who is five years old or younger?
  2. Is there any child who is five years old or under who is asleep?
  3. Is there any child who is five years old or under who lives in the house but is not presently at home?
  4. Is there any child in the house who is visiting from another community or town?
  5. Is there any child in the house who has difficulty moving any of his or her limbs?
Senior health officials from Kano State Ministry of Health and development partners hold a review meeting to share experience from the field and identify areas that need improvement. The review meeting is chaired by the Executive Secretary of the State Primary Health Care Board. Photo credit: Nigeria Health Watch

The aim is to ensure that no child eligible for the OPV is missed out, according to Yahaya Nayaya, the Disease Surveillance and Notification Officer (DSNO) of Fagge LGA. Nayaya provides supportive supervision for the SIPD in Fagge A, B and C wards. According to the Local Immunisation Officer (LIO) of Fagge LGA Muhammad Salisu, senior health officials of every LGA are assigned to provide supportive supervision to immunisation teams in wards in their areas. “I supervise teams in Sabon-Gari, one of the largest wards in the LGA,” he says, after reviewing the work plan and tally sheets of a team in Abadi settlement.
 
Complementing Routine Immunisation
The National Immunisation Plus Days (NIPDs) are supplementary immunisation campaigns carried out periodically in all states to complement routine immunisation in the country. Coordinated by the National Primary Health Care Development Agency (NPHCDA), the model is to take vaccines directly to the doorstep of the children by going from house to house. The NIPDs aim to improve overall herd immunity of children under five years of age against the Wild Polio Virus by catching children not previously immunised or only partially immunised and by boosting the immunity of children who have already been immunised. Kano used to be one of the polio-prevalent states in Nigeria, but with support from development partners such as the World Health Organisation (WHO), United Nations Children Fund (UNICEF), the Bill & Melinda Gates Foundation (BMGF) and others, Kano now conducts its own SIPDs in addition to the NIPDs. ‘’We conduct at least two Polio SIPDs every year in addition to SIPDs on Measles, Yellow Fever, Meningitis and others,” says Dr. Sa’adatu Ibrahim, the State Immunisation Officer (SIO). Each polio SIPDs includes a list of activities that happen before, during and after the vaccination days.

Image credit: Nigeria Health Watch

State-wide Training
The first activity is always the training of people responsible for immunisation delivery at all levels, according to Dr. Ibrahim. To ensure efficiency across board, the state was divided into six zones, each with a specific number of LGAs. Senior health officials from all LGAs were trained by state officials and development partners. The training is then stepped down to Technical Officers and Ward Focal Persons at LGA levels, and to vaccinators, recorders and mobilisers at ward levels. The model is a trickle-down approach where interpersonal communication is emphasised. Salisu explains that: ‘’If the vaccinating teams have good communications skills and know how to approach parents and convey the message well, there is a higher chance people will accept the vaccination,” 
 
Directly Observed Polio Vaccination (DOPVs)
Directly Observed Polio Vaccinations, also known as DOPVs, are preliminary vaccination activities that take place on the streets, in schools, social gatherings, markets, and car parks. For the first immunisation days of 2020, DOPVs were carried out in 27 LGAs two days before the full SIPDs start. Vaccinating teams go to communities not doing well in routine immunisation to vaccinate every eligible child they come across. All vaccinated children are marked with ink on their thumbs, so they are not given the vaccine again when their homes are visited during the SIPDs.

Fagge LGA Local Immunisation Officer Muhammad Salisu on supportive supervision in Abadi settelment, Sabon-Gari ward. Photo credit: Nigeria Health Watch

Provision of required vaccines
Before any SIPD begins, the state and NPHCDA decide the amount of vaccines required, using metrics like the amount of vaccines used during previous SIPDs, routine immunisation coverage and size of the target population. Vaccines supplied by NPHCDA to the state cold chain stores, are distributed to zonal cold chain stores and on to the PHCs. All vaccines for each ward must be at the ward’s PHC the evening before the SIPDs begin. Every morning throughout the SIPDs, vaccinating teams go to their respective PHCs to pick up the day’s vaccines as well as packs of sachet milk and sweets, used as incentives, which are also provided by the NPHCDA through the WHO.
 
Kano State Commissioner of Health Dr Ibrahim Tsanyawa said 3.7 million vaccines were received for a target population of 3.5 million children for this round of immunisation days. The extra vaccines are to ensure buffers for unexpected shortages or higher needs than projected especially in LGAs that have borders with other states. ‘’Some of these LGAS might experience influx of children from neighbouring communities that are not in Kano State,’’ said Dr. Ibrahim.

Image credit: Nigeria Health Watch

Polio Task Force: A vehicle for facilitation and sustainability
Building collaboration between policy makers and traditional leaders is key in achieving any goal in Nigeria’s northern region. Kano State’s Task Force Committee on Polio Eradication was established in 2012 to facilitate programs that combat polio in the state. Chaired by the Deputy Governor, the committee members include all 44 LGA chairmen; all district heads and key ministry of health officials. They meet regularly to assess progress and challenges such as LGAs lagging behind in RI.
 
On the eve of the first polio SIPDs of 2020, Deputy Governor Dr. Nasir Gawuna chaired a planning and review meeting of the committee. Every LGA’s polio immunisation data from the last Lot Quality Assessment Survey by the NPHCDA was presented and deliberated upon, with emphasis on how to make improvements.
 
Ward, LGA and State Review Meetings
There are various teams supporting the LGAs from the state level, and at regular meetings each team shares their experience in the field and suggests areas for improvement which are developed into action points. However, officials from the wards or LGAs do not attend, missing an opportunity to hear directly from those carrying out the exercise in communities.

Mustapha Hussaini, who is a polio survivor is a Polio SIPDs Supervisor in Sabon Gari ward, Fagge LGA. Photo credit: Nigeria Health Watch

Sustaining and scaling up gains
Kano State has made progress in its drive to eradicate polio, thanks to the dedication and sustained drive from the top down. From the highest level of government to those going to the last mile, there seems to be a sense of ownership and enthusiasm to sustain the gains that have meant the state has not recorded a case of polio since June 2014. As Nigeria marches towards complete eradication of the crippling disease, Kano and other states must make efforts to keep up the momentum and sustain programmes that have brought Nigeria this far.
 
The critical policies and infrastructure that have been put in place for the eradication of polio should also be used to improve other areas such as maternal health, child malnutrition and other serious childhood diseases. Kano is making progress with its 100% funding for Routine Immunisation activities; but with RI coverage of 46% in the 2018 National Demographic Health Survey (NDHS), more needs to be done. The fact that vaccinators are still reporting cases of parents rejecting the vaccine suggests that more community engagement, information and awareness is needed to achieve the desired immunisation coverage, and ultimately ensure that Kano State’s children under five are healthy and grow to their full potential.

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