The last mile: On the frontlines of polio eradication in Kano State

In August 2016, the last poliovirus case in Nigeria was diagnosed in Monguno Local Government Area in the North-Eastern state of Borno. Since then, those working in the polio space, nationally and globally, have worked hard and are watching vigilantly with bated breath as Nigeria again comes close to being declared polio-free by 2019, incidentally also an election year in the country. We were so close in 2016, but the insecurity in the Northeast of Nigeria ultimately led to sufficient gaps in immunisation coverage for the virus to re-emerge.

When polio is eliminated in the last three remaining countries where it is endemic, and ultimately eradicated globally, it will only be the second disease to be eradicated around the globe, after smallpox. For a country that just over six years ago accounted for almost half of the global poliovirus cases, it is clear that the concerted and coordinated efforts in Nigeria by the responsible agencies, policymakers, international partners, philanthropists, and religious and traditional rulers, are yielding the desired results. Yet, often forgotten in this narrative is the significance of the work of those whose daily work it is in the communities to report cases and monitor progress – the frontline public health workers. Without relentless and unwavering commitment to their tasks, the fight against polio may not have gotten this far in Nigeria.

Eradicating a disease, i.e. getting to zero transmission, is an incredibly ambitious task that requires a holistic approach. Eradication without a vaccine has never succeeded, yet the availability of vaccines are not enough. Leaders must agree on targets; lots of money must be made available to procure, store and transport the vaccines; people must be educated and most importantly, the target population must be covered as much as possible. Finally, there must be a continuous follow up to prevent re-occurrence of the disease. Every step requires a specific approach and a specific set of resources. Even with all of the above, eradication is still incredibly difficult. It was in 1988 that the World Health Organization (WHO) declared polio as the next eradication target. Thirty years down the line, the target is yet to be achieved, although remarkable progress has been made. But in eradication efforts, even 99% success is still a failure. In 2018, only three polio-endemic countries remain; Pakistan, Afghanistan and Nigeria.

Five-year-old Isah Amadu from Rimi Village in Sumaila Local Government Area was diagnosed with polio in June 2014, the last confirmed case in Kano state. Photo credit: Nigeria Health Watch

Polio eradication activities in Nigeria are coordinated by the National Primary Healthcare Development Agency (NPHCDA). The agency provides policy direction and targets, such as the 2018 National Polio Eradication Emergency Plan. From this plan, states also develop their own policy approach depending on their risk status. Kano State, with the second largest population in the country, is one of the high-risk polio states. This is attributed to its geographical location – it borders many other states from the north-east and north-west, as well as Niger Republic – and its status as a trading hub means that many people cross its borders and can spread diseases as they move. Some years ago, immunization activities in Kano state were received with great apprehension, attributed to conservative religious beliefs. To mitigate this, traditional and religious leaders were included in the immunisation campaigns, not just in Kano, but in many other states across Northern Nigeria. The influence of these leaders was seen by many stakeholders as a major turning point in convincing people to immunise their children in Nigeria.

Five-year-old Isah Amadu from Rimi Village in Sumaila Local Government Area was diagnosed with polio in June 2014, the last confirmed case in Kano state. Keeping a state like Kano polio-free has required the sustained efforts of the frontline workers, particularly immunisation workers, Disease Surveillance and Notification Officers (DSNOs) and environmental health officers. They have continued to work hard to ensure that Kano state stays polio-free, recognising the consequence of failure. Indeed, all over the country, from the sandy and sunny terrain in the north, to the thick forests of the middle belt and the swampy marshes of the South-South, these men and women are almost always on the move; either immunising children, carrying out sensitisation activities, picking up and reporting suspected cases or collecting environmental samples. There is always work to be done to ensure that Nigeria stays polio-free.

Lawan Mato, Disease Surveillance and Notification Officer, Sumaila LGA. Photo credit: Nigeria Health Watch

Lawan Mato, the DSNO for Sumaila Local Government recounts the last polio case in Kano – Isah Amadu- “Isah’s was suspected by a local immunisation worker when he was about 16 months old. Another polio-infected child from Ningi town in Bauchi state who had already lost the use of his legs had visited and stayed in the same house with Isah for about two months, together with his extended family and many other children”. Fortunately, all the other children received the routine oral polio vaccines, except Isah, whose uncle prevented him from receiving the vaccine. “He was running a high temperature and we noticed his right hand and leg weren’t active”, Isah’s mother, who appeared to be in her early 30s, said. Mr. Mato was immediately alerted and said that when he arrived and learned that Isah had not been vaccinated, he suspected immediately that the young boy could have been infected with the poliovirus. Isah’s stool sample was taken and sent to be tested, and the results confirmed Mr. Mato’s suspicions.

Rimi is one of the 12 wards under Mr. Mato’s jurisdiction and because of its large population, is one of the six priority wards that he must visit at least once every week for surveillance of polio and other infectious diseases. Four other wards are medium priority; he visits them once every two weeks and the remaining two that are low priority, visits once a month. All of this he does on his motorcycle. In 2015, he reported up 20 suspected polio cases which when tested were confirmed negative. In 2016 he reported 48, in 2017 he reported 27 and so far, this year he has reported 7 suspected cases, all of which have been confirmed negative. To be sure that there is no polio circulation, every case with suspected paralysis (weakness on movement in arms and legs, has to be tested for polio).

One initiative that he said has helped his work immensely is the engagement of community informants, whom he trained to recognise the signs and symptoms of polio. These informants are in every community of the state, according to Kano State Chief Epidemiologist, Dr. Imam Wada Bello. They include traditional birth attendants and patent medicine vendors resident in the communities. Besides reporting suspected polio cases to the DSNO, they also notify the Local Immunization Officer (LIO) of any upcoming social gathering in their communities, and immunisation workers are sent to the occasion to vaccinate children – all for free.

Ahmed Ayuba, Local Immunization Officer, Fagge LGA, Kano State. Photo credit: Nigeria Health Watch

Another creative approach by Kano State are ‘Health Camps’, which are organised and run by the Local Immunization Officer in each LGA. In this program, health workers are sent out in groups of five to the communities with malaria test kits and drugs, deworming tablets and Oral Polio Vaccines. Two or three days before every health camp visit, a community mobiliser is sent to settlements to make announcements. “We usually set up our tent at the district head’s residence and within 10 to 15 minutes, you see hundreds of children gather”, Rukayya Bashir, a community health worker in Fagge Local Government Area who takes part in the health camps, said. According to Ahmed Ayuba, the LGA’s Immunisation Officer, during these health camps hundreds of children are immunised. The health camp also provides antenatal services to pregnant women, and this has helped attract more children as the women usually come with them. Health camps take place either monthly or once in two months and last between 3 to 5 days.

Population and cultural tendencies will always make it difficult to reach every child in Kano state with one approach. WHO recently scored Kano low on routine immunization. In a high-stakes situation such as polio elimination, several innovative mechanisms need to be in place to capture those ‘chronically missed children’ and ‘habitually non-compliant’ ones. ‘Zagayawa da kewayawa’ or “Revolving Around” is one of such mechanisms the state employs. This program usually takes place three days before and three days after every Supplementary Immunization Activity (SIA). “Immunisation workers go deep into the communities to vaccinate every child they come across, but they don’t knock on anybody’s doors”, said Mr. Ayuba. After vaccinating a child, his thumb is marked with ink and for a child whose parents may not be willing to have their child vaccinated, his toe is inked so they don’t notice.

In what they term ‘Church Strategy’, Mr. Ayuba said he and his team reached out to about 200 churches and trained some of their members to be able to vaccinate children whose families worship at the churches during every immunisation round and this has also increased the number of children immunised. The question however is, why aren’t they using the same strategy for mosques? Kano is a predominantly Muslim state and one hardly walks a kilometre without encountering a mosque. But Mr. Ayuba believes it wouldn’t achieve the same results because young children are seen much more in churches than in mosques.

Site of environmental sample collection in Rimin Kebe area of Ungogo LGA, Kano State. Photo credit: Nigeria Health Watch

Nigeria has no doubt come a long way in the goal of polio elimination- no case of wild poliovirus has been reported for two years. However, recent cases of Circulating Vaccine-Derived Polio Virus type 2 (cVDPV2) is causing concern to everyone involved in elimination efforts. cVDPV2 is a virus that is excreted by children who have previously been vaccinated with the polio vaccine and is usually found in poor sanitary environments. Though it is a weakened virus, the danger it poses to unprotected children cannot be ignored. The first cVDPV2 case in the country in 2018 was recorded in Kaugama district in Jigawa state in April, and prompted increased surveillance for Acute Flaccid Paralysis (AFP) cases across the country. Since then, 3 more cases of cVDPV2 have been confirmed, one in Geidam in Yobe State and two in Sokoto state. cVDPV2 is detected from environmental samples collected in the neighbourhood, usually from running gutters.

Kano state has five sites where these samples are collected on a rotating basis every Monday morning. Gadar Bulbula in Rimin Kebe Community, which sits in a roughly three-km drainage that cuts across Nassarawa and Ungogo Local Government Areas, is one of the five sites. The drainage passes through several densely populated communities; refuse dumps and dirty water from small gutters in the communities compete inside. This makes it an ideal place to collect samples to test for cVDPV2. On this Monday morning, sample collectors, Hamisu Isa Abubakar, Nasiru Abubakar Waziri and other officials gather here at about 7.30 a.m. Hamisu is wearing a protective jacket, a disposable face mask, gloves and knee-high rubber boots. He carries with him a small metal bucket to which he has tied a rope, a small jerry can and an icebox. At exactly 7.45 a.m., Hamisu, standing on the small bridge over the drainage, releases his bucket into the dirty water and fetches from it. He then pours the dirty water into the small jerry can, labels it and stores it in the icebox. According to Mr. Nura Karaye, the Kano State deputy epidemiologist who supervised the sample collection exercise, this sample will be taken to a laboratory in Ibadan, Oyo State for testing. On the Monday of the next week, the cycle continues.

Malam Galadima Alhaji, local cold chain officer in Sumaila LGA Kano State. Photo credit: Nigeria Heath Watch

As Nigeria marches towards what everyone hopes will be the total eradication of polio, these foot soldiers must be acknowledged and given the full credit that they deserve. The media needs to highlight the work they do, just as much as they report when an outbreak occurs. The Government must support them with the necessary tools to carry out their difficult task. For instance, Mr. Mato must visit Massu village which is 72KM from Sumaila where he lives, at least once every two weeks. His only means of transport is his motorbike and this leaves him vulnerable especially during bad weather conditions.

Isah’s mother can’t thank Mr. Mato enough, “Any day he comes to our village he must come and see my son,” she said. Isah is now in Primary Two and his mother still uses a cloth soaked in warm water to massage his limbs, a local physiotherapy technique that Mr Mato taught her.

2019 is a big year for Nigeria, as the next round of general elections take place, including a much-anticipated presidential election. It could also be a huge year for the Nigerian, and in fact the global health community, if Nigeria is declared polio-free. When that does happen, the efforts of frontline workers like Mr Mato and Mr. Ayuba, like Hamisu Abubakar and Rukayya Bashir, will become part and parcel of the global polio eradication story. They too will be able to say, with heads held high, that they did their part to rid the world of this crippling disease.