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Poliomyelitis . . . Who?ll Tame Nigeria?s Stubborn Nemesis?

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  • Poliomyelitis . . . Who?ll Tame Nigeria?s Stubborn Nemesis?

    http://www.thisdayonline.com/nview.php?id=61853

    10.29.2006


    Nigeria?s dismal health indices are further rubbished by the persistent rising cases of wild poliomyelitis virus in the country. In the wake of the recent categorisation of Nigeria by the World Health Organisation as one of the four most endemic countries in the world, and with less than two months to the eradication target, policy makers speak of renewed efforts aimed at reversing the ugly trend. Godwin Haruna writes

    On the sprawling Marina Car Park in the central business district of Lagos, it is a spectacle at weekends when the area is cleared of its contents. As they crawl around on the very subdued locally fabricated low wheel chair, they toss the ball among themselves in what is supposedly a football, but played with their hands from one end to the other. Even as they and the spectators enjoy the fun with hilarious laughter, it is hard to overlook their obvious disabilities brought on them from their childhood by the lethal poliomyelitis infection. The result of this childhood infection has crippled them thereby depriving them of playing the ball with their feet.

    This is the modern-day scourge of Nigeria and a few other countries of the world even as the earlier eradication target set by the global health monitor is fast approaching. In a recent report by the World Health Organisation (WHO), it identified Nigeria, Pakistan, India and war-torn Afghanistan as countries constituting the greatest obstacle to the worldwide anti-polio war.

    WHO's Advisory Committee on Polio Eradication (ACPE), in that report, disclosed that all new infections of polio this year had been traced to Nigeria and the three named polio-endemic countries. It also alerted the nation to the fact that countries that had attained polio-free status are now seeking ways of protecting themselves from polio-endemic nations. This has made the Kingdom of Saudi Arabia to seek for polio-free certificates from Nigerian pilgrims to the Holy Land.

    Another report quoted George Cooke, chief of United Nations Children Fund (UNICEF) field officers in Nigeria as saying that 78 per cent cases of poliomyelitis infection in the world are traceable to Nigeria. Cooke said efforts made to eradicate poliomyelitis in Nigeria "have not been successful." He advised that all hands must be on deck so that the recent outbreak of bird flu in Nigeria did not become like poliomyelitis.

    According to health experts, in most parts of the world, three or four doses of polio vaccine, administered on a small baby, are enough to provide protection. But in Nigeria, there is so much poliovirus around those children under the age of five have to be immunised over and over again in order to tame the lethal virus. Rates of non-compliance are high, and even though vaccination rounds are done several times a year, some children are not reached.

    Also, in Nigeria, polio is now largely confined to just 11 states in the northern part of the country. But the number of victims is rising, not falling. Confirmed cases grew from 781 in 2004 to 801 in 2005. So far this year, there have many new polio victims especially at the beginning of the year.

    However, speaking to THISDAY during an interview in her office, Dr. Edugie Abebe, interim coordinator/chief executive of the National Programme on Immunisation (NPI), said although the virus was very much in the country, new rate of infection is being scaled down. Abebe stated that at a meeting in Geneva recently, it was noted that the wild polio virus transmission in the four endemic countries must be interrupted rather than fix unreliable dates of eradication.

    Speaking specifically on the Nigerian situation she said: ?We know that inspite of the many immunisation activities we had in the past, we still continue to have increasing number of the wild polio virus. So, we did a lot of consultations with the various communities and stakeholders and we asked questions: ?Why don?t you want to receive OPV (oral polio vaccine), why do you not comply with immunisation, what are we doing wrong?? At the end of the consultations, we realised that the community is fatigued with just OPV and they had requested that there are other health issues of concern to the community, which we have not looked at.

    ?Based on all the issues that came up from the community, we decided to change our strategy. We now started what we call Immunisation Plus. With this strategy, you don?t just give only OPV, we give also the DPT and measles vaccines. In order to promote ownership, we now also ask that the states and local governments must provide the plus such as the insecticide-treated nets, de-worming tablets. Of course, through our partners, we provide the Vitamin A and some of the states and local governments provided paraceutamol because of the effects of injections that we give.

    ?Secondly, with Immunisation Plus, each immunisation regime is recorded on the child?s health card so we can make the child health card available. Each immunisation is recorded on the child?s health card. We just don?t use anybody to vaccinate, we use health workers as vaccinators and this gives the communities a lot of confidence. In the area of social mobilisation, we introduced what is called community dialogue. We hold this dialogue before the exercise to discuss issues of health specifically on immunisation and through the dialogue, their complaints came up and we address them?.

    The NPI chief executive however acknowledged that even in the current strategy, there are pockets of non-compliance. She added that a lot of the community and religious leaders were being employed to resolve the issue of non-compliance.

    She stated that the National Immunisation Days (NIDs) have been replaced with Immunisation Plus Days (IPDs), whose total package is more comprehensive than the former.

    Abebe explains to THISDAY: ?In all the IPDs we do, you have polio, you have measles and you have DPT. In the next one we are even planning to include tetanus for pregnant women?.

    She also disclosed that in the current strategy, attention was being focused on the more endemic states of the country, which she identified as falling between the Northwest and Northeast sections of the country. Using the analogy of a house on fire, she admonished that it was more fruitful tackling the fire from the root of the inferno rather than just pouring water on the whole house.

    ?When we came in, we sat down and looked at the epidemiological reports from the field. Where are we having more of the virus? Where are we having more children being missed during the campaigns? Where do we have very low routine immunisation coverage, because routine immunisation coverage is very critical to eradication of polio. Based on these, we drew a line and we identified 11 states.

    ?So for May/June and September, we have been focussing on these 11 high-risk states. Even when we looked at the epidemiological report again sometimes in September and we saw that Niger State was also becoming a high-risk state; we included it in the September round. We have focussed on these states and since it is not a national event, we target our social mobilisation and other activities there. But in the areas down south, where we have not identified any wild polio virus for two years now, we encourage them to keep on doing routine immunisation to increase their coverage so that we can protect them and if there is any importation into any of those areas, it does not spread?, Abebe stated.

    Asked to comment on the political commitment of states described as high-risk in the country, she stressed that the various governments were responding well. She added that the states have been contributing their own quota towards reducing or eliminating the dreaded wild poliovirus.

    However, the national coordinator stated that some have not been as cooperative and she urged them to have a rethink on their approach to the polio issue. ?I think where we need a lot more commitment is at the local government level because it has the primary responsibility of primary healthcare, which immunisation is a key component?, she added.

    Asked to comment on the changes that her administration have brought to bear on the process since she assumed office, Abebe noted that there was more participation in the current strategy across board. She added that the states and the local governments are showing signs of owning the programme.

    Another point she raised is that inspite of the fact that cumulatively there have been more wild polio virus in this year than last year, the chart of the spread on a monthly basis from 2004 through 2005 to 2006, showed that there are high transmission periods. She stated that although the spread of the virus rose during the early months of the year, the introduction of the IPDs have systematically reduced infection rate as the year draws to a close.

    ?By the time we introduced IPDs, we were able to reach more children than before and were able to hit the virus more specifically than before?, she said.

    The chart showed that as at August this year the rate of infection of the wild polio virus have significantly dropped compared to the same period in 2004 and 2005. The chart, perhaps, explained the cumulative argument earlier posited by the national coordinator.

    ?There are two types of the wild polio virus, Type 1, which is more virulent and common. Type 3 is not too virulent, but we are targeting it using the normal prevalent OPV. In all these, even though we have identified 11 high-risk states, six of them are responsible for almost 85 per cent of all wild polio virus cases in Nigeria in 2006. The states are Kano, Katsina, Kaduna, Jigawa, Zamfara and Bauchi and they are responsible for most of the disease burden in Nigeria. The IPDs have effectively checkmated the rising cases of the virus in these high-risk states. So while we still talk about Nigeria still have 922 polio virus this year as compared to 539 last year, the epidemic was in the first part of this year. It is by December/January that you will see the latent drop. It takes time to do the analysis. We are very confident that the number will still drop, but we are not going to fold our arms because we are not out of the woods?, Abebe explained.

    She said they were about 68 LGAs with or without the IPDs that have continued to transmit the virus and we have the epidemiological data and they would be looked at critically in the November round. She added that hitherto, about seven states in the north were not participating in the IPDs, but all the 19 states would be covered in the November edition.

    The NPI chief executive commended the international partners, whom she said have been wonderful in the fight against the dreaded virus in the country. She said they are all on board contributing to the funding of the operations.

    According to her, the Federal Government invests a huge sum of money on the entire process. She said about N4 billion would have been spent on vaccines by the end of the year because it has been a year of accelerated activities.

    Given the increased tempo of activities in the agency and Nigeria?s notorious standing on the world infection index, when does the chief helmsman project the country will be out of the doldrums?

    The answer was quick and down to earth: ?We can talk about Nigeria interrupting the transmission of the wild polio virus sometimes next year, but as to saying Nigeria is free, it will take years. This is because surveillance must continue and there should be no single wild polio virus case in Nigeria for a minimum of three years?.

    She gave the example of South Africa, which has just been certified polio-free to buttress her point. According to her, the last wild polio virus case was reported in South Africa in 1989, but were certified free about two weeks ago. She said it took a longer time to be given the certificate of eradication, because as long as its traces of transmission could be found elsewhere, there could not be talk of eradication.

    Abebe noted that their concentration is stopping the transmission rate using a concerted approach that involves states and local governments.

    ?We met in Benin last week and we all resolved to work hard to interrupt the transmission of the wild polio virus. If we can do that for Nigeria, that will be a big feat because Nigeria will now be taken from the list of the endemic countries. So that is what we are targeting now and eradication can come in later while we are maintaining high routine coverage of the OPV?, the coordinated stressed.

    She said through IPDs, they have moved routine immunisation from 38 per cent last year to about 60 per cent as at today with a further hope of rising to 65 per cent by the end of the year. She said the Federal Government would fulfil its part of the bargain by providing the vaccines for immunisation.

    However, she contended that until the local government and those charged with provision of primary healthcare take ownership of immunisation and by extension, primary healthcare, sustainability of the current strategies would be a mirage. This is because as she said, the tempo could not be maintained from Abuja, which had been the major challenge of previous efforts.

    ?We have to be on routine immunisation and in doing that, train the people on the various components. Most health facilities now offer immunisation services and that is good for us. The only bad thing is that some of them are still charging, but we expect them to be given free. The Federal Government buys them and we distribute them to the states and local governments free and we want them to give the people free as a public good and as a social responsibility?. Abebe.

    She said sustainability would entail that routine immunisation must be functional all year round at similarly functional health facilities. She advised the relevant agencies to take ownership of these health institutions as well despite the lax provisions of the constitution on the matter, which she hoped the proposed health bill before the National Assembly would rectify.

    The number of countries with indigenous polio has dropped to an all-time low of four, as polio eradication efforts enter a new phase involving the use of next-generation vaccines targeted at the two surviving strains of virus.

    In 2006, monovalent vaccines, aimed at individual virus strains, will be the primary platform for eradication in all remaining polio-affected areas, according to partners in polio eradication, which include WHO, Rotary International, the US Centers for Disease Control (CDC) and Prevention and UNICEF ? enabling the eradication drive to hone in on poliovirus types 1 and 3. Monovalent vaccine targeted at the type-1 poliovirus circulating in Egypt was used during vaccination campaigns there in May 2005 for eradication to be successful, at least for the past 12 months.

    Jonathan Majiyagbe, past President of Rotary International, was apt in his recommendation: "To fully exploit these new tools, government commitment in Nigeria must remain high at all levels to ensure that all children are vaccinated?.

    .
    "The next major advancement in the health of American people will be determined by what the individual is willing to do for himself"-- John Knowles, Former President of the Rockefeller Foundation
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