WHAT'S NEW THIS THURSDAY: IMB REPORT, POLIO ERADICATION/ IMB DISCUSSION ON NIGERIA

Wednesday, 28th of November 2012

IMB REPORT, POLIO ERADICATION/ IMB DISCUSSION ON NIGERIA

Summary is at http://www.polioeradication.org/Portals/0/Document/Aboutus/Governance/IMB/7IMBMeeting/7IMB_ReportSummary_EN.pdf

Full text is at http://www.polioeradication.org/Portals/0/Document/Aboutus/Governance/IMB/7IMBMeeting/7IMB_Report_EN.pdf

Below, I reproduce the text for Nigeria, less graphics.

Good reading.

NIGERIA

Sanctuaries: Kano, Katsina and Kaduna

These central northern states have witnessed an explosion of polio in 2012. Together they have recorded 59 cases this year – 60% of Nigeria’s total case count. Micro-planning has in the past been poor in all 44 Local Government Areas (LGAs). To address this, the Programme is conducting an intensive review of micro-plans together with on-the-ground verification exercises. Routine immunisation coverage is also very low: only 33% of children receive OPV3. As such, there is little safety net for children not reached during supplementary immunisation activities. The Programme is increasingly talking to LGA Chairmen about the importance of routine immunisation but must now significantly ramp up this activity.

Sokoto and Zamfara

The polio virus retains a tenacious grip on these two north western states. More than 105,000 children were missed during the October 2012 campaigns in Sokoto alone. Inadequate commitment from the Sokoto State Governor was a problem in the past. We are pleased to hear that the Governor personally flagged off campaigns in June and September and donated much need equipment such as solar fridges. We hope this continues and that other State Governors follow this example. The Programme has now identified poor quality evening review meetings as a problem. These meetings are hugely important to implementing a successful vaccination campaign. Urgent improvements are necessary.

AT A GLANCE

Borno

Northeast Borno must deal with a volatile security situation as well as implementing programmatic improvements. The bravery and dedication of polio programme staff who continue to serve their communities in these challenging conditions is to be highly commended.

Members of a respected Islamic women’s group have been engaged to work in security compromised areas and are proving to be a great asset. A disruptive rainy season also caused inaccessibility problems. The Programme conducted Short Interval Additional Dose campaigns in May to help mitigate the effect on vaccination coverage. The rainy season also coincided with an influx of nomads. The Programme provided some additional resources to help vaccinate these often zero-dose children. Reaching all these nomads is a key priority.

Sanctuaries within sanctuaries

At quick glance, the sanctuaries for the polio virus identified above suggest that polio cases are uniformly spread across the whole of north Nigeria. Delve deeper however and we discover that this is not the case.

In fact polio cases are highly concentrated in a relatively small number of districts (figure 9). Indeed, 23% of polio cases in 2012 have been found in just three Local Government Areas: Katsina, Batsari and Minjibar.

This is the purpose of the sanctuary model – to pinpoint precisely those areas where the virus persists, to understand the unique mix of reasons why it persists, and to formulate the appropriate package of interventions to reach missed children. The better the Nigerian Programme can pinpoint these ‘sanctuaries within sanctuaries’, the better it can target its efforts and the sooner transmission can be interrupted.

National Analysis

Everybody who knows the Global Polio Eradication Initiative is watching Nigeria more closely than anywhere else in the world. In 2012, the increasing amount of polio here has stood in painful contrast to the gains made in every other country. Having grown for two years in a row, everyone wants to see the number of cases fall next year – nobody more so than the leaders of the Nigerian Programme, whose commitment is strong. New measures are being put in place that have the confidence of GPEI leadership.

It is clear that there are still basic problems with the Programme in Nigeria. Whole communities are being found missing from microplans. The detection of orphan viruses highlights the existence of major surveillance gaps. One-third of the children paralysed by polio in 2012 had not received the vaccine because their parents refused it.

The IMB was concerned to learn that spending on social mobilisation is lower in Nigeria than in countries where non-compliance (refusal) is, in relative terms, less of a problem (see figure 10). Explicit refusals are only the tip of the iceberg. ‘Child not at home’ was the reason given for 66% of children being missed in Katsina in the July campaign. It can be easier for a mother to make this excuse than to outright refuse the vaccine.

Community engagement efforts need more development. Even the basics – polio posters and banners – have been conspicuous by their absence. It is no secret that polio is not often top of the Nigerian mother’s list of concerns. The Programme must open its ears fully to understand what is top - the unique needs of every community - and respond to these needs. A community furious at the amount of rubbish on their streets? Send in sanitation lorries with the polio vaccination teams. A village with no clean water? Offer chlorine as well as polio vaccine. A slum suffering an outbreak of infant diarrhoea? Polio social mobilisers provide oral rehydration solution.

The engaged leadership of LGA Chairmen and traditional leaders is crucial. In some places, these individuals are highly committed. In many others, they are failing even to chair meetings of their LGA Task Force – the heart of campaign preparation and implementation. In Katsina State, only 12 of the 34 LGA Chairmen attended evening review meetings during the most recent vaccination campaign.

But for all that is still wrong, it seems that Nigeria’s Polio Programme is changing for the better. It has put in place a major personnel surge. It has started microplanning house by house. Improvements are being made from one round to the next by analysing vaccinator tally sheets in detail. Nomadic populations are being identified – over 1500 “new” settlements so far. Vaccinator teams have been restructured, and their workload rationalised. The Programme has readily welcomed colleagues from India, and is learning from their experience. There is a new-found energy. These are promising developments.

The power to stop polio transmission is now in the hands of everybody in the chain from President to vaccinator. The traditional leaders and LGA Chairmen of the north are particularly important. It is they who can lead the expulsion of polio from Africa. It is the job of everybody else to encourage and support them to do so. Experience elsewhere shows that data – and its quality – will be important to empower these individuals to act.

The commitment of national leaders must be driven down and reflected in the commitment of local leaders. And as a practical step, would it help if the Head of the State Task Force telephoned the leaders of each high-risk LGA every week to maintain a check on progress? It is promising to hear of the President taking a personal interest in which LGAs are performing and which are not.

A highly competent and able network, traditional leaders are hugely respected by their communities. They need to be empowered to play the vital role that they undoubtedly can.

The strong leadership of the Sultan of Sokoto is admirable, directing traditional leaders to take ownership of the Polio Programme. A strong relationship of equals between LGA Chairmen and traditional leaders is the foundation of a winning team.

What happens in Nigeria is of concern globally. But primarily, what happens in Nigeria is of concern to Nigerians. However many world leaders visit the President, whatever report we write, whatever anybody else says, the only thing that will transform the Polio Programme in Nigeria is if a critical mass of people – parents, leaders, and influentials – truly grasp the mission to eradicate polio as their own. If this happens, Nigeria can quickly be rid of polio.

We are asked to make a judgement of how well the Programme is progressing. It is a difficult judgement to make. There are clearly the makings of programmatic improvement, yet we continue to hear of basic problems. There is some evidence to suggest that fewer children are being missed, although this evidence is not uniform. The bottom line must be the amount of polio that we are seeing. If this trend is to be reversed, the green shoots of improvement we are now glimpsing must be nurtured and continue to grow.

We welcome the establishment of a state-of-the-art Emergency Operations Centre in Nigeria.

This provides a unique opportunity for the world’s experts to engage with and support (with advice and encouragement) the Nigerian team as they carry out their vital work.

We recommend that a continual live audiovisual feed should be broadcast online from the Nigerian Emergency Operations Centre, with a facility for the world’s polio experts and the IMB to observe and provide input at any time.

Nigeria may be the last country in the world with polio. No one in Nigeria will wish the country’s name to become synonymous with polio. Nigeria as a nation cannot afford another year of increasing transmission. The Global Programme’s and the country’s leadership strongly believe that in 2013 the number of polio cases will fall. The IMB welcomes this new mood of determination.