Persistence of poliomyelitis in Nigeria
Authors: Festus D Adu, Itam Hogan Itam
Journal: The Lancet Global Health (2014)

The World Health Assembly launched the Global Polio Eradication Initiative in 1988 and declared the year 2000 as the target by which to achieve poliomyelitis eradication.1WHOGlobal eradication of poliomyelitis by the year 2000. Resolution of the 41st World Health Assembly, WHA 41.28. World Health Organization, Geneva1988Google Scholar After aggressive mass immunisation, backed up by effective routine immunisation, cases of poliomyelitis reduced from 350 000 in 165 countries in 1988 to 355 occurring mainly in three countries—Nigeria, Afghanistan, and Pakistan—by 2013.2Centers for Disease Control and PreventionProgress towards eradication of polio—worldwide, January, 2011–March, 2013.MMWR Morb Mortal Wkly Rep. 2013; 162: 335-338Google Scholar Nigeria is the only country in the world where the three poliovirus types are still circulating; as of December, 2013, it had contributed 14·1% of all poliomyelitis cases worldwide.3WHO Regional Office for AfricaImmunization, vaccines and emergencies. Afro polio weekly update (as at 6th December 2013). World Health Organization Regional Office for Africa, Brazzaville, Congo2013Google Scholar, 4Centers for Disease Control and PreventionWild polio remains a threat in Nigeria.MMWR Morb Mortal Wkly Rep. 2013; 62: 1009-1013PubMed Google Scholar In the past 4 years, Nigerian Government and donor investments have increased and traditional leaders have committed to poliomyelitis eradication.5National Primary Health Care Development Agency2012 Nigeria polio eradication emergency plan. Nigeria Federal Ministry of Health, Abuja, Nigeria2012Google Scholar Despite all these efforts and many years of mass vaccination campaigns, wild poliovirus continues to circulate in the northern part of the country, leading stakeholders to wonder whether something hidden or unknown is affecting the vaccination programme in Nigeria. In The Lancet Global Health, Tara Mangal and colleagues6Mangal TD Aylward RB Mwanza M et al.Key issues in the persistence of poliomyelitis in Nigeria: a case-control study.Lancet Glob Health. 2014; 2: e89-e96Summary Full Text Full Text PDF Scopus (38) Google Scholar report the results of their case-control study into the persistence of poliomyelitis in Nigeria, which identified low vaccine efficacy, poor vaccine coverage, suboptimum population immunity, rejection and refusal of vaccine, and lack of awareness as issues responsible for the persistence of the virus in Nigeria. A report by the Nigerian Expert Review Committee on Polio Eradication following their 25th meeting in September, 2012, also identified a lack of shared sense of emergency by some states, slow improvement in poliomyelitis campaign performance in some local government areas, and neglect of routine immunisation as reasons compromising the success of the programme.7National Primary Health Care Development Agency. Expert Review Committee on Polio. 24th meeting of the Expert Review Committee (ERC) on polio eradication and routine immunization in Nigeria; Abuja, Nigeria; Sept 10–11, 2012.Google Scholar Although these findings represent substantial quantifiable and perceivable reasons, and have added to the understanding about poliomyelitis in Nigeria, in our opinion there are other obscure and intractable factors contributing to the problems facing poliomyelitis eradication in Nigeria. The issues affecting poliomyelitis eradication can be linked to larger problems affecting the whole country. Political, cultural, and religious considerations often dictate attitudes and the course of action in Nigeria. Notably, the 2004 rejection of the oral poliovirus vaccine in the northern part of the country followed the election result, which some leaders from the northern part of the country felt was not in their favour.8News24. Vaccine boycott spreads polio. (South Africa), Feb 11, 2004.Google Scholar, 9Odutola A Nigeria: polio, politics and power play. African Networks for Health Research and development (AFRO-NETS).http://www.afronets.org/archive/200401/msg00069.phpDate: Jan 20, 2004Google Scholar Nigeria was close to eradicating poliomyelitis in 2004 when the campaign against the oral poliovirus vaccine began. That action is still affecting the programme now, although its effect has been significantly reduced by the involvement of political, community, and religious leaders, and intensified communication strategies. Differences in culture and social behaviour have contributed substantially to the persistence of poliomyelitis in the country. In some parts of the country, a paralysed child is seen as a taboo; as such, people living in these areas are greatly aware of the importance of vaccination. Minimal effort is needed to convince caregivers to take those under their protection to be vaccinated in these regions. This awareness is not apparent in other parts of the country, where most paralysed children have to turn to begging in the streets. In such a situation, a single defiant influential voice, asking people to reject and refuse the vaccine, is sufficient to turn the programme from success to failure. The level of education of caregivers, especially mothers, is crucial. Education leads to better understanding, knowledge, and attitudes. A well informed, educated mother is capable of making an independent beneficial decision on her own, and can be easily convinced about the advantages and disadvantages of acceptance or refusal of vaccines. Neither of the two major religions (Islam and Christianity) is against immunisation, but a lack of awareness, low social status, and high illiteracy levels can easily turn a willing mother into a defiant, non-compliant caregiver. All these factors are directly responsible for many children not being vaccinated, which has been the major reason for the persistent circulation of the virus in Nigeria. For the total success of the programme, these factors have to be addressed. Fortunately, new strategic approaches to address some of these factors have been put in place. New step-based approaches for change—addressing the issues of demand, refusal, and rejection, and reaching out to chronically unvaccinated children—as well as an increase in routine immunisation coverage, increased and intensified communication strategies addressing non-compliance, and improved supplementary immunisation activities, have produced good results. Impressive achievements have been made in the last 9 months. Poliomyelitis cases have reduced by 57%, and genetic diversity of wild poliovirus type 1 has been substantially reduced. Wild poliovirus type 3 has not been reported in the past 12 months. Most importantly, poliomyelitis cases in the north, and those contracted during the high transmission season, have reduced substantially.10National Primary Health Care Development Agency. Expert Review Committee on Polio. 26th Meeting of the Expert Review Committee (ERC) on polio eradication and routine immunization in Nigeria; Abuja, Nigeria; November 26–27, 2013.Google Scholar, 11National Primary Health Care Development Agency. Expert Review Committee on Polio. 25th meeting of the Expert Review Committee (ERC) on polio eradication and routine immunization in Nigeria; Abuja, Nigeria; March 19–20, 2013.Google Scholar If this level of success is sustained, the circulation of wild poliovirus will hopefully be interrupted in Nigeria by the end of 2014. We declare that we have no conflicts of interest. Key issues in the persistence of poliomyelitis in Nigeria: a case-control studyAlthough high refusal rates, low OPV campaign awareness, and heterogeneous population immunity continued to support poliomyelitis transmission in Nigeria at the end of 2012, overall population immunity had improved due to new OPV formulations and improvements in programme delivery. Full-Text PDF Open Access