Govt, partners join hands to bolster immunisation coverage
WITH immunisation coverage less than 60 per cent and the number of childhood vaccine preventable diseases looming large, CHUKWUMA MUANYA writes on the new government initiative expected to shore up immunisation coverage in the race to meeting the health-related Millennium Development Goals (MDGs) of reducing significantly child and maternal deaths by 2015.
FRESH efforts to reach the un-immunised Nigerian child with Oral Polio Vaccine (OPV) begin tomorrow in 36 states and the Federal Capital Territory (FCT).
The Federal Government and its development partners plan to use the immunisation campaign to deliver a broad range of child survival interventions in the race against the reduction of under-five mortality rate in the country.
Nigeria and the rest of the world are expected to meet the health-related Millennium Development Goals (MDGs) 4 and 5 of reducing significantly child and maternal deaths by 2015.
The MDGs were developed out of the eight chapters of the United Nations Millennium Declaration, signed in September 2000.
Already, Federal Government has deployed 57 million doses of trivalent OPV (OPV-3) for the four day campaign. The vaccines are target at the three type of the Wild Polio Virus (WPV), that WPV-1, WPV-2 and WPV-3 whch are said to be prevalent in the country.. The government plans to administer the vaccines using 180,000 health workers, 140,000 vaccinators, 3,400 supervisors in 33,000 posts. She also plans sub-national campaigns for July, August and October 2009.
The government has also adopted new strategies which include: engagement of political and religious leadership, and civil societies; publishing the coverage, successes and failures of States; revision of guidelines for the conduct of immunisation campaign; and creation of special teams to capture children on the street.
Latest figures on polio eradication in Nigeria from the FMOH, indicate that the progress with immunisation activities reported during the first quarter of 2009 has not been uniform in all states and local councils.
According to government sources about 19 per cent of all local councils failed to achieve the target of 90 per cent coverage during the last campaign held in March 2009.
Of the close to two million children that remained unvaccinated during the March 2009 campaign, 58 per cent were because the children were absent from the house at the time of the vaccinator visit, 30 per cent were missed because of lack of parental/caretaker consent for child to be vaccinated, while 12 per cent remained unvaccinated because vaccinator team did not visit the house.
According to the FMOH report, the significant number of un-immunised children has resulted in sustained transmission as well as circulating vaccine derived poliovirus.
As of May 4, 2009, Nigeria has registered 63 confirmed WPV-1 cases and 177 WPV-3 cases. It also shows that WPV transmission is no longer confined to the polio endemic states in the north but has spread to several previously polio-free states in the South of Nigeria.
Nigeria had commendable progress in polio eradication from 1998 to 2002 but suffered a major setback in 2003 to 2004 as a result of controversy over the safety of the OPV. That set back ensured that Nigeria is one of only four countries globally yet to interrupt the wild poliovirus transmission.
Last year, the 61st World Health Assembly (WHA) adopted a resolution that urged Nigeria to "reduce the risk of international spread of poliovirus by quickly stopping the polio outbreak in northern Nigeria through intensified eradication activities that ensure all children are vaccinated with oral poliomyelitis vaccine."
The 62nd WHA, which ended last week heard progress reports on a variety of health issues such as polio eradication, where delegates expressed deep concern with continued polio transmission in endemic countries but re-iterated their firm commitment to the goal of global polio eradication.
Minister of Health, Prof. Babatunde Osotimehin said since the 61st WHA one year ago, Nigeria has put in place important measures and has also recorded commendable outcomes in her polio eradication efforts, but gaps still exists.
Osotimehin, in his statement to the 62nd session of the WHA last week explained why the country is still harbouring the WPV despite huge progress made in the last 12 months in quality of the enhanced Supplemental Immunisation Activities (SIAs).
Osotimehin gave reasons: Lack of uniformity in SIAs improvement across all states and local councils; absence of target children from homes during campaigns; lack of parental/caretaker consent; and poor logistics for the vaccination team to reach all nooks and crannies of Nigeria.
He, however, said: "At this point, I am happy to announce that we have the highest political support and we are working very hard to overcome the challenges to break the transmission of the WPV and eventually eliminate polio in the world. We are on course."
The Minister said: "Nigeria has implemented six rounds of enhanced SIAs campaigns, three of which have been national. The quality of these campaigns has shown a steady improvement. During the SIAs of July 2008, 550 out of the 774 local councils in the country achieved 90 per cent coverage, while during the March 2009 SIAs, 627 of the 774 local councils achieved 90 per cent coverage and both figures were confirmed by independent monitors. As a result of the steady improvement in quality of the SIAs, the estimated number of children left unvaccinated during campaigns have significantly declined."
Director General of the National Primary Health Care Development Agency (NPHCDA), Dr. Mohammed Ali Pate, told The Guardian: " Right now we have about 57 million doses of trivalent OPV because we are talking about estimated number of children we are going to reach, including wastages and unforeseen figures.
"The coverage target is the 36 states and the FCT with the deployment of over 180,000 health workers using 33,000 posts. In all plus governments and independent workers as partners we deploy about 3,400 monitors and supervisors. The vaccinators and the recorders are the implementers. On the whole there are about 140,000 to 145,000 of them throughout the country."
Pate said the MDGs 4 and 5 are the ones that most countries including Nigeria are lest likely to achieve, but "If we are able to invest in the system that will deliver basic services we should be able to significantly reduce maternal mortality because the causes of maternal mortality is very clear."
Pate continued: "In terms of child mortality, vaccine preventable diseases are very important, micronutrients are also very important because deficiency in micronutrient are still leading to vulnerability to diarrhoea and to other conditions. Respiratory infections that can be treated with single antibiotics with the PHC."
On revitalizing PHC, Pate said: " You know 2008 marked the 30th year of Alma ata declaration which marked the commencement of the PHC agenda. So in the context of the WHA is a resolution, which basically commits global health community to revitalising PHC as a way to improving health outcomes and to do so equitably. If you look at the health equity situation, in Nigeria, we have four health outcomes for children and women, but the four health outcomes are not the same across the board. There is significant inequities between the rich and the poor in terms of health outcomes."
"In general our health outcomes are poor. But even within that low level of health status there are significant in country differences. And to reduce those differences we have to provide basic services such as immunisation, nutrition, health promotion, also maternal and child health services through primary health care. That is the consensus of the international community and it is reflected in the resolution that is on the table here at the WHA."
To the Director of special Duties FMOH, Dr. Abdulsalami Nasidi, one of the major challenges to polio eradication was the acceptance of the non-compliant communities to come out.
Nasidi, who is also the chairman of polio eradication committee said: "Who are the children you are immunising? The same children, the ones that have refused are still missing. So you see that percentage of children that are not immunised remain 30, 40 to 60 per cent. So the challenge is how do you reduce the 30, 50, 60 per cent to less than five per cent or three per cent. So before you control the virus out of a community, knock it off, you must achieve what they call herd immunity and with polio the herd immunity is about 80 per cent. So the challenge is how do you get that 80 per cent. So that means you must get every child within the vicinity to get at least polio vaccine three times.
"The second challenge is continuity. You know Nigeria, you start well you do not sustain, we go back to zero. So the continuity in the activity must be there in the next five, ten years until the virus is completely knocked-off."
Director of Public Health Federal Ministry of Health, Dr. Jonathan Jiya, argued in the same way. He said: "The problem we have is that we are still missing some children, so what the immunisation day plus is to achieve is to catch those that are missed. If immunisation is done more frequently, chances of having missed children drops. Never mind that people are complaining that immunisation is too frequent. Since last year we have reduced the rate of circulation of the WPV."
On the number of times a child should take the polio vaccine, Director of Immunisation, NPHCDA, Dr. Emmanuel Adebayo, told The Guardian: "WHO benchmark is that once a child has four doses of OPV he/she is protected for a life time. But there is a caveat. One is that there are three strains of WPV- type 1, type 2 and type 3. A child may take WPV-1 four or five doses but may be attacked by WPV-3. Since 2002 we have been using this mono-valent vaccine of either WPV-1 or WPV-3. But if all children actually take four routine polio vaccine four times by the time they are one year, they are actually going to be protected.
"We are giving this monthly doses because of poor records. We do not know which child has taken. Usually there are no records and we do not want to miss out. But having said that, it has been found out that there is no harm in giving multiple doses of OPV. There is no danger even if it is 10 times."
On the ways forward, Nasidi said States and local councils are key to polio eradication. He said somebody has to be held responsible. "Get everybody together and hold somebody responsible. What is happening is the person they are holding responsible for failure in influenza is the one they will hold responsible for failure in maternal mortality. So there is competition. 'Come you are chairman of local government in Ogbe, how come that maternal mortality in your area is so high and his own area in Mannamu is so low,' and there is competition, healthy competition. But who are the people that are competing? Who are you holding responsible? In Nigeria context it is the local government chairman," Nasidi said.
He said the success recorded by Kano state in reducing the transmission of WPV is due to the exemplary leadership of the Governor.
He said: "One other thing that people do not know that happened, that really changed the situation is the acceptance of the Kano State Governor to come out openly to immunise his child. That is one of the most central. When the people that were following him saw that they all brought out their children to be immunised. It was one of the cardinal things because the world before was blaming him for the failure of Nigeria. So I told him come out and make a statement not with mouth, but with action. Immunise your child let them know. You see that is what they are promoting now. It changed a lot. Kano was the headquarters of polio. Now, there is almost no one WPV in Kano, not one. The same thing with Zamafara, which was having high polio rate. Zamfara did so well in the last National Immunisation Days (NIDs). All the Emirs in Zamfara are either the chairman of the local council or they are actually being held responsible in their community by the governor.
"So this model should not only be used for polio but for all the public health issue. One WHO expert who was in the north he came to me, he looked for me in Kano and came to my house and said that I have come to look for you, 'see that idea you brought should not be used for only polio but for all primary health are system to push this thing, not just that and it is working'," Nasidi said.
"From almost 40 per cent of children that were not immunised, they reduced it to less than five per cent. People that were hiding their children before brought their children out. It was so easy and vaccine was everywhere".
Nasidi continued: "If you check polio spread in Kano, it is now zero, virtually zero, unbelievable. Kano was 60 per cent last year. From the entire country Kano was red. So it is not the making, but the sustainability. The only way to sustain it is tie it to other primary health care services and get those LGA chairman."
On what the agency is doing about the issue of rejection of OPV by some groups and communities, Adebayo said: "We have seen that the issue of rejection has to do more with the attitude of the health workers. That is why we are increasing intra-personal communication. You can go to a house hold and they reject you, and I might go there and they accept me because of the way I interact with them. Compared to four years ago when the issue of non-compliance was global, that is usually not the case now. You have isolated cases of people rejecting it, even some faith based organizations in the South. But again we have been able to overcome that one by persuasion and increasing community engagement with them."
However, Osotimehin said the efforts to improve routine immunisation performance are bearing modest dividends and national routine OPV3 coverage increased from 47 per cent at the beginning of 2008 to 63 per cent in the first quarter in 2009; a 75 per cent increase within 12 months.
Osotimehin said certification standard Acute Flaccid Paralysis (AFP) surveillance performance was maintained at national level in all but one state in 2008.
"At LGA level, 73 per cent of all LGAs in the country met the two main AFP surveillance performance indicators. Both national laboratories in the country located at Ibadan and Maiduguri maintained WHO accreditation in 2008," he said.
Osotimehin further explained: "The improved quality of immunisation activities has impacted positively on population immunity. The proportion of non-polio AFP cases aged six to 35 months that were reported never to have received a single dose of OPV declined from 15 per cent in 2006 to less than five per cent by the first quarter of 2009. Similarly, the proportion of non polio AFP cases aged six to 35 months that were reported to have received at least three dose of OPV increased from 62 per cent in 2006 to 78 per cent by the first quarter of 2009. The most dramatic improvement in population immunity was registered in Kano, where for the first time ever, the children never vaccinated, reduced to less than 20 per cent."
Pate said the international community recognised the efforts that Nigeria has been making recently and some of the good reports that have been put forward. "But it is too early to say that we are fulfilled. It will be a dangerous mistake for us to say we have achieved the result lets back off. What the government is trying to do is to have a national round and a good quality national round of immunisation with trivalent vaccine and three sub national rounds in July, August and October," he said.
Pate explained: "And if we are able to do those rounds we should significantly reduce not only the WPV-1, which has already gone done significantly compared to what it was last year but also the WPV-3, which is the weaker one of the three type. With the triple trivalent OPV, which we are going to use, we should be able to make progress on the type 2 polio virus. But having done that, it is for short-term success. In the long term we need to keep pushing for increase in our routine immunisation coverage so that trivalent OPV coverage goes up through the routine system. Currently it is about 63 per cent. But it needs to go to about 70 to 75 per cent so that we are able to hold the gains, because even if you eradicate polio from Nigeria if you do not have good routine immunisation it can come back."
On the new strategies to interrupt WPV transmission in the country, Pate said: "We intend to do that by immunisation plus days and there are so many processes we have put in place. One, engagement of political leadership, which is very important. We systematically engage them at state level, at national level, all the governors, all the local council chairmen. But more importantly to us is the national coordinating mechanism. To engage this level has been very good. So we have been able to call all the states and most of the local councils and the stakeholders for consensus building meetings.
"We realized also the importance of some of the segments of the society like women organization, the Christian Association of Nigeria (CAN), The female fellowship and so on, which we have also engaged. These are people, which have had best practices in some other components of health which they are presiding over and they are using these best practices to help us reach most of these children.
"Again one of the things we are doing is that we are putting this issue of low coverage in the political agenda of the various governments. We are doing it indirectly by putting them in a public space. For instance the agency is going to be publishing the coverages, our various immunisation figures in the newspapers so that they will be challenged to doing better
"But more importantly, we have increased the technical program oversight at national level. For instance we have revised the guidelines for the conduct of the immunisation campaign especially the polio campaign. This guideline is now user friendly and we have also adapted that guideline to be used even at the state level and local council level".
"The critical issues are house not visited or children absent. 60 per cent of these children that are absent are found on the street. So we have revised our strategy to capture these children by the creation of special teams on the streets. We piloted this one in Kano in February, we up scaled it in March and with very beautiful results. So this special teams are now loaded with vaccine carriers and so on and they go around the field, playground, the streets immunizing these children that we are missing and we hope we are going to get good result out of this."
Pate further stated: "The way we are looking at it, there are three things that we are trying to do but the polio issue is becoming a distraction. We have to move forward, improve the quality of our programme, the campaign that we have to actually achieve results. Because once we control polio, we demonstrate to the rest of the world the fact that we are making progress and we are very serious, and they will give us respect and the distractions will be less.
