Why Nigeria could still be declared polio-free by March 2020

*NPHCDA, WHO, UNICEF celebrate three years without any reported case of wild virus in country on August 21
*Inaccessible areas occupied by Boko Haram have prevented vaccination of more than 66,000 children in Borno
*Poor health seeking behaviour, vaccine hesitancy, malnutrition, dirty environment, inadequate funding threaten fragile success
*How decades-long polio infrastructure provides benefits across larger public health interventions, by experts

Stakeholders are unanimous that Nigeria is on the verge of eliminating polio despite the activities of Boko Haram and the significant further increase in Wild Polio Virus type one (WPV1) cases globally in 2019, particularly in Pakistan where 15 cases have already been reported.

According to them, there is also need to collectively address the remaining challenges facing the programme today, including the poor access to children in some parts of the country due to insecurity, poor health seeking behaviour of Nigerians, vaccine hesitancy, malnutrition, poor sanitation, and inadequate funding for Primary Health Care (PHC), especially at State and Local Government Area (LGA) levels.

The stakeholders include: the National Primary Health Care Development Agency (NPHCDA); Rotary International, World Health Organisation (WHO), the United State Centers for Disease Control and Prevention (CDC), United Nations Children’s Fund (UNICEF), and the Bill & Melinda Gates Foundation.

They are excited that Nigeria has not detected any case for over three years and may be certified WPV free by WHO by early 2020.

Indeed, Nigeria made history yesterday, August 21, 2019, having achieved three years without a case of Wild Polio Virus (WPV). The last WPV case was isolated in a child in Borno State on August 21, 2016.

The certification, according to WHO would happen after careful assessment of the risk of missed transmission in inaccessible areas of Borno, and other countries in the region where there is lack of confidence in surveillance.

According to the WHO, after three years of no incident of the virus on the African continent, official ‘certification’ of polio eradication would be conducted at the regional level.

The global organisation, for the first time on September 25, 2015, delisted Nigeria from the polio-endemic list after interrupting transmission for 12 months beginning from July 24, 2014. Unfortunately, 25 months later, on August 21, 2016, another case of WPV was discovered.

Executive Director of NPHCDA, Dr. Faisal Shuaib, had told The Guardian that there were a number of processes to surmount before the certification.

Shuaib said following this achievement of three years without the WPV, Nigeria has commenced the process of documentation towards the final certification by the Africa Regional Certification Commission (ARCC). He said this process involves a detailed assemblage and review of surveillance, Routine Immunization (RI) and Supplemental Immunization Activities (SIAs) Data by the National Certification Committee (NCC) before submission of the final documentation to ARCC in March, 2020. “If ARCC is satisfied with the country’s documentation, Nigeria will be certified Wild Polio Virus free,” he said.

The NCC is an independent body of experts chaired by erudite professor of community medicine and public health, Zubair Iliyasu, with other members drawn from the academia to independently assess the progress of the Polio Eradication Initiative (PEI) programme towards the nation’s getting a clean bill of health.

The public health expert, however, said the success achieved is still very fragile as this WPV-free status would have to be maintained through a robust and sensitive surveillance system for Acute Flaccid Paralysis (AFP) and strong RI to prevent possible reoccurrence of the WPV, which may cause the ARCC to deny Nigeria the certification.

The epidemiologist said it is imperative that all stakeholders continue to support the polio programme, through technical, financial support and political oversight to prevent the reoccurrence of the WPV and stop the spread of all the other types of polio virus in all states and LGAs in Nigeria.

He said polio campaigns will therefore continue in the current tempo and intensity to ensure children and the environment are protected against all types of the polio virus while further strengthening routine immunization against vaccine preventable diseases.

The NPHCDA boss said the implementation of Immunization Plus Days (IPDs) where we deliver Oral Polio Vaccines (OPV) to children under five years of age irrespective of their Immunization status will continue even beyond 2020. This is aimed at boosting the population immunity to maintain the WPV-free status.

According to a report published on Monday, August 19, 2019, by The Guardian UK, using violence and misinformation, Boko Haram militant group has hampered efforts to get every child in Nigeria vaccinated against polio, leaving nearly 66,000 children in remote villages in northern Nigeria without the vaccine.

But public health officials are pushing back, teaming up with the military and volunteers who have put their lives on the line to get vaccines to everyone.

Boko Haram has controlled territory in northern Nigeria since around 2003, when they implemented Sharia, or Islamic law, in the region. As part of an effort to dispel Western views, the group — whose name roughly translates to “Western education is sinful” — spread vaccine misinformation, claiming that the vaccine could lead to infertility and bone injuries.

The group has also used violence to deter vaccinators. In 2013, at least nine vaccination team members in the state of Kano were murdered, and witnesses pointed to Boko Haram as the culprit.

The group’s efforts worked: In 2016, after nearly three years without an outbreak, polio resurfaced in the country — a sobering reminder that public health efforts, even when backed by strong leadership, millions of dollars in funding and years of planning, can be quickly undone.

National coordinator for the polio transition planning committee of the NPHCDA, Dr. Ngozi Nwosu, said: “In 2016, we almost disrupted the transmission of polio, but our efforts were derailed by insurgency groups in the northeast. We don’t want that to happen again.”

That means public health officials need to get the vaccine to kids in remote villages in Boko Haram-controlled territory.

“Now, health care workers are accompanied by the military and vigilantes to keep them and the vaccines they carry safe,” Nwosu said. “We also use satellite imagery to see where these hard-to-reach communities are located so we know exactly where to go.”

The vigilantes sometimes go where health care workers cannot. They are young men who have been trained by the military on how to de-escalate potentially dangerous situations as well as how to properly administer vaccines. Armed with this knowledge, they go family-to-family in remote camps, dispelling anti-vaccine myths for parents and providing vaccines to the children.

United Nations Children Fund (UNICEF)’s deputy representative for Nigeria, Pernille Ironside, said their vaccination efforts have been invaluable in helping to achieve Nigeria’s 30-year goal of eliminating polio.

Ironside told NBC News: “There are still enormous challenges that we face like the 66,000 children we can’t reach with certainty with our efforts so there is this risk that the virus may still be circling.”

The vigilantes provide health care workers with on-the-ground information, including whether any children show symptoms of polio. But without access to the areas, it’s difficult to know exactly what’s going on.

One vigilante, who asked to remain anonymous, told NBC News that the number of children they’ve reached is hard to quantify, but added that thousands of children have likely been vaccinated, thereby conferring some level of herd immunity to those who are unvaccinated. Herd immunity means that enough people are vaccinated against an infectious disease to protect others in the community who are not.

The vigilantes also help educate the people living in these remote areas on proper hygiene and sanitation practices when they can, Ironside said.

“Polio is spread in the faeces, and Nigeria will soon overtake India as the number one country in public defecation. That is not a distinction you want to have,” she added.

Nwosu stressed that while global public health efforts and strong leadership by the Nigerian government have stemmed the anti-vaccine tide, it’s not time to let up.

“We have to remain vigilant in our vaccination and surveillance campaigns,” Nwosu said. And polio isn’t the only safety concern in the area: Kidnappings, armed robberies and poor sanitation are also worsening the conditions in which people live, she said.

Ironside, who is also a human rights attorney, applauded Nigeria as a global public health success story and said that she is excited that this chapter in the fight against polio is coming to an end. Still, she acknowledged that a conversation with Boko Haram leadership might be necessary to keep events, such as the resurgence of polio in 2016, from happening again.

“We know that Nigeria is doing everything in its power to check their influence,” Ironside said of Boko Haram, “but it is prudent to listen to their message and find new ways to address them.”

Meanwhile, the Global Polio Eradication Initiative (GPEI) has given five reasons why polio can be eliminated.
Poliovirus causes acute, non-persistent infections

The virus causes acute, short-term infections, meaning that a person infected with polio can only transmit the virus for a limited amount of time. Prolonged infection with wild polioviruses has never been documented and in most cases infected people can only transmit the virus for one-two weeks.

Only infectious people or their waste transmits virus
Some diseases can be transmitted in a multitude of ways, which can make a disease an impossible candidate for eradication. But the poliovirus is typically transmitted just one-way: through human waste. Eradicating polio is not an easy task, but the way polio is transmitted simplifies our ability to tackle the disease.

Survival of virus in the environment is finite
Did you know there is just one strain of wild poliovirus that continues to infect humans? (There used to be three strains of poliovirus that regularly infected humans.) The wild poliovirus cannot survive for long periods outside of the human body. If the virus cannot find an unvaccinated person to infect, it will die out. This is why we have to keep every single child vaccinated—so the virus cannot find any humans to infect. The length of poliovirus survival varies according to conditions like temperature, and the poliovirus infectivity decreases over time.

People are the only reservoir
Hundreds of diseases can be transmitted between insects, animals and humans. One of the things that make polio eradicable is the fact that humans are the only reservoir. No poliovirus has been found to exist and spread among animals despite repeated attempts to document this.

Immunization with polio vaccine interrupts virus transmission
Not only are there two safe and effective polio vaccines, but also vaccination against polio generates herd immunity, which increases the percentage of the population that is immune to the disease.

Mass campaigns using oral polio vaccine, where all children in a specified geographic area are immunized simultaneously, interrupts wild poliovirus circulation by boosting population immunity to the point that transmission of polio cannot be sustained.

But what truly drives our conviction in numbers results. Since the world took up the cause of eradicating polio globally in 1988: we have eliminated polio from 125 countries and reduced the global incidence of polio cases by 99 per cent; and, successfully eradicated certain strains of the virus.

There are now only three countries that have never stopped polio transmission. This marathon of a public health endeavour is in the last mile.

The GPEI has also disclosed five ways the fight against polio is a fight against other diseases.

From the epidemics in the 1950s to the 1000 cases per day in the 1980s, polio’s devastation has seeped across generations. That is, until Global Polio Eradication Initiative and anchoring partners, Rotary International, WHO, UNICEF, CDC, and most recently, the Bill & Melinda Gates Foundation, united efforts and resources to develop a comprehensive polio eradication infrastructure.

Ranging from cutting edge research to dedicated laboratories to community engagement to sewage sampling, the polio infrastructure is as widespread as it is comprehensive. With presence in over 200 countries, the polio programme is second to none, making it one of the largest public-private health partnerships in history.

While the polio eradication infrastructure helps get us closer to a polio-free world, did you know that it is also used to fight and protect against other diseases, too? Here are five examples of the polio infrastructure at work:

The cold chain
The Oral Polio Vaccine (OPV) requires constant refrigeration and vaccine must be kept cool between 2-8 degrees, or it risks losing its effectiveness. This is no easy task in countries and areas where electricity is either unavailable or unreliable.

So, the programme developed what is known as a cold chain system — made up of freezers, refrigerators, and cold boxes — to allow polio workers to store the vaccine and transport it over long distances in extremely hot weather. In Pakistan, a measles immunization program now relies on the same system. With the help of the cold chain, Sindh province recently reached its goal of immunizing more than 7.3 million children against measles.

Micro-planning
A critical component in immunizing more children against polio, especially in remote regions, is micro-planning. A micro-plan allows health workers to identify priority communities, address potential barriers, and develop a plan for a successful immunization campaigns.

The workers collect as many details as possible to help them reach and vaccinate all the children. This strategy has helped keep India polio-free for five years. Now the Mewat district of India is using micro-planning to increase its rates of vaccination against measles and rubella.

Surveillance
The polio surveillance system helps detect new cases of polio and determines where and how these cases originated. Environmental surveillance, which involves testing sewage or other environmental samples for the presence of poliovirus, helps workers confirm polio cases in the absence of symptoms like acute flaccid paralysis (AFP).

In Borno state in Nigeria, the AFP surveillance system is now being used to find people with symptoms of yellow fever and was one of many tactics used during a 2018 yellow fever outbreak that resulted in the vaccination of 8 million people.

Contact tracing
Since polio is a transmittable disease, health workers use contact tracing to learn who has come in contact with people who might be infected. Contact tracing was also critical to containing an Ebola outbreak in Nigeria in 2014. When a traveller from Liberia was diagnosed with Ebola, Nigerian officials were able to quickly trace and isolate the traveller’s contacts, helping prevent the disease from spreading further.

Emergency operations centres
An important part of the polio infrastructure that Rotary and its partners have built is the emergency operations centres network. These centres provide a centralized location where health workers and government officials can work collaboratively and generate a faster, more effective emergency response. The emergency operations centre in Lagos, Nigeria, which was originally set up to address polio, was adapted to handle Ebola, and it ultimately helped the country respond quickly to an Ebola outbreak. Only 19 Ebola cases were reported, and the country was declared Ebola-free within three months.