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Monday, February 16, 2015

Maintaining Momentum in Nigeria is Crucial for a Polio-free Africa

Expert Review Committee in Nigeria urges vigilance in light of tentative steps towards eradication in Nigeria

A child in Kano, Nigeria, shows her inked finger to show that she has received the polio vaccine during a subnational immunization day. Levels of immunity in Kano urgently need to be increased to protect children against poliovirus.
A child in Kano, Nigeria, shows her inked finger to show that she has received the polio vaccine during a subnational immunization day. Levels of immunity in Kano urgently need to be increased to protect children against poliovirus.
© WHO/ T. Moran

On the 21st and 22nd of January, the Expert Review Committee (ERC) on Polio Eradication and Routine Immunization in Nigeria met in order to discuss  progress and challenges against the virus in the last polio endemic country in Africa.

In January, six months passed since the most recent case of wild polio virus was confirmed in Nigeria, with onset of paralysis on the 24 July 2014. This encouraging progress in Nigeria has led to a cautious optimism that the innovations of the programme in the past two years have led to greater protection for children.  

This 29th meeting of the ERC concluded that Nigeria has a long way to go before this tentative progress can be taken as evidence that transmission of the virus has stopped. The ERC stressed that Nigeria will remain on the World Health Organization’s list of polio endemic countries until no wild poliovirus has been detected for a period of at least 12 months, dependent on the systems of surveillance being of certification quality. The wider certification of the African region as being polio-free will take at least three years.

With a strong and reliable surveillance system so crucial to the eventual certification of Nigeria and the African region as polio free, the ERC stated the importance of continuing to improve environmental and surveillance and acute flaccid paralysis surveillance.

In preparing to finish polio, the ERC stated that Nigeria must address several threats to the interruption of transmission. Firstly, while the country is in a better position than ever before to end polio for good, it is essential that complacency regarding progress does not lead to a loss of momentum for the national programme. With elections this month in Nigeria, ensuring that political commitment is maintained, that the scheduled introduction of IPV goes ahead and that programmes continue to operate are essential for not letting progress slip.  

With the national elections on the 14th February, it is possible that political attention and support will be diverted. With polio still a way off being eradicated in Nigeria, the ERC recommended that an advocacy plan be developed to ensure support in high risk areas and to ensure continued engagement across political parties, traditional and religious leaders, and civil society.

Despite the reduction in the presence of wild poliovirus, Nigeria has seen recent cases of circulating vaccine derived poliovirus type 2 (cVDPV2), with the most recent onset of paralysis in November 2014. It is essential the Nigeria stop every chain of cVDPV transmission if Africa is to reach a polio-free status. Ensuring that inactivated polio vaccine introductions in February go smoothly and preparing for the April 2016 withdrawal of trivalent OPV are crucial steps in ending cVDPV transmission. 

Nigeria plays a crucial role for the whole of the African continent in ensuring that the threat of polio is removed for good. Therefore the ERC emphasised the importance of cross-border coordination with Cameroon, Chad and Niger to ensure that populations living on the borders are reached with vaccines, and that surveillance systems support and feed in to one another.

The second threat to eradication in Nigeria identified by the ERC is the challenge of reaching every child with the vaccine, addressing performance gaps in Kano and security issues in Borno and Yobe.

In Kano, levels of immunity must be increased as they are currently below the threshold of 80% coverage for children of 6 to 9 months. With this unacceptably high proportion of children still being missed by campaigns, there is not a strong enough barrier against the virus should it continue to circulate undetected by surveillance systems. The ERC recommended that measures be taken to increase accountability witg vaccinators being directly observed, and that coverage should be increased through health camps and vaccinations in markets.

The ERC marked its appreciation of the valiant efforts made by health workers to protect children in insecure areas.  Despite the challenges, 2.5 million doses of OPV were administered between May and December 2014 in Borno and Yobe, despite inaccessible areas in Borno increasing from 17% to 60% of the province during the same time period. To respond to this, the ERC recommended increasing the number of permanent transit vaccination points to reach children as they enter and leave inaccessible areas.

The ERC stated that from this point forward, the detection of a case of wild poliovirus from any source in Nigeria would constitute a National Public Health Emergency. They recommended that a National Emergency Outbreak Response  Plan be drafted accordingly, so that immediate, large scale mop-up activities could be rolled out immediately should that eventuality occur.

With these cautions in mind, six months with no cases of polio reported in Nigeria does mark a significant achievement for the programme. Achieving a polio-free Nigeria is more achievable now than it has ever been. The ERC recommended that Nigeria initiate a government –led polio legacy planning process to document lessons learned and plan for the future contribution of this innovative programme to other public health and development goals.

The guarantee of a polio free future is a gift that Nigeria can deliver to children across the African continent if they sustain the hard-won gains and address the risks that threaten interruption of the virus.