11 September 2018

Nigeria: Identify and Report - How Grassroots Informants Accelerated the End of Polio in Niger State

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The streets of Masaga district in the northern part of Bida local government area of Niger state were adorned with a colourful display of varying designs of outfits as both the young and elderly march to different destinations for marriage ceremonies. Fridays are usually for wedding ceremonies, explains Baba Buhari, the Disease Surveillance and Notification Officer (DSNO) in charge of Bida Local Government Area. The other things that adorned the streets were antique shops displaying alluring shapes, colours, and intricate designs of beads, brass and glass works, for which the town is famous.

A few minutes from one the shops that boldly welcomes visitors and potential customers to the "Masaga Glass Work showroom Bida" is the Gbogbontigi Primary Health Centre where the last case of Acute Flaccid Paralysis (AFP) was identified in July 2018. A 20-minute drive on a motorcycle from the health centre leads to where the patient, three-year-old Amina Mohammed, lives with her parents and other extended family members in an unpainted block of buildings very close to a semi-discarded refuse dump.

Amina's mother, Fatima Mohammed, said her daughter's problem was likely caused by an injection she received which resulted in high fever, convulsions and flaccid limbs. Once the symptoms were noticed at the health centre, the DSNO was notified and he sprang into action.

Out of the seven North Central states, Niger State has the second lowest percentage (7.8%) of children between 12-23 months with evidence of vaccination for polio according to the Multiple Indicator Cluster Survey (MICS) of 2017. Despite this, the state was recently declared polio-free by UNICEF.

Beating the Odds

Getting to the point of being declared polio-free requires concerted efforts to ensure children receive routine immunisation where it matters most; hard to reach areas. It also requires active case surveillance for conditions that manifest polio-like symptoms just like Amina's. For Niger state, a couple of actions seemed to have contributed to their success.

Political commitment from the state government was instrumental as it helped put the right frameworks and policies in place, thus, creating an enabling environment for partners and stakeholders to thrive. This is evidenced in the fact that Niger state was the first state to enact a law that prosecutes parents who deliberately deny their children immunisation. Traditional leaders also contributed significantly towards polio eradication efforts, according to Jummai Idris Mohammed, the Director Planning Research and Statistics of the Niger State Primary Health Development Agency.

Dr. Khalilu Muhammad, Niger State Project Coordinator for the Eradicating Polio and Strengthening Primary Health Care in Nigeria Project, emphasised that the state achieved this status through multi-stakeholder efforts, but also added that much of the success can be attributed to efforts at the grassroots level.

"Globally, the World Health Organisation (WHO) led with other partners including GAVI and UNICEF but then if you narrow down locally, we cannot overemphasise the role played by community leaders, and traditional and religious institutions across board," he said. Dr. Muhammad also attributed the successes against polio to health workers in the rural areas who worked hard to translate strategy to action. "They say behind every successful general, there is always a willing and motivated troop," he said.

The polio foot soldiers and supporting weak links

The steps outlined by the Global Polio Eradication Initiative, a public-private partnership by national governments and five key partners, for certifying a country polio-free, lists active surveillance for Acute Flaccid Paralysis (AFP) as an important step. To continue to identify potential poliovirus cases, AFP surveillance is very important. The WHO sets the case definition for AFP as any child under 15 years of age with acute flaccid paralysis or any person of any age with paralytic illness. If polio is suspected the case is to be reported to the DSNO for immediate action.

Some of these steps are easier in urban and metropolitan areas but in rural and often inaccessible locations, it is difficult, and this is where it matters most; the last mile. Usually, when access is restricted to these areas as seen in states with conflict and insecurity, it undermines the efforts aimed at eradicating polio as seen in 2016. It is also efforts to reach last mile locations that is helping states such as Kano stay ahead of the poliovirus in their state.

When AFP cases are detected, stool samples are transported using a cold chain system to one of the two WHO-accredited reference laboratories in Nigeria to confirm if it is a case of polio. A cold chain system ensures the integrity of the samples are maintained by providing a controlled transportation. "Case identification, notification of the DSNO, investigation of case, sample collection and transportation to the laboratory must happen within 14 days for the process to be considered adequate," Baba Buhari said.

In the case of three-year-old Amina, she turned out negative for polio and her mother said she's managing her floppy limbs by applying shea butter to them. Amina's convulsions and high fever have also stopped.

Even if AFP results turn out negative for polio, it shows there is an active search for polio cases, Dr. Adesola Yinka, who represents the Nigeria Centre for Disease Control at the Polio Emergency Operations Center (EOC) coordinated by National Primary Healthcare Development Agency (NPHCDA). Current data from the NCDC shows there were 132 new cases of AFP across the country, in the reporting week 33 which ended on August 19, 2018 and none was confirmed as polio. Between week 1 and 33 of 2018, 5459 suspected cases of AFP have been reported from 728 LGAs in 37 States.

The work of Baba Buhari is made possible by community informants like 49-year-old Man Alfa, head of a large traditional bone-setting family that resides along the busy Titijinba street in Bida. Since joining Baba Buhari's surveillance network, Man Alfa said he has notified him of two AFP cases that both turned out to be negative for polio.

The network of informants is comprised of bone setters, traditional and spiritual healers, patent medicine vendors, traditional birth attendants and nomads. Their work is quite important because "they are in touch with the people. They are usually the first contacts when people have these symptoms," Baba Buhari said. The community informants are brought together once a year and they are trained and updated on case identification, channel of surveillance network and given tools like posters of signs and symptoms printed in local languages. He currently has six informants across the 14 wards of the local government.

UNICEF also supports active community surveillance and engagement for polio in the state through another network of voluntary community mobilizers otherwise called VCMs. "They are in the communities with the people, they are from the people and their role essentially is to go out continuously and check from house to house if there are children with symptoms that look like polio and when they pick this AFP up, that becomes like the red flag," says Dr. Muhammad. In the past 12 months, the VCMs have picked up five cases of AFP and Dr Muhammed says their work is critical to the eradication of polio in Niger state.

Pointing out another strategy that is helping the state keep polio at bay, Dr. Muhammad said UNICEF in the last two and half years has been implementing a project that is supported by the Global Affairs Canada called the Hard to Reach Project which is in about 850 extremely difficult to reach settlements. Dr. Muhammad said despite the name of the project, it is actually about eradicating polio and strengthening primary healthcare in Nigeria. The project teams go out every morning to visit these 850 settlements one after the other. When all of them are visited, a cycle has been completed, and they start over.

When the team gets to a settlement, they provide oral polio vaccines to eligible children, including children that never had an opportunity to be vaccinated against polio. But beyond polio they also render other health services, because the program adopts an integrated approach. Some of the teams have midwives that take deliveries, and this makes it easy for the communities to accept them, Jummai Mohammed says.

"As we are giving vaccines to the supposedly healthy child, which is what the community thinks, we are also treating their sick children, whether it is malaria, or diarrhea, pneumonia, even very complex cases. We've had cases of surgery that we linked them to specialists and they had very successful surgeries. Because of this integrated approach, the community is more willing to accept the polio immunisations, because as far as they are concerned, since you are solving their problem, it means you are genuine. You have their interests at heart. Whatever else you give them, they will accept unlike when you just go in and start talking about polio, there's a lot of suspicion," Dr. Muhammad explained.

He said there have been instances of children who were over four years old and never had a drop of vaccine until teams from the program tracked and vaccinated them. "These multiple strategies coupled with political will of the state government starting from the Governor, the Commissioner, the ED of the SPHCDA helped. When you have this cooperation and collaboration across board, it enhances the response to your intervention and I think that is what has happened in Niger state," he said.

A chain can only be as strong as its weakest link, and Hajiya Jummai Mohammed said Niger state's 90 day Accelerated Action on Immunization (AAI) is currently supporting two local governments that have the lowest performance in service delivery. During the review meeting for the program, Niger state's First Lady, Dr. Amina Bello, displays a scorecard for every LGA and this motivates those with low performance to improve on outreaches, advocacy and sensitisation efforts. The outcomes and problems identified by the program are used to impact policy making in the state.

Staying strong, getting ready to win

No worthwhile journey comes without its share of hurdles. The sheer size of Niger state, being the state with the largest land mass in Nigeria, poses a challenge in program execution, says Dr. Muhammad. Its' terrain is equally difficult to navigate, and because of this, the population is very dispersed. "Within a community, settlements can be as far as 30 minutes from each other, and some of these communities are totally inaccessible during the rainy season," he said. This is also worsened by infrastructural decay which has not been fixed immediately due to competing demands and limited earning capacity on the side of the government, he added.

While various stakeholders have contributed to the successes recorded in the state, managing this multi-stakeholder relationship can be daunting sometimes, and this can also pose a challenge to the process of ensuring that polio surveillance and eradication is kept a priority.

The grassroots front is also not devoid of challenges. Baba Buhari listed inadequate motivation, lack of mobility, lack of tools for effective documentation and unsteady power supply to run the cold chain refrigerators as some of the challenges he faces with his work. To overcome these, he wants the local government to take ownership and not leave everything to international agencies supporting the state.

It is the persistence of the sojourner to remain committed to the mission that leads them to the destination. As Nigeria prepares to be declared polio-free in 2019, we must show that we are ready and committed by collaborating with relevant agencies to access the last frontiers for surveillance and immunisation. As Professor Oyewale Tomori, Nigeria's renowned professor of Virology, succinctly put it, this is the solution to eradicating polio in Nigeria. "The final solution to polio is to open Sambisa forest so that people can go there, vaccinate whoever is there and do surveillance," he said.

Nigeria must also show it is ready to commit resources used in fighting polio to other public health needs. This has already been proven to be effective when the country used AFP surveillance resources and approaches to facilitate its successful response to the Ebola epidemic in West Africa in 2014, with the help of graduates and residents of the Nigeria Field Epidemiology Training Program (NFELTP). While efforts are being made to develop a business case to convert human resources and assets used for the polio fight into other priorities of primary health care in Nigeria, we still need to remain vigilant to ensure children like Amina with AFP are identified and tested. This way, families in communities like Masaga can continue celebrating important moments without their children staying at home as a result of paralysis from poliovirus infection.

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