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| Poor environmental condition such as shown in the picture contributes to spread of diseases. |
By Dr. B.M. Afolabi
Introduction
Dr. Afolabi and I are two members of a highly dispersed, loose-knit, and very informal network of interdisciplinary experts created by Dan Durett to work on the medical, social, cultural, political, and other aspects of the AIDS/HIV epidemic in Africa. Dan is an associate of the Institute for Indigenous Resource Management. We are pleased to spotlight Dr. Afolabi's work in Nigeria. We asked him to prepare this report on his work because we think it takes on added signficance as we seek to identify and examine the reasons for the low rates of vaccination for meningococcal B disease in New Zealand and for influenza in the United States. Mervyn L. Tano.
Background
The inception of the Polio Eradication Initiative (PEI) was in 1988 when the 41st session World Health Assembly (WHA) of the decided and agreed on the eradication of polio by the year 2000 later 2002 and 2003) [1]. The only reservoir of the poliovirus is humans and transmission is mainly through the faeco-oral route, although there may be oral-oral route of transmission. Poor environmental conditions are conducive to transmission of the virus. Polio, a highly infectious disease, presents a different type of challenge. Since 1979 when the last case of wild polio was reported in the United States of America, global efforts to rid the world of the disease intensified. This climaxed in the 1988 decision of the 41 st World Health Assembly (including Nigeria ), to eradicate polio by 2000 (later 2002 and 2003). (WHO/Nigeria: 2001: 7-8).
In 2004, after 11 months, Kano State government has finally approved the use of polio vaccination it had previously suspended in the state. The state governor, Mallam Ibrahim Shekarau, who disclosed this at a press briefing, said that the decision to resume the exercise was taken following the presentation of expert committee's report on July 16, 2004 . According to him, the committee, led by Prof. Sadiq Wali, former Chief Medical Director of Aminu Kano Teaching Hospital, had confirmed the presence of the disputed substance but noted that it was too insignificant to harm human beings. "Kano State government has accepted the conduct of the vaccination in the state. We are satisfied with the findings of the committee, hence our decision to resume the vaccination programme," he said. Shekarau, however, dismissed the insinuation that the government decision to suspend the programme was politically or religiously motivated. He said the government took the decision following series of complaints by the people who were suspicious of its safety. "We took the decision because we have a moral responsibility as a government but we were not in any way influenced by Ulamas or anybody." [2]
Kano City is an ancient town with a long history of trans-Saharan trade. It is situated in Northwest zone of Nigeria with an estimated population of 12 million and a target population (of under-fives) of 3,823,604. Gwale, is one of the metropolitan Local Government Areas of Kano State. It has 9 Health Districts and is sub-divided into 10 Political Wards, namely Dandago, Diso, Dorayi, Galadanchi, Goron Dutse, Gwale, Gyaranya, Kabuga, Mandawari and Sani Mainagge. With an under-fives (target population) of 172,691, and for the purposes of the sNID, 114 Sweep Groups, 114 Sweep Group Supervisors, 228 vaccinators and 228 recorders were formed. A total of 114 Community Leaders were contacted. Among the Kano State Ministry of Health Core Trainers Gwale (as area of assignment) were Hadiza A. Adamu and Dr. Aminu Ibrahim. Mallam Sani Na Gambo was the State Technical Facilitator for the Ward. As at July of 2005, there were 9 AFP cases detected and investigated in the LGA of which 3 were wild polio virus positive. I was deployed to Kabuga Ward in for 9 days.
Re-training of Sweep Team and Recorders
Hajjia Saratu Ibrahim, the Ward Focal Person was supervised and given technical support in conducting the re-training in local language (Hausa) with the dictum that “day preparation is vital.”
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| Hajjia Saratu (right), explaining a point to Sweep Team and Recorders during re-training session. |
Respective traditional and religious leaders were met as my point of entry into the community. Their personal involvement and commitment was high and commendable. They were even involved in team selection. One, Alhaji Ishaq Umar Bello, Chairman AS K/Kansakali Local Guide even printed a handbill at his own expense distributed it widely. Members of National Youth Service Corps (NYSC) were also involved in the 6-day exercise. The person attached to me was particularly helpful in verifying that many schools in the Ward were informed and in organizing Ward flag-off of the exercise, without any fan-fare. All deep freezers for Cold chain were inspected, as well as vaccine carriers, power source(s), forms, tally sheets and vials of Oral Polio Vaccine (OPV) whose VVM (Vaccine vial monitoring) were all in stage 1.
After the re-training, final selection of 96 Sweep Team members and Recorders was made. The roles and responsibilities of the Ward Heads present were assigned to them. These were: signing of tally sheets and ensuring that the exercise is conducted well and done rightly. We selected two take-off points at (i) Kabuga Clinic and K/Waika Clinic.
Firstly, we met Ward Heads did the first training and selection of team members and agreed to meet and talked with Quranic scholars.
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| Members of Sweep Team and Recorders at re-training session. |
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| Picture taking with an Islamic teacher after talks on the importance and relevance of polio immunization to children in his school. The girl squatting on my right was immunized. |
Meeting with Islamic scholars
Although social mobilization had been widely carried out by trained women in Kano metropolis and its suburbs, this was further strengthened just before the exercise began. For example, I met with the Chief Imam of a mosque in Kano for discussion the outcome of which was Quranic verses should be quoted to explain to the people and let them know and be convinced of the importance and necessity of Oral Polio Vaccine. In addition, through verses in the Quran, the Holy Book of Islam, the people should be informed that they should not belittle or be negligent of their health and especially the health of their children. Numerous Quranic schools of varying student population and age, abound in the city, I was able to visit a few of these schools to discuss with their teachers. Some of the Islamic scholars still held on to their view of suspicion of the polio vaccines, most agreed for their wards to be immunized.
Aim of the Exercise
The exercise aimed at ensuring that all children between the ages of 0 - 5 years were immunized according to Federal Government of Nigeria's Polio Eradication Initiative (PEI).
In the field:
We ensured that first of all, team members were punctual at take-off points and all were on the field. A team consisted of supervisor, 2 vaccinators, 2 recorders and a community leader. As much as possible, all houses were visited and children were vaccinated. Males were not allowed to enter the house (Ba'a shiga, hausa word for “Do not enter” for males). For this reason, the presence of the female NYSC member who also speaks Hausa language fluently was invaluable. When there was a rejection in a single house, we did not waste more time as we left the community leader to solve the problem while the team continued in other houses. Occasionally, I remained behind to give a stronger technical support to the community leader. As much as possible, most of the houses where children under the age of five reside were covered. After finishing the day's implementation, I went round the community where we worked for in-process monitoring of 30 randomly selected houses. In days 5 and 6, these were 60 randomly selected houses. The day-to-day operation of my team is as described below.
Day One: Places visited included Kabuga A and Kabuga B. On getting to this areas there was general acceptance. The only rejection encountered was from a Quranic School for the reasons of suspicion of the safety of the polio vaccine and outright lack of information on the exercise. This was reported to the focal person and immediate action was taken. The Islamic teacher was visited again and after being talked to and the whole exercise explained to him, his attitude changed positively.
Day Two: Kofar Waika and Cikin Waika were visited. We spoke to a number of occupants on our mission and the need to immunize their children. In the course of this visit, a polio case was discovered. Effort was made to enlighten and get children in the neighborhood immunized. While some agreed for their children to be immunized, there was rejection from another Quranic School . However, at the end of this visit, observation and complaints were forwarded to the coordinator for attention and follow up,
Day Three: The Team took off as scheduled. Places visited included Kansakali, Custom Barracks and Prisons. The interesting aspect of this visit was that there was absolute compliance. The sampling carried out in this area gave a greater proportion of acceptance and success.
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| Excited children at a school. |
Day Four: Location visited was Islamiya. Ignorance of the exercise, grievances against the local government were the major problem we were confronted with. We experienced individual rejections and we were threatened due to religious opposition to the programme.
Days 5&6: Sampling was carried out on large scale. Each independent monitor randomly sampled 120 houses. The result shows good success rate.
All feasible problems emerging from my assigned ward were solved and I made attempt to ensure that all children the Sweep teams encountered were vaccinated. The primary targets of my Sweep Team every morning were the Quoranic schools, Nursery schools and other places where under-fives are gathered. Sweep teams also operated in the vicinity of mosques during prayers for opportunity to immunize children that were missed earlier. After Friday J'umat services, Sweep Teams were allowed to give the children the antigen and some mothers passing by also agreed that their children should be immunized. Every evening, I organized and participated in Ward-level meeting with Sweep Group Supervisor, Community Leaders, the Central Facilitator after each day of polio immunization exercise.
Recommendation
Percentage rate of success was high compare to previous NID's. However, in view of the problem associated with overall success of the programme: the Immams in both the bigger and Smaller Mosque's should be involved in future programme. Much enlightenment campaign should be carried out to make the people aware and be more involved. This will not only ensure that people embrace the programme but also ensure that government objectives are achieved.
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