Why Nigeria took so long to get non-polio endemic status

A health worker vaccinates children with drops of polio vaccine in a classroom in Lagos, Nigeria. Reuters/George Esiri

For both Nigeria and the continent, the country’s removal from the list of polio endemic countries is a huge step towards Africa complying with the global goal of becoming polio free by 2017. The goal is part of the World Health Assembly’s Global Polio Eradication Initiative, to deliver a polio-free world in the next three years.

Until now, Nigeria was one of only three countries in the world on the ignoble list of polio endemic countries. The other two were Pakistan and Afghanistan. The list contains the countries that have never interrupted the transmission of polio. To be removed from the list you must have no polio for at least one year. And to be declared polio free, the World Health Organisation needs to certify that the country has had no new cases of the wild poliovirus reported for three successive years. If Nigeria continues its current trend, it could be declared polio free by 2017.

But considering the resources that have been pumped into polio eradication in Nigeria and the detailed prevention strategy in place in the country, Nigeria could have been declared polio free 10 years ago.

Nigeria’s move off the list of polio endemic countries leads us to three questions: Firstly, why did it take Nigeria so long to get to this stage? Secondly, what led to Nigeria’s sudden achievement? And third and most importantly, what must Nigeria continue to do to ensure that the country is finally free of polio?

The challenges around polio

In 2008, Nigeria alone accounted for 86% of all the polio cases on the continent. The other cases came from Niger, Congo, Senegal, Angola and Chad.

There are two reasons the country was the epicentre of the virus at the time. One relates to immunisation. The country’s national immunisation programme performed sub-optimally. There was an abysmally low number of routine immunisations during this period.

But the main stimulus for a high number of polio cases came in 2003. It was a call by a front line medical practitioner and a prominent member of the Supreme Council for Sharia in Nigeria to boycott anti-polio vaccinations in the country’s northern states. The call followed fears that the polio vaccine had been contaminated with anti-fertility steroids.

The resulting boycott brought the wobbly national polio eradication programme to a total collapse. As a result, the average annual reported polio cases shot up from 400 between 1998 and 2002 to 750 cases after the 2003 call. By 2006, there were over 1100 new cases of polio that year.

Frantic national and international efforts were made to end the boycott. This included a resolution being adopted at the 61st World Health Assembly in 2008 calling on Nigeria to reduce the risk of international spread of poliovirus by ensuring that all children in the north of the country were vaccinated against polio. The special and negative mention Nigeria received at the global level appeared to have moved the country in the right direction for achieving polio eradication.

What Nigeria did right

Volunteer Health officials wait to immunise children at a school in Nigeria’s capital in 2010. REUTERS/Afolabi Sotunde

The polio eradication strategy was twofold. Firstly, traditional and community leaders, civil society organisations and women groups were brought into the polio eradication activities to encourage the community to “own” the initiative.

Secondly, emergency operations centres were established in Abuja and six Northern states. Through these centres real-time and detailed information was gathered about the eradication programme in key endemic states. This meant any new polio cases were rapidly detected and the appropriate approach could be co-ordinated in these states.

The system was further enhanced with an accountability framework for team members and groups involved. Individuals, and not just the system or organisation, were held responsible and accountable for their performance.

The system proved so successful that they were deployed and used to control the 2014 ebola outbreak in Nigeria.

The road to become polio-free

Nigeria still has some distance to go to polio free status. It must be continuously stressed that the end of polio is only in sight and at the end of a two year tunnel. On two previous occasions - in 2007 and 2011 - Nigeria shifted focus from polio eradication to electioneering campaigns. As a result, polio resurged.

For the country to achieve a polio free status, it requires two things: a sustained political commitment to polio eradication and a massive operation with adequate funding and meticulous co-ordination. Nigeria’s progress against polio over the last few years has been a combination of this grand coordination and attention to small-scale detail.

All levels of government need to implement routine immunisation. Insecurity in the northeast part of the country has left many settlements in the area inaccessible to health workers. Access to these areas will be critical.

Nigeria cannot afford to be complacent. The current government must build on the achievement of the past government and sustain political commitment to eradicating not only polio and controlling other infectious diseases that still plague the country. Adequate funding must be provided to sustain and expand the operations of emergency operations centres to every state, with adequate funding and management by qualified staff.

Had Nigeria done what was right regarding the polio eradication initiative and routine immunisation, none of these Nigerians would have been maimed, incapacitated and paralysed forever by polio. This is the poignant message for the world, of Nigeria’s current non-polio endemic status, and a reason to ensure polio free status by 2017 and forever.