Introduction
Since the launch of the global drive to eradicate polio in 1988, the incidences of polio have reduced by 99% . In spite the remarkable success of the eradication efforts that has been reported so far, there are countries where polio is still endemic. As of August 2012, there were 128 cases of polio that had been reported worldwide. 96% of these cases had been reported in the countries where polio is still endemic which are Nigeria, Afghanistan and Pakistan. The number of polio cases that were reported in 2012 represents the least number of cases that has ever been recorded over a period of seven months in the last 10 years .
Nigeria remains the country that is most prone to polio endemics with a record of over 70 cases having been reported in the country by August 2012. In the period between 2010 and 2011, the number of polio cases that were reported in Nigeria rose from 21to 62. In the period between January and September 2012, the number of wild polio virus that were reported in Nigeria was 99; this represented a rise from 42 cases that had been reported over a similar period in 2011.
In response to the incidences of polio, measures have been put in place to respond to the outbreaks and to stem further spread of the disease. A response plan refers to measures that are undertaken in the event of an emergency such as a disease outbreak. It outlines critical steps to be undertaken such as who should be contacted, the steps that will be taken, the supplies that are required and the timeline for the response. The response plan in Nigeria that was put in place as a result of the polio outbreak entailed carrying out vaccination for all children under the age of five, conducting environmental surveillance for wild type polio virus and genomic analysis of the polio virus. The vaccination program was carried out in stages in order to ensure that all children were vaccinated. The response plan adhered to ethical standards since the parents of the children had to give consent for their children to be vaccinated. Prior to the vaccination, the parents were given information regarding the vaccination hence their decision to vaccinate their children was informed.
It is estimated that over 90% of the children in Nigeria have been vaccinated but the remaining percentage is hard to reach. It is estimated that the percentage of children that receive the trivalent polio vaccine has increased over the years. This is because the remaining population is difficult to reach given that they are part of a nomadic population who often travel from one location to another . This essay shall evaluate the rural response mounted against polio in Nigeria, compare it to the urban response plan and highlight the existent partnerships and the application of technology in the eradication of polio. A recommended response plan will also be discussed in the paper.
2.0 Geography, culture and demographics of northern Nigeria
The recent outbreaks in polio were mostly reported in northern Nigeria. Northern Nigeria is mainly comprised of nomadic communities; the Hausa and the Fulani are the most predominant communities. These communities are mostly traders and herders who often travel from one place to another in search of pasture and opportunities for trade. The predominant religion is Christianity although there are traces individuals who practice traditional African religion and Christianity. The country was separated into the north and the south during the colonial era and rivalry between the two regions has been persistent over the years .
The rivalry between the two regions is to a large extent as a result of infrastructural differences. The north was largely ignored by the colonialists and subsequent leaders have also neglected the region. The neglect of the region has led to the collapse of the manufacturing industries in the northern region and in turn the region lags behind in terms of development. Private investors have also shunned the area over the years due to the volatile nature of the region but have invested heavily in the south. The south therefore has well developed roads, proper health infrastructure and properly trained health personnel. On other hand, the health system in the north is poorly coordinated and ill equipped. The education level of the individuals in the north is much lower than that of the southern population due to the fact that the northern population is mainly nomadic .
3.0 Evaluation of government’s response to polio in rural Nigeria
In response to the polio in Nigeria, the government has launched intensive vaccination programs in the rural parts of Nigeria particularly in the northern parts of the country. To begin with, a supplemental immunization program has been launched in order to ensure that the number of children who contract the polio virus is reduced to nil. In the period between January 2011 and September 2012, one national and ten subnational supplemental immunization programs were carried out with the aim of reaching the high risk rural northern states. Children who are aged below the age of five received the bivalent oral polio vaccine for type 1 and type 2 polio viruses. After the initial round of vaccination, three national and four subnational vaccination programs were conducted during which the children who are aged less than 5 years were vaccinated using the trivalent oral polio vaccine.
After the four national vaccination campaigns had been carried out, an assessment of 12 high risk northern districts was conducted in order to determine the quality of the supplemental immunization activities. The quality assurance revealed the following: after the February 2012 SIA, it emerged that 82% of the sampled local government areas failed to reach less than 20% targeted threshold. After the subsequent supplemental activities, the numbers reduced in following order: 74%, 65% and 63% .
The government together with partner organizations also mounted an intensive surveillance program in order to identify and therefore contain the polio virus in endemic regions before it spreads further. Environmental surveillance was carried out in the high risk northern state of Kano. As from July 2011, samples were collected from sewer systems in the state after every 4 to 5 weeks. In the period between July and December 2012, vaccine derived polio virus was identified in 67% of all the samples that were collected from Kano during that period .
Out of the 38 cases of polio that were reported during the same period, 97% occurred in children who were below the age of five while the remaining 3% occurred in children who were aged between 5 and 14 years. 18% of the polio cases were reported among children who had not received any polio vaccine while 5% of the cases were reported among the children who had received more than 4 doses of oral polio vaccine.
In addition to environmental surveillance, surveillance for acute flaccid paralysis (AFP) was also carried out. This is the method used for confirming the presence of the virus in addition to laboratory tests for poliomyelitis. Quality surveillance is normally measured through set targets: NPAFP detection rates of ≥2 cases for every 100,000 children aged less than 15 years and adequate stool specimen collection in more than 80% of AFP cases. The annuals national NPAFP rate in Nigeria (for 100,000 population aged below 15 years) was 7.9, and the proportion of acute flaccid paralysis cases with adequate specimen collection was found to be 93% .
An analysis of the polio virus is also carried out often in order to determine the patterns of transmission access the diversity of the polio virus and track the speed of international spread of the virus . This is particularly important in rural high risk northern states that are known for their nomadism. There has been an increase in the clusters of wild polio virus type 1 from four in 2010 to eight in 2011. On the other hand, genomic analysis has revealed that there has been a decline in the wild polio virus type 3 from six in the year 2010 to four in the year 2011.
4.0 The inequalities in the urban and rural areas
Much of the high risk northern Nigeria is rural while most of the regions in the southern parts of the nation are urban. There are several inequalities that exist between the two states as shall be outlined in this section:
The government has in the recent past focused on developing the southern states as compared to the northern states. This is due to fact that most of ruling elite comes from the northern states and the presidents of the country in the recent past have all come from the southern states. The northern states are therefore neglected; a fact that is evident from the dilapidated state of health care facilities in the north .
Given that the president of Nigeria in the recent past has come from the southern region, the area enjoys a sufficient health care budget in addition to well-equipped health care facilities. The budgetary allocation to the northern states is also less than that of the southern states. In fact, it is estimated the budgetary allocation of the northern states is only two thirds of the southern states. The funding for healthcare in the northern states is mostly drawn from local government authorities and the national government. On other hand, the private sector in the southern region also contributes to the funding of health care .
A survey that was carried out in urban and rural states in northern Nigeria showed that the level education determines the likelihood of a mother taking her children for vaccination. In fact, the survey showed that an educated mother was eight times more likely to take her children for vaccination as compared to a mother who is uneducated. In addition to this, the survey also revealed that the children who live in urban areas are more likely to be vaccinated against polio as compared to those who live in rural areas .
5.0 Potential collaborations
Given that polio has not entirely been eradicated from Nigeria, it is important for the government to collaborate with strategic partners in order to ensure that the efforts to eradicate polio are successful. The community and religious leaders are among the strategic partners who are vital for the success of immunization. In 2003, there was a boycott of vaccination because the local imams in northern Nigeria started a rumour that the vaccinations were meant to wipe off the population of Nigeria and that the vaccines were laced with HIV. This led to a wide spread boycott of vaccination and a subsequent increase in the number of cases of polio that were reported. The government reached out to the leaders in subsequent campaigns and ensured that they fully understood their role in the eradication of polio from the northern states. This move has led to improved participation in subsequent vaccination campaigns and in future it is likely to be of same benefit.
In order to reach out to hard to reach areas of northern Nigeria, it is important for the government have adequate resources. Some of the resources that are required include: the oral polio vaccines for both type1 and type 3 wild polio viruses, well trained staff, vehicles for transportation and storage facilities. The birth rate in Nigeria is quite high hence the number of children in the country is increasing by the day. In order to have these resources, the government needs to partner with international donor organizations which have the funds to procure these resources. Some of the organizations that have donated resources towards the Global Polio Eradication Initiative are USAID, UKAID, Danida, Rotary International, World Health Organization, National Population Commission of Nigeria and Ministry of Health in Nigeria.
6.0 The recommended response plan
Vaccination needs to be made compulsory in all parts of Nigeria in order to ensure that all children below the age of five are vaccinated. Stiff penalties should be meted out to parents who do not take their children for vaccination. The law should also require every federal jurisdiction in Nigeria to dedicate a certain percentage of their annual budget to funding polio vaccination every year. This allocation would go towards training of health workers, equipping of health facilities with proper storage facilities and acquisition of the vaccines. In so doing, the citizens of Nigeria would become more responsible for the eradication of polio from the country.
The government of Nigeria should also work towards setting up regional centres where vaccination is co-ordinated from. The regional centres should have up to date information on the areas that have reported incidences of polio. In addition to this, they should also have well equipped storage facilities that can have polio vaccines throughout the year. This would ensure vaccination can be carried out at any time should it emerge that there is an area that missed out on a vaccination campaign. In addition, the government should set up mobile units to support the regional centres in reaching the remote villages.
7.0 Application of technology
One of the areas that need to be exploited in response to polio in the future is technology. To begin with, surveillance of polio is done through the surveillance of incidences of acute flaccid paralysis. It is also important to carry out environmental surveillance in order to identify existing and current strains of wild type polio virus that are found in the environment. The data that is obtained can be shared via websites and satellite or mobile phones can be used to convey information about reported incidences of acute flaccid paralysis. This will aid in the improvement of the surveillance efforts as compared to solely relying on surveys that are carried out from time to time.
Suffice to say, it is necessary to develop better diagnostic tools that would detect the virus in the body before the disease develops to the level of paralysis. In addition, there is need to establish well equipped and specialized laboratories polio endemic/prone areas such as in the northern regions of the country. Genomic analysis ought to be done in order to determine whether the wild polio virus is mutating and identify any new strains that are currently emerging. The patterns in which various strains of the virus are spreading can be determined from the information obtained from the genomic analysis .
Given that the northern region is prone to polio outbreaks yet it has poor infrastructure, mobile health units can be set up. The mobile health units need to be equipped with storage facilities and well trained facilities. This would improve the coverage of the vaccination program particularly in the hard to reach areas. In conclusion, the rural response to polio in Nigeria is dependent on effective vaccination programs, surveillance, collaboration with strategic partners and technological innovation.
7.0 Adherence to ethical standards
Medical standards in medical practice are based on the key ethical principles. As such, every response plan and medical research is weighed against established ethical standards and must adhere to the said standards. The compulsory vaccination has always raised ethical debates particularly with regard to principles of autonomy, respect of persons and informed consent. The principle of autonomy gives each individual the right to determine the way to live as an autonomous entity without interference and influence by another entity. According to the second principle each right should be respected such that whatever she decides should be respected. On the other hand the third principle empowers each competent (well informed and of legal age) to voluntarily and freely consent or refuse to consent to a medical procedure based on adequate information of the benefits, risks and burdens involved. Thus, some could argue that compulsory vaccination violates these principles. In addition, there are cases of religious and philosophical persuasions regarding vaccinations. The other ethical issue surrounding the issue of compulsory vaccination is the right of parents to raise their children as they wish. On the other side of the debate is whether the government should protect its citizens against the spread of vaccine-preventable diseases and also the rights of children to healthcare.
In my considered opinion, compulsory vaccination adheres to ethical standards and especially in polio endemic areas. The government has the prerogative to not only provide healthcare but also to protect its citizens against the spread of vaccine-preventable diseases. According to the principle of beneficence, we ought to do good and avoid good. Protecting an individual and the community from vaccine-preventable diseases is definitely doing good. On the other hand leaving children and the community exposed to polio virus while we can protect them by vaccination is evil. Compulsory vaccination also adheres to the principle of common good which places the good of society above that of an individual, as vaccination would prevent the spread of polio. Respect of an individual should not compromise the health and safety of the society. With regard to the rights of parenting, where the parents refuse to give consent for their children to be immunized the rights of the children to healthcare override those of the parents. Finally, given that the vaccination is given to children who are not of legal age (under five), the principles of autonomy and individual respect do not hold much weigh. However, the parents, acting on behalf of children, should not be allowed to compromise the health of the children in the name of ethics. In my opinion, allowing this is in itself unethical.
References
Akande, A., & Akande, T. (2006). Polio eradication in Nigeria: controversies and way forward. Afr J Clin Exp Microbio , 173-179.
Antai, D. (2010 ). Migration and child immunization in Nigeria: individual- and community-level contexts. BMC Public Health , 116 .
Babalola, S., & Adewuyi, A. (2005 ). Factors Influencing Immunization Uptake in Nigeria: A Theory-based Research in Six States. Abuja: Paths .
Bradley, P. (1999). Should childhood immunisation be compulsory? Journal of Medical Ethics , 25 (1), 330-334.
Centre for Disease Control and Prevention. (2012, November 9). Progress Toward Poliomyelitis Eradication — Nigeria, January 2011–September 2012. Retrieved March 3, 2013, from Morbidity and Mortality Weekly report: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6144a4.htm
Itimi, K., Dienye, P. O., & Ordinioha, B. (2012). Community participation and childhood immunization coverage: A comparative study of rural and urban communities of Bayelsa State, south-south Niger. Nigerian Medical Journal , 21-25.
NA. (2012, November 14). Polio still endemic in Nigeria. Retrieved March 3, 2013, from pmnewsnigeria.com: http://pmnewsnigeria.com/2012/11/14/polio-still-endemic-in-nigeria/
National Population Commission. (2009 ). Nigeria Demographic and Health Survey 2008. Calverton: National Population Commission.
The college of Physician of Philadelphia. (2013). Ethical Issues and Vaccines. Retrieved March 3, 2013, from The History of vaccines : http://www.historyofvaccines.org/content/articles/ethical-issues-and-vaccines
World Health Organization. (2009 ). State of the world's vaccines and immunization. Geneva : World Health Organization.
