All hands on deck in Kano State as Nigeria on track to being declared polio-free

By Adam Alqali (Lead Writer)

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The Emir of Kano His Royal Highness Muhammadu Sanusi II playing with an infant during a community sensitisation campaign in Tofa LGA, Kano State. Photo source: KeCCOHD

Just five years ago, Kano State was arguably the epicenter of Nigeria’s polio virus epidemic, accounting for over 80% of total cases in the country. Various socio-cultural factors accounted for the state’s huge burden at the time, from ignorance and misconceptions about the polio vaccine, to the state’s high population and finally its strategic location as a center of commercial activities in the West African sub-region — hence the continued influx of people into the metropolis.

A major setback in the efforts to eradicate polio from Kano came about in 2003, when then-Governor Ibrahim Shekarau banned polio vaccines on the assertion that local scientists had discovered the vaccines lead to infertility, particularly among girls. Ten years later the Boko Haram insurgency did its own damage, when 11 polio vaccinators were shot dead in the line of duty in Kano metropolis by gunmen suspected to be members of the Boko Haram sect.

Yet, Kano had since the aftermath of the dastardly incident implemented various strategic and innovative interventions which has seen the state transformed from being the most polio endemic state in Nigeria to one with 92% coverage — according to the LOT Quality Assessment Survey (LQAs) results for the first quarter of 2019.

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A community health worker with members of the Community Women and Child Survival System (COMWACSS) at Dawakin Tofa LGA carrying out data reconciliation exercise for Routine Immunisation.
Photo source: dRPC

How has the state been able to make such dramatic progress in the past five years?

1. The establishment of an effective incident management system

Established in 2013, the Kano Emergency Operations Centre (EOC) has become a major hub for joint programming, implementation and evaluation of the Polio Eradication Initiative (PEI) in Kano State. Set up with the support of development partners working in the area of polio eradication, the Kano EOC is today the nucleus for the coordination of Kano’s strategic and innovative interventions that have seen the state go five years without a case of poliovirus disease.

Such innovations include the introduction of a Vaccine Direct Delivery (VDD) System, which ensures easier direct-to-facility delivery of vaccines, for round-the-clock availability of vaccines at PHCs. The state government established six satellite stores across the state and re-designed the vaccine distribution system by engaging private vendors to deliver vaccines down to PHCs. They also installed Solar Direct Drive (SDD) refrigerators in 97% of focal PHCs in each of Kano state’s 484 political wards, to ensure vaccines delivered under the VDD system are stored under the right temperatures.

Other innovations include the introduction of temporary clinics, known as health camps, at persistently non-compliant communities during Supplementary Immunization Activities (SIAs); the health camps are aimed at resolving non-polio related health challenges such as malaria — as incentives to community members to allow their children receive the vaccination.

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Image credit: Nigeria Health Watch

2. A robust cold chain infrastructure and logistics system

Until the declaration of poliovirus as an incident and the subsequent establishment of an incident management system in Kano, the state’s cold chain system was virtually “obsolete and non-existent”, according to Dr Imam Wada Bello, State Epidemiologist and the Incident Manager of the Kano EOC. The restructuring of the cold chain system became possible due to a tripartite agreement between the Kano State government, the Bill & Melinda Gates Foundation and the Dangote Foundation focused on strengthening Routine Immunisation (RI) in Kano state, Bello said, adding that this was important because, “You have to maintain the potency of the vaccines from the manufacturer up to when the last drop is administered to a child. The temperature in Kano is around 42 degrees Celsius and the vaccine must be kept under between +2 degrees Celsius and + 8 degree Celsius”.

Signed in November 2012, the tripartite agreement proved a masterstroke in Kano’s journey towards polio eradication. The agreement supported interventions across core RI thematic areas such as governance and service delivery, vaccine supply chain, and supportive supervision. The agreement also supported data management as well as community engagement and social mobilization. It also gave birth to the innovative and groundbreaking Vaccine Direct Delivery (VDD) system, which has become an international best practice for delivery of vaccines, as well as the introduction of the Solar Direct Drive (SDD) refrigerators.

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The Emir of Kano His Royal Highness Muhammadu Sanusi II is himself a staunch advocate of child health. Photo source: dRPC

3. Effective community engagement through traditional & religious institutions

Recognising the strategic and influential role traditional and religious institutions play in influencing people’s attitude and behaviors including the acceptance of new government policies, the state collaborated with religious and traditional leaders in a campaign to change long-held misconceptions about poliovirus disease and immunisation.

The collaboration is spearheaded by the Emir of Kano Muhammadu Sanusi II, a staunch advocate of child health. Village heads across the state register all newborns in their communities and conduct joint monthly data reconciliation meetings with community health workers. This is aimed at tracking children who have not accessed immunisation services.

After every meeting, Voluntary Community Mobilisers (VCMs) conduct house-to-house verification to track those children and ensure they are immunised. “In Kano, you will find village heads accompanying a mother to a healthcare facility to get her child immunised and also a district head accompanying vaccination teams to resolve issues of non-compliance,” said Dr Kabiru Ibrahim Getso, Kano State former Commissioner of Health.

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4. High-level political support and supervision

Another game changer in Kano’s effort to eliminate polio was the implementation of high-level supportive supervision led by the State’s Deputy Governor Dr. Nasiru Gawuna, who also chairs the Kano State Task Force on Immunisation and Polio Eradication. As chair of the task-force, the deputy governor works closely with the EOC in monitoring and coordination of vaccination campaigns especially during the quarterly Supplementary Immunization Activities (SIAs) which last for a whole week. During the SIAs, the State Governor Dr. Abdullahi Umary Ganduje himself leads one of the four SIA teams while the Deputy Governor not only leads another team but also chairs the final review meeting at the end of the exercise. Dr Getso believes the high involvement in immunisation by the two state executives is integral to the success the state has recorded in its polio eradication drive, and is a good model that other states should emulate.

5. Integrated Disease Surveillance and Response (IDSR)

Kano has established various proactive strategies for effective surveillance against poliomyelitis including continuous surveillance for Acute Flaccid Paralysis (AFP) to ensure timely detection. When suspected cases of polio are detected through the state’s network of field volunteers and community informants, the government responds immediately. “Once a suspected case is investigated, we take a stool sample and send it to Ibadan for testing; everything has to be done within 24 hours. This is what helps us break the transmission of Wild Polio Virus despite our long stretch of borders with other states,” Dr Bello said.

A case of Circulating Vaccine-Derived Polio Virus type 2 (CVDPV2) was discovered in the sewage around Darmanawa area of Kano metropolis in May 2019, and this was linked to poor environmental sanitation. Although not a case of Wild Polio Virus, CVDPV2 poses great danger to unvaccinated children and the incidence highlights the need for the state and local government councils to engage in a campaign to boost sanitation across homes and neighborhoods. The state government has done tremendously well towards eradicating polio from Kano; local governments need to also show the same level of commitment especially in areas of environmental sanitation and taking part in immunisation coordination.

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On many occasions, Emir Sanusi had personally led community sensitization and dialogue campaigns around the state. Photo source: dRPC

The successes recorded by Kano in polio eradication were achieved under the oversight and technical coordination of the EOC, but also with the active support of development partners working Kano such as the World Health Organisation (WHO), UNICEF, the CORE Group, Bill & Melinda Gates Foundation, SOLINA Group, Clinton Health Access Initiative (CHAI) and e-Health Africa (EHA).

While the successes point to a combination of factors, one overarching factor that has made this sustainable is the unwavering political commitment of the state government in the area of immunisation. Kano State has completely taken over funding of immunisation since the expiration of the tripartite agreement with the Bill & Melinda Gates Foundation and Dangote Foundation in 2016. This series of government-led and community-driven joint interventions being led by the deputy governor — with the active support of the Emir of Kano and his district and village heads as well as religious leaders and development partners — has helped to change negative perceptions about immunisation. It has also improved information sharing, programming, implementation and surveillance of immunisation campaigns in the state. It has been a long journey with many challenges along the way, however the active collaboration of all stakeholders in Kano State and across Nigeria has put the country on track to being declared polio-free by September 2019.

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