Isioma Madike The Authorities Should Rethink How Vaccination Works –Adesanya
Immunisation is an essential, cost-effective strategy to reduce childhood morbidity and mortality. Unvaccinated children remain vulnerable to vaccine-preventable diseases and are often disadvantaged due to poverty, conflict, and lack of access to basic health services. ISIOMA MADIKE, reports
Most of Nigeria’s children may not have had the opportunity to go through the immunisa- tion trips. They grew up to often navigate through hard terrain and the scorching weather, over rickety bridges, and through slums. They dealt with numerous bumps and scrapes. In some more volatile lo- cations, there is also the threat of violence. That was punishing, both physically and emotionally. Polio, a medical disorder, is one such childhood condition that has dealt a devastating blow to humanity without boundaries. Our reporter encountered many sufferers from the streets and those that survived the scourge of a bug that has hounded the human race with devastating effect.
One of such victims is Abu, from Kano State. Every day, there is pain. Abu’s right leg is an inch and a half short- er than his left leg, causing him to limp. His feet are misshapen, while his joints and muscles ache so badly. It is usually tough to go to sleep by the end of the day. Abu had developed a fever and began stumbling dramatically. “My mother recognised the symptoms, and within a few hours, she rushed me to the hospital,” Abu said with the help of an interpreter. However, the damage was done. Within days he was paralysed from the waist down. The full paralysis lasted only a few weeks, but his largely dysfunctional legs caused him pain. For more than a year, his mother massaged his son’s limbs every three hours, even in the middle of the night, to keep his muscles from weakening. Eventually, Abu endured eight surgeries, many of which were unsuccessful.
“In those days, doctors didn’t always know what they were doing,” he recalled. He regularly wore a leg brace, and he was confined to a wheelchair after each surgery. Soon, Abu realised that he was not the same as other children. When he lost his balance and fell over, his four older, healthy siblings would rush to pick him up. “But other kids could be very mean. They would imitate the way I walked. I remember that I slapped a girl for doing it. She never made fun of me again,” Abu said. The social ostracism grew worse as he got older. During a dance in a junior school party when Abu was about 13, students were playing a game in which the boys each tossed a shoe into the middle of the party. He said: “A girl, who liked you, would pick it up and bring it back to you and ask you to dance.
My awkward orthopaedic shoe was the only one that didn’t get picked up. I was sitting on the bench with one bare foot and couldn’t walk down to get it. A girl finally handed it to me, but she didn’t ask me to dance.” Incidentally, Abu’s case is not an isolated one. Kexter was six months old when he contracted polio. At age nine he was placed in a hospital until just after his first birthday. “I am not sure what type of polio I had, but I was never in an iron lung. Due to my illness, we travelled home by air and returned to Lagos by road,” he recalled. He had several surgeries to correct the muscle contraction that was occurring in his left foot throughout his childhood.
Tendons were stretched, and a toe bone removed and inserted in the arch of his foot to try to keep it from curling. He always walked with a slight limp and could not stand flat on his left foot. A few years ago, he had another operation to stretch all the tendons and remove another toe bone to straighten the left foot, again. The gains made are already reversing. While never an athlete, he was always active. He could swim, ride a bike, walk and dance. He could never run no matter how hard he tried. His body simply could not accommodate running; his muscles could never figure it out. In spite of this handicap, Kexter always participated in sports, trekking and swimming with friends. He always had friends, who encouraged him to participate with them no matter how pathetic his performance might be.
He credits them with keeping him active with their “Just do it anyway” coaching. Since the age of 20 he has been doing yoga off and on. He now finds it to be the one physical activity that works well for him. With this physical frailty, he turned to reading and mental pursuits, which have served him well. Excelling at school became his focus. He is today married with two children and doing well in his busi- ness. However, Abu and Kexter are not alone. Musa came down with a rag- ing fever when he was three years old. When his feet arched back to touch his head, his parents took him to the nearest hospital, where other people, who shared their tips on dealing with polio, were quartered. He was put into an isolation ward and did not see anyone from his family for several years.
Musa could still remember the masked figures in a large semi-circular room and the spotlights. Musa also remembered the smell of woolen blanket strips put into boiling hot water in washing ma- chines and squeezed out before being wrapped on twisted limbs. He remembered it now after being hypnotised as an adult because the memories were too traumatic for him for years, and he would remember them now only as nightmares. They moved to Lagos from Sokoto, where after much work, he was able to walk without crutches or braces by the time he was in junior high school. In his last years at school, post-polio symptoms set in, which he attributed to growing up. But, after a routine physical with his doctor, he referred him for further testing to a neurologist.
It was the doctor that later diagnosed him with post-polio syndrome. Now he is fully grown and has had surgeries on both legs so that he can get around with the help of a cane. However, for anyone over the age of 50, polio still casts nightmarish shadows of babies entombed in iron lungs, hobbling in leg irons and adults confined in wheelchairs. Seemingly appearing out of nowhere in unstoppable epidemics, polio killed or paralysed millions, and mostly affected children. The disease grabbed headlines, stoked panic and drove massive fundraising campaigns. Doctors and scientists were powerless to prevent or treat the scourge at its early incursion. Polio, as Gareth Williams, one of the famous personalities that survived the blight suggests in his fascinating study, was one of the diseases that defined the 20th century. It is a disease that also defines the history of medicine.
Polio was virtually unknown before the end of the 19th century. Although the disease was first not- ed in 1789, only isolated cases surfaced until the first epidemic struck a village in France in 1885. From then on, polio gathered strength; there were epidemics in North America from the 1890s, Scandinavia from the early 1900s and the United Kingdom, Africa, Australia over the following 40 years. Today, however, scientists put the sudden decline of the malady on better sanitation, which prevented babies coming into contact with the virus while they still enjoyed maternal immunity. In 2020, the chairperson of the African Regional Certification Commission for polio eradication (ARCC), Rose Leke, announced that the region had successfully met the certification criteria for wild polio eradication. While Leke called it a momentous day for the continent, Africans tagged it most refreshing news as no case of the wild poliovirus was reported for upward of four years.
Prior to that time, polio was said to be paralysing an estimated 75,000 children in Africa annually, even though eradication efforts had also prevented up to 1.8 million children from crippling life-long paralysis and saved approximately 180,000 lives through campaigns such as the Nelson Mandela-inspired Kick Polio Out of Africa. A unique effort by governments, communities, global polio eradication partners, and philanthropists, which shook off weak health systems and significant logistical and operational challenges across the continent, had inspired greater hope ahead for the future. It was however resolved that vigilance was vital among campaigners in order that a reversal would not be witnessed. But Nigeria, according to some analysts, is not cautious enough considering the negligence by some concerned officials and other stakeholders in what is supposed to be a concerted effort at warding off the threat of this preventable disease from children.
Apart from polio, other vaccine-preventable diseases like tuberculosis, measles and pneumonia continue to rank among the top killers of children under age 5 in Nigeria and other developing countries. Each year, nearly 31 million children under 5 suffer from these diseases and many of them end up dying from the diseases. Pneumonia alone, according to reports, claims the lives of more than 800,000 children every year. These are deaths that could be prevented with adequate vaccine coverage. According to the Federal Ministry of Health, a child is considered fully vaccinated if he or she has received a Bacillus Calmette-Guérin (BCG) vaccination against tuberculosis; three doses of DPT to prevent diphtheria, pertussis (whooping cough), and tetanus; at least three doses of polio vaccine; and one dose of measles.
Nigeria, reports say, contributes about 30 per cent of the global number of unimmunised children under-5. Government efforts to strengthen routine immunisation coverage and reduce under-5 mortality, according to such reports, have had limited success over the last decade. Recent review however, is not reassuring. The World Health Organisation (WHO) and UNICEF have noted that COVID-19 related disruptions may have reversed any hard-won progress in immunisation rates world- wide. These organisations pointed out that the situation is compounded in the northern part of Nigeria by persistent conflict and insecurity, especially for the poorest households and most vulnerable children. According to them, delivery of essential services and life-saving immunisation to these zones is now becoming more difficult. They have also noted that the rural–urban divide continues to widen in the country.
This, they say, is sustained by various barriers preventing access to health services, such as the limited number of available or accessible facilities in remote areas and high out-of-pocket payments for health service. As a result, the uptick of basic essential services like antenatal and post-natal care, they say, remains low, especially among women and children in rural communities. In a story by UNICEF Nigeria on April 28, 2021, a Director of Nursing and the Local Immunisation Officer in the Ahiazu Mbaise Local Government Area in Imo State, Mrs. Margaret Uwakwe, shared her first-hand experience of the effects of not getting vaccinated.
Part of her job is to make sure vaccines are available from the local government, and to educate workers on new vaccines, and follow through with vaccination campaigns. She recalled once trying unsuccessfully to change the minds of parents who refused to vaccinate their children. A few years later, two of their children died of measles – a vaccine-preventable disease, she said. “It was a very sad situation,” said Uwakwe. “Because of that, I have always seen my profession as a vocation. It’s a very important job, as it helps prevent so many deaths. I don’t think I will ever get tired of talking to people about the importance of immunisation.” Vaccines are one of the great breakthroughs of modern medicine, saving millions of lives every year, at a low cost.
Africa experienced the eradication of the wild poliovirus a few ago due to the power of vaccines and the dedication of immunisation workers. Sadly, in 2020, the world witnessed an alarming decline in global vaccine coverage and uptick due to the COVID-19 pandemic, which disrupted the delivery of immunisation services. A 2020 report by UNICEF and WHO showed that the West and Central Africa region is much further behind in vaccination than other regions, with Nigeria topping the list of countries with high numbers of children, who did not receive their vaccines for diphtheria, tetanus and whooping cough (DTP1) in 2019. In Nigeria, immunisation coverage varies dramatically, and all states fall below the global goal of 90 per cent coverage for three doses of pentavalent vaccine, which protects children against five major diseases: diphtheria, tetanus, pertussis (whooping cough), hepatitis B and Haemophilus influenzae type b.
But within the country, the South-East region has the highest immunisation rate. This is a point of pride for Uwakwe. She said: “My local government area was among the three that were selected for documentation evaluation during the polio eradication exercise and it came in first place, with 99 per cent coverage. I am proud that I contributed to Nigeria being a polio-free nation.” Many people aren’t able to seek vaccination due to poor road access in rural communities and difficulty in finding health centres. Others avoid vaccines due to incorrect beliefs about their safety. With a struggling health system and too few health workers and facil- ities within reach, frontline workers like Uwakwe are key to keeping children and adults healthy and vaccinat- ed. UNICEF, together with partners and donors, is working with the Nigerian government to ensure that health workers like Uwakwe can continue to deliver routine immunisation services in a safe way.
A Family Physician, Dr. Rotimi Adesanya, fears for this period as he said the post-election era is known to be challenging as administration changes have been known to stall the continuity and stability of previous progress, particularly in the health sector. He nonetheless said that a strong PHC system is vital to delivering vaccines to all children, especially those with least access to health services, who are the most vulnerable. He said: “Across all public health policies, there is a need to deliberately emphasise on strengthening maternal, newborn and child health services. Efforts to empower, train, and retrain health workers will need to be scaled up and extended to Community Health Workers (CHWs), which is the backbone of PHC. “To make these changes sustainable, public health authorities will need to continuously evaluate and consolidate relevant policies to create an enabling environment. Scaling up immunisation coverage in Nigeria is not just a goal, it is imperative.
“It is incumbent on the authorities to rethink how it can make immunisation work in Nigeria despite the challenges and complex dynamics. “This will require stronger national ownership as well as continued collaboration across health actors, international agencies and civil society to ensure that immunisation remains a political priority in the months and years to come.”
