Spotlight on missed children
With 52 WPV cases in 2011, Nigeria is experiencing a surge of polio, and remains the only endemic country in Africa. The programme is addressing challenges in campaign quality and community engagement whilst dealing with a deteriorating security situation in the aftermath of August’s attack on the UN.
The northern states of Borno, Kano, Jigawa and Kebbi account for 85% of all cases nationally, and the worsening security situation in these states risks further declines in coverage. States like Borno, Bauchi, Yobe, Kaduna and Plateau have faced repeated incidents of violence in 2011, and bombings and killings have become almost routine occurrences in Borno.
Nationally the percentage of non-polio AFP cases with zero doses of OPV fell from 3% in 2010 to 2% in 2011. However, Borno has more than 12% zero dose children followed by Kano (7%), and Katsina (5%). Three high-risk states – Gombe, Jigawa and Yobe – have improved over the past year, reporting no zero dose AFP cases. Progress has also been achieved nationally this year with 75% of the AFP cases having more than 4 doses, up from 68% in 2010.
Reasons for missed children
Child absent’ was the main reason for missed children in 2011, accounting for over 50% of missed children in every campaign, and 66% in November (see Figure NIG1).
Children who are absent when vaccination teams visit are usually at playgrounds, which are most often not far from their homes. Other times, they may be at social events, which often take place in or nearby the household. In Sokoto, for example, 32% of children absent from the house in the September campaign were identified to be in the playground, while 27% were in the fields, and 19% were attending a social event with their mother or father (see Figure NIG2).
These absent children can be recovered with a little extra effort and this needs to be monitored and emphasized more strongly in programme review meetings, and included routinely in microplans and field monitoring.
Persistent community resistance to the programme is profoundly impacting progress in Nigeria. Caregivers in Nigeria still refuse to vaccinate their children more frequently than any other country in the world, with 25% of missed children in the fourth quarter due to refusals (See Figure NIG3). In many of the high risk wards where campaigns do not achieve 90% coverage, this means that upwards of 3% of all children are missed due to refusal.
States like Borno, Kano, Jigawa and Yobe still have a high number of LGAs with persistent non-compliance (>300 households) that leaves these communities more vulnerable to polio. In the November campaign, Kano state had the highest non-compliance (39%) which has remained a trend throughout the year.
In Sokoto, “no felt need” is a dominating reason for refusal, with almost half of caregivers refusing OPV citing this reason. (See Figure NIG4) Many social studies have revealed that high risk populations in Nigeria do not know how many doses of OPV their children require. Additionally, caregivers have concerns over the safety and effectiveness of OPV, or do not feel their children are susceptible to polio, which could contribute to the response of “no felt need.” Other social and political norms also contribute to refusals. In Kano, for example, “no caregiver consent” is the largest reason for refusal.
Pilots demonstrate progress
Although refusals in Nigeria are still the largest in the world, rates have declined compared to 2010, when at one point, non-compliance accounted for 47% of children missed during campaigns nationally. Communication activities implemented in 59 high risk wards as part of the Intensified Ward Communication Strategy (IWCS) have shown results in 2011, particularly in addressing localized pockets of refusal. These interventions, however, do not reach everywhere, and efforts are underway to expand community engagement activities in Nigeria.
Grassroots programmes that deploy local volunteers to map and search for unvaccinated children in their own communities, as well as to engage with caregivers who refuse vaccine, are showing good results so far (see Box NIG2). In Zamfara where several new programmes have been implemented, refusals have begun to show substantial decline, going from 25% in September to 12% in November. In local areas and communities, these declines are translated into hundreds of additional children immunized from one month to the next. It is critical to monitor implementation and plan scale up systematically to ensure activities are implemented in areas where they can make the greatest impact.