How Nigeria beat polio: from 'hit-and-run' vaccine squads to digging wells

Shola Lawal
·7-min read
A health official giving the polio vaccine to a child in a camp for displaced people in Maiduguri, Nigeria - AP
A health official giving the polio vaccine to a child in a camp for displaced people in Maiduguri, Nigeria - AP

Dr Tunji Funsho, described by TIME last month as "the person who did more than any other to drive polio to continent-wide extinction" in Africa, could be forgiven for taking a break. 

In August this year, that goal was reached: Nigeria, where Dr Funsho is based, was declared free of the wild polio virus, the last country on the continent to reach the milestone. 

But speaking to The Telegraph from his aptly named Polio House office in Lagos, Nigeria's economic capital, with a colourful woven cap emblazoned with the words 'End polio now' atop his head, Dr Funsho is not finished yet. 

"Nothing could be more satisfying than to live to see the day that Nigeria was certified free [of wild polio] under my leadership," he said. But he added that there was work to be done maintaining that status - and, moreover, work to be done elsewhere to achieve the same goal. 

Polio, which has left hundreds of thousands of children globally paralysed or, in some cases, even dead, remains endemic only in Pakistan and Afghanistan, the last barriers to a wild polio-free world.

There may be lessons available in that final struggle from Nigeria's long journey to zero polio. It took decades of advocacy and vaccination drives, with major setbacks along the way and one huge need, according to Dr Funsho: money. 

The 72-year old, a cardiologist by trade and chair of Rotary International's polio eradication programme in Nigeria for the last seven years, said the team has spent five times the amount of money in Africa alone that was originally budgeted to rid the entire world of the disease. 

In 1996, when African governments partnered with the Global Polio Eradication Initiative (GPEI) - made up of Rotary, the World Health Organization, and others - on the Nelson Mandela-led ‘Kick Polio out of Africa’ campaign, Dr Funsho was part of a team that raised $230 million to target 50 million children for vaccination and eradicate polio in Africa by 2000. The money spent, he said, has surpassed the initial budget by far.

“It takes a lot to ask people to keep giving continuously," he said. "They give money this year and you have not finished the job, next year we come again and ask for more. So it becomes tougher and tougher to raise funds.”

That's despite the progress that has been made: about 75,000 African children annually were affected  by poliomyelitis 20 years ago. The infectious disease is caused by poliovirus - gastrointestinal viruses that attack the nervous system of children under five and destroy nerve cells that allow for muscle movement. The virus transmits through a faecal-oral route, often through contaminated water or food, and causes lifelong paralysis in hours.

It was not just money, though. Vaccinators, try as they may, struggled to convince some populations of the usefulness of the polio vaccine and could not counter widespread rumours that the vaccine sterilized children.

In 2003, a state-backed vaccine boycott in the northern states of Kano, Kaduna and Zamfara caused a particularly devastating setback, rolling back years of progress at a time when Nigeria recorded nearly half of the polio burden in the world.

The boycott was fuelled by memories of the Trovan trials in 1996, in which 200 children with meningitis were given experimental drugs by Pfizer, killing 11 of them, and leaving many more with brain damage, paralysis and slurred speech.

So when top Islamic leaders - who were convinced America would attack Muslims everywhere in its war against Iraq - openly opposed vaccinations, their followers heeded their call. The boycott led to an alarming 30 per cent increase in polio prevalence. By 2008, polio cases originating from Nigeria had spread to 20 countries, reaching as far as Yemen and Indonesia and paralysing 1,500 children.

It took Nigerian scientists getting involved in testing and talking to religious leaders, and so-called "give-or-take" deals with communities, to end the boycott.

“You cannot be coming here and giving us all these drugs when we don’t have clean water,” villagers would tell Dr Funsho’s team, and Rotary would dig wells or boreholes for them, he said.

The war on polio | Is an end to the childhood disease in sight?
The war on polio | Is an end to the childhood disease in sight?

Then came the rise of Boko Haram in 2009. With the terrorist war raging in Nigeria’s northeast - now in its 11th year - vaccinators faced death or kidnap trying to reach children in conflict-ridden areas. In one instance in February 2013, female health workers gathered around a health centre in Kano, attending to mothers and their babies, when shots rang out from attackers on motorcycles, killing seven of them.

But they did not give up. Volunteers mounted "Hit-and-run" operations, landing in areas recently freed by the military to drop doses of oral polio vaccine (OPV) in kids’ mouths and then fleeing before the terrorists regrouped. To get to Boko Haram-held territory, undercover vaccinators embedded in villages to distribute vaccines, sending back data with the help of chips hidden in their mobile phones. Soldiers were handed bottles of the vaccine in areas considered too dangerous for civilians. And to reach evasive nomadic tribes, data teams operating out of hubs in Abuja used GIS to map their trails as they walked their cattle.

It looked like all the immense efforts paid off by 2015, and WHO removed Nigeria from the endemic countries list. But in 2016, four cases of wild polio were discovered in displaced persons’ camps in Borno state.

"[2015] was a joyous moment,” said Dr Funsho. "Unfortunately the insurgency put paid to that because we had missed immunizing children for two years in most of Borno.”

More emergency vaccination drives were mounted, targeting under-fives in the camps. In 2018, a fresh round of rumours saying vaccines were infecting children with monkeypox virus shook things up again. But then finally, in 2019, Nigeria was free - with its official status declared one year later, after four years without any new cases.

But health experts like Dr Funsho say it is no time to get carried away.

“Our next major challenge is to keep polio at zero, and to ensure that even if a child comes in contact with an imported virus, the child is sufficiently immunised to be protected,” he said.

But routine vaccinations cost money that may be hard to get from governments and donors, and Nigeria's primary health care system, which should help those in far-off areas readily access vaccines, is underfunded.

Dr Edmund Ogbe, the WHO lead in Bayelsa, a state in southern Nigeria, told Telegraph budgets for regular vaccinations are inadequate in most states.

“I feel sad seeing people jubilate because it will make the work ahead harder. We have not reached our destination yet, but many people will still say 'have we not already eradicated polio? Why are will still immunising if there is no outbreak?'"

Children queuing for the vaccine in 2016  - AP
Children queuing for the vaccine in 2016 - AP

And health workers are still not safe in their work. Earlier this year, a young local government worker attached to Dr Ogbe’s unit in the restive Niger Delta was kidnapped by militiamen on a vaccination trip, and only freed after a ransom was paid by his family.

Then there is the circulating vaccine-derived (cVDPV) polio strain, first discovered in Madagascar in 2001. When a child vaccinated with oral polio vaccine (OPV) passes stool or urine in places with poor sewage facilities, where the sewage can get back into the body system, the weakened virus in the polio vaccine can mutate and become infectious against children who have not been immunised. However, it is rare: two cases were discovered in Nigeria this year and several countries in the region are affected. Globally case numbers are below 800.

Plus, Dr Funsho said, cVDPV polio is less difficult to contain because it only speaks to low vaccination, not a total lack of it. Outbreaks can be put out in less than six months. Rotary is also testing a more stable vaccine that cannot mutate and become infectious.

The focus now is to keep the mass vaccination levels up. Regular vaccine coverage in Nigeria, now at 60 per cent, doubled in the last three years and is expected to be near-total by 2023. The WHO recommends two doses to protect children fully. And to bar possible imports of polio, travellers coming into Nigeria from Pakistan and Afghanistan must be polio-vaccinated.

 Because “as long as there is a case of wild poliovirus anywhere, no child is safe,” said Dr Funsho.

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