Author: Anne McArthur, March 4 2015 - I’ve been working on immunization programs for the past 14 years, including seven years as Immunization Advisor to the Partnership for Reviving Routine Immunization in Northern Nigeria/Maternal Neonatal and Child Health Initiative (PRRINN-MNCH), a DFID [Department for International Development]-Norwegian government funded project.
As part of my Distance Learning Master’s program with the London School of Hygiene and Tropical Medicine, I did a literature review and data analysis on the impact of Polio Eradication Initiative (PEI) activities and routine immunization (RI) in Jigawa, Katsina and Zamfara states, all in Northern Nigeria. Key findings from the study show:
• Nigeria needs sustained high RI coverage to achieve polio eradication, but there has been no long-term improvement in RI since 1999. Poor RI has resulted in continued transmission of pertussis, yearly measles outbreaks and circulating vaccine-derived poliovirus (30 cases in 2014).
• Supplemental Immunization Activities (SIA) can occur up to 11 times a year and interrupt RI and primary health care (PHC) services.
• The use of incentives for PEI activities is widespread and health workers’ could prioritize incentivized activities over other health priorities.
• Use of community health workers helps to expand acceptance of polio vaccination and is now being used to promote RI and other health issues.
• Nigeria has been refocusing its efforts on routine immunization and with the introduction of Inactivated Polio Vaccine (IPV) there is an opportunity to assess and address challenges to RI delivery in the country.
For the interest of CI readers, this blog will concentrate on the community engagement findings.
The full thesis is linked below.
Nigeria is at a historic point in its polio eradication effort with only six reported cases in 2014. Polio Eradication Initiative (PEI) efforts have largely been focused on the northern states of Nigeria where polio transmission has been highest, the health system is weak and immunization coverage is poor. After 18 years of PEI activities, however, there has not been an associated increase in routine immunization (RI) coverage as had originally been the mandate of the Global Polio Eradication Initiative. 
Polio and community engagement in Jigawa, Katsina and Zamfara states
Resistance to polio vaccination in Northern Nigeria occurs in poor and marginalized communities and the needs of those communities have been historically overlooked by government health initiatives and services. Polio and other campaigns are viewed with suspicion when local priorities and specific community needs are not addressed, which in turn can lead to vaccine refusal.
The 2003-2004 polio vaccination boycott in Northern Nigeria was largely due to community suspicion, top-down programming and distrust in the government. Following the boycott, PEI increased its focus on community needs and to engage community, traditional and religious leaders in their communication and outreach activities.
To address the community health needs beyond polio, Immunization Plus Days (IPD) were developed to meet some of the communities’ demands for better health care. Vitamin A, antihelmintics and other medical commodities (including bednets) were added to polio campaigns and this was accepted and appreciated by communities. But if there were no “pluses” (either due to lack of budget or insufficient stock), people often refused vaccination.
The polio program also worked more at the community level. Community engagement workers have helped to improve trust among parents and their role has expanded to include information on RI and other health issues; to answer questions; to track missed children and to participate in active surveillance. PRRINN-MNCH had similar results working with community health workers on immunization awareness, increasing standing permission for mothers to vaccinate children and learning the warning signs of an unsafe pregnancy.
A PRRINN-MNCH study in 2013  found that, despite the gains, there is still resistance, distrust and campaign fatigue among communities in Northern Nigeria, but while there may be lingering distrust they are supportive of routine immunization. Providing regular RI and PHC services is essential to gaining and maintaining community trust.
This thesis shows the importance of understanding the concerns of communities targeted by health programs and the importance of building programs that better serve the needs of those communities. We need to focus on the community and recognize that “one size does not fit” all when planning and implementing health interventions.
The widespread use of community engagement workers by PEI has improved trust, demand for and use of health services. The community infrastructure established during PEI activities could be part of polio’s legacy in Northern Nigeria. The retention of community engagement workers after PEI would add an important resource to improve access to services and understanding of community health needs and perceptions. However, these community engagement workers are largely donor supported and they have received incentives during PEI. Because of the precedent set by PEI incentives, post-PEI funding for these community engagement workers is in doubt.
It is also crucial to recognize that when community demand for services has been built, quality health services and sufficient vaccines must be available to meet their demands. Regaining community trust requires a commitment to improving overall health services to ensure they are available to all members of a community.
Polio eradication requires a commitment from GPEI [Global Polio Eradication Initiative] partners and governments to strengthen and support routine immunization, especially in countries with weak health systems and low levels of community trust. Without a strong RI system, not only will there be a risk of polio returning, but communities will continue to suffer from vaccine preventable diseases and will not benefit from the new vaccines being introduced and we once again risk losing their trust.
Finally, GPEI’s experience in Nigeria can provide important lessons to other disease initiatives, including:
• Community engagement is important in different cultural and political environments and strategies must be adapted to meet community needs and address their concerns;
• Vertical programming can divert priorities away from a countries health agenda.
• Incentives can motivate health workers, but they also deter them from routine services and impact volunteerism; and
• Vertical programs have an impact on health worker time and health system effectiveness.
We must ask ourselves this question: What can immunization programs learn from PEI and what can we do to ensure that routine immunization is sustainable and continues to reach all children and ensure the trust and confidence of communities?
Anne McArthur, email: firstname.lastname@example.org
1. McArthur A. Assessing the impact of Polio Eradication Initiative activities in Jigawa, Katsina and Zamfara States, Nigeria. London School of Hygiene and Tropical Medicine Distance Learning Project. September 2014.
2. World Health Assembly. Global eradication of poliomyelitis by the year 2000. In: 41st World Health Assembly WHA41.28; 1988 2-13 May; Geneva.
3. Adegoke O, McArthur A, Onipe Y, Umar C. Survey on the Impact of the Polio Eradication Initiative on Routine Immunization and Primary Health Care Services. Kano: PRRINN-MNCH; 2014.