Women at the Centre of Polio Elimination Efforts in Nigeria

By Treezer Michelle Atieno

It is a Thursday morning, and Nafii Ibrahim is expecting a group of women at Kumbotso Local Government Hospital in Kano for training on how to administer polio vaccines in the community.?

The women begin to arrive and settle in the hall. Nafii, the World Health Organization Coordinator of the hospital, is familiar with activities like this.

"After a series of trainings, these women will join our list of Volunteer Community Mobilizers (VMCs) and be assigned to different areas for routine polio vaccination and general health surveillance in the community," says Nafii.

Kano, located in Northern Nigeria, is one of the 36 states in the country. The state has 44 Local Government Areas (LGAs), 484 wards, and 27,233 settlements. Kano was a major source of Wild Polio Virus (WPV) cases in Nigeria until 2015. In 2009, the state reported 168 WPV cases out of the 388 reported nationally.?

From 2010 to 2015, a total of 65 confirmed WPV cases were reported in Kano State. Almost half of these cases were reported in 2012. The number of reported cases fell to 15 in 2013 and further decreased to 5 in 2014. No new WPV cases have been detected in Kano since 2015.?

However, in 2021, circulating Vaccine-Derived Poliovirus 2 (cVDPV2) was detected in 18 states in Nigeria, including Kano, where four children had already been confirmed paralyzed by the disease. The first confirmed case of cVDPV2 in 2021 in Kano was a 63-month-old boy from Albasu LGA.

To interrupt the transmission of cVDPV2, the National Primary Health Care Development Agency (NPHCDA) is taking the lead in efforts to eliminate all forms of poliovirus.?

This initiative is being supported by the World Health Organization (WHO) and partners of the Global Polio Eradication Initiative (GPEI).?

The aim is to strengthen immunization coverage by using both the fractional Inactivated Polio Vaccine (fIPV) vaccine and the novel oral polio vaccine type 2 (nOPV2). These efforts are specifically targeting 13 high-risk and security-compromised states, including Kano. To achieve this, VMCs and women in different other sectors in polio eradication are important.

Women are considered the backbone of global immunization efforts due to their strength in supporting their community. They overcome gender discrimination, stigma, and even violence to protect children against vaccine-preventable diseases. In Nigeria, women are at the heart of polio immunization efforts.

According to Sa'adat Ibrahim, the State Immunization Officer of Kano state, all the VCMs in Kano are female residents of the communities where they work.?

"The VCMs are selected by the Ward Development Committee (WDC) based on age, character, and other requirements. They are highly respected and possess knowledge of the community's culture. Additionally, they are fluent in the local language and have some reading and writing skills," says Sa'adat.

Suleiman Issa, a member of the WDC in Chirin ward, explains why these requirements are important. "As part of the team responsible for selecting VCMs, we look for someone who is above 18 and has good interpersonal communication skills."

After the selection process, the VCMs undergo up to two weeks of training. "We train them on various topics such as the importance of the Polio Eradication Initiative (PEI), routine immunization, Acute Flaccid Paralysis (AFP) surveillance, social mobilization and community engagement, the use of behavior change communication tools, and interpersonal communication skills," says Nafii.

"Normally, one VCM is assigned to a single community, although in certain cases, two VCMs may be assigned based on unique qualities or the size of the population. Each VCM is responsible for approximately 150 to 300 households within her community," says Sa'adat.

During scheduled routine immunization days, the vaccines are transported in cold boxes from the LGA hospitals to the ward hospitals, where they are distributed to the VCMs.

"If the daily vaccine implementation plan requires VCMs to vaccinate 300 children, they are each given 300 doses of the vaccine carriers, and it is their responsibility to confirm the potency of all the vaccines before embarking on the vaccination activities," says Nafii.

Hadira Bello is a VCM in charge of Maidinawa village, Kumbotso LGA, and this is her fourth year doing this work.

"As a VCM, I am responsible for mobilizing households for polio and routine immunization. Through a community-friendly approach, I identify and report issues related to chronically missed children and non-compliant parents. Using flip charts, I also carry out door-to-door vaccination activities, providing interpersonal counseling on immunization and promoting key household practices, such as the treatment of diarrhea, prevention of malaria, and breastfeeding."

At birth, VCMs also mobilize mothers and caregivers of newborns to ensure that they bring their babies to receive the Oral Polio Vaccine (OPV) within the first few critical days of life. Sometimes, VCMs have to travel a long way to reach the children.

"We ensure that no child is missed by taking vaccines to hard-to-reach and nomadic settlements. Some of these communities are extremely remote, requiring us to cross rivers or travel long distances on bikes or by foot to reach the children," says Hadira.

The job of the VCMs is not full-time. On regular days, VCMs work a minimum of three 8-hour days (or 24 hours per week), although many work longer hours during periods of increased activity.

"During immunization campaigns or microplanning, we work throughout the week to ensure that immunization messages and vaccines reach every child," says Hadira. "As for payment, we receive stipends of about $30 per month, as well as non-monetary incentives such as training opportunities, umbrellas, bags, and a uniform."

While the VCMs are important in polio vaccination, they do not work alone during vaccination. They must be paired with an independent vaccine supervisor to ensure that all vaccines are administered to the children and to minimize wastage.

The directly observed polio vaccination strategy has improved the uptake of polio vaccines and population immunity in high-risk areas for polio transmission in the north.

Fatima Abdul from Rimin Gado local government area in Kano has been a polio vaccine supervisor since May 2014. Independent vaccine supervisors are selected from reputable partner civil society organizations, and Fatima is a member of the Muslim Women Association in Nigeria (FOMWAN).

FOMWAN is the umbrella body of all Muslim associations in Nigeria and has been in existence for over 40 years, with branches in 600 local government areas in Nigeria.

"Each morning, the Ward Focal Person assigns a number of vaccines to each Volunteer Community Mobilizer (VCM), and each VCM is responsible for administering all assigned doses. As an independent supervisor, my role is to walk with the VCMs door-to-door and confirm that they are indeed vaccinating children and not wasting the vaccines," says Fatima.

According to Fatima, convincing non-compliant households can be a challenge and can take up to an hour. To address this hurdle, some VCMs simply pour out the vaccines and mark the houses as fully vaccinated.

There are instances where non-compliant households cooperate with the VCMs and have the hands of the children marked without being vaccinated.

"There was a time when we went to a community in Rano LGA. The VCMs had arrived a few minutes before me, and when I caught up with them, they claimed to have already visited and administered vaccines to three households. However, when the traditional leader approached us, he stated that nobody in the LGA would be vaccinated until certain political issues were resolved. This prompted me to check the vaccines of each VCM, and to my shock, they were still intact!" Fatima recounts an instance that nearly resulted in skipping an entire village during the vaccination process.

The role of an independent supervisor is not limited to merely witnessing the vaccination of children; they are also responsible for monitoring the practices employed by the VMCs. They also provide alternatives to finger marking in cases where one parent opposes the vaccination.

For instance, if the mother prefers the child to be vaccinated in secret, the supervisor can mark the toe instead of the finger, or refrain from marking altogether. In such cases, the supervisor will indicate in the report that the vaccination has taken place.

To ensure the integrity of the supervisors, they are assigned to different teams each day, sometimes even rotating between two teams in a single day.

Despite the challenges of navigating unfamiliar areas, Fatima expresses her satisfaction at being involved in polio vaccination campaigns in Kano.

Aisha Ahmed, the Zonal Coordinator of FOMWAN in Northern Nigeria, explains that the organization has been actively engaged in polio eradication since 2012.

In addition to providing vaccine supervisors, FOMWAN organizes door-to-door campaigns, community discussions, market campaigns, and even sponsors radio programs in northern states to increase awareness about the polio virus and the importance of vaccines.

Aisha mentions that they also collaborate closely with the Ulama (Muslim Scholars) to dispel the misconception that the vaccine contains birth control elements. As a VCM, Hadira is partnered with a village head who fulfills both traditional and religious leadership roles to address issues of vaccine non-compliance.

In Kano, women must seek permission from their husbands and heed the opinions of traditional and religious leaders regarding the use of vaccines for their children. If non-compliance persists even after involvement from the village heads, the State Immunization Officer notifies the NPHCDA. Then, an officer is dispatched from the National Polio Emergency Operations Centre (EOC) in Abuja to collaborate with the traditional and religious leaders.

Eunice Damisa is currently the Traditional & Religious Leaders Engagement Consultant at NPHCDA, working in the polio EOC in Abuja. She has been working in polio eradication for over 22 years, has over 14 published research papers on engagement of traditional and religious leaders in polio eradication and was part of the team that developed the strategy for Formal Systematic Engagement of Traditional Religious Leaders in Northern Nigeria in 2009.

"I joined polio eradication work in 2001 as a community engagement and behavior change specialist at NPHCDA. After several years, I rose to the position of Deputy Incident Manager then I became the Director of Advocacy and Communication at NPHCDA before starting my current role," says Eunice.

"When reports of non-compliance come in at the EOC, I help in mapping out traditional and religious leaders who are anti polio vaccine in the reported area. Then I approach them with facts about polio, such as the importance of vaccination and the global use of the vaccine," adds Eunice.

Once the traditional leader is convinced, they send a message to their community to accept the vaccine. At this point, the VCMs and their teams can resume the vaccination process. However, there are instances where the compliance message is rejected by the people. In such cases, Eunice accompanies the traditional leader and visits the villages to have conversations with the community members to fully resolve the non-compliance issue.?

Initially, men were the primary polio workers. However, it quickly became evident that they were unable to reach children under the age of five because they were not permitted to enter homes according to cultural norms in Northern Nigeria.

The involvement of women in polio eradication has proven to be the key solution to various challenges, including the widespread rejection of the oral polio vaccine, high levels of non-compliance, child absenteeism during immunization campaigns, a significant number of missed children and a high rate of immunization dropouts. By going door-to-door, women are able to reach populations that were previously overlooked.

These women play a crucial role in tracking and resolving routine immunization dropouts, non-compliant families and defaulters as well as strengthening surveillance for Acute Flaccid Paralysis (AFP). Sa'adat affirms, "Without the critical participation of women as vaccinators, surveillance officers, and social mobilizers, Nigeria would not have made such significant progress in the eradication of polio."?

In October 2003, the governors of Kano, Kaduna, and Zamfara states in northern Nigeria decided to suspend polio vaccination until the vaccines were investigated and proven safe. They succumbed to rumours and suspicions that had been circulating for several years, resulting in widespread rejection of polio vaccination among the people in the north.

"The notion that polio vaccines were contaminated was initially propagated by some Islamic preachers. These claims gained credibility when they were endorsed by the self-proclaimed Supreme Council for Shari'ah in Nigeria (SCSN), led by physician and one-time presidential aspirant Datti Ahmed," says Dr. Ndeayo Lwot, the Coordinating Consultant for Development of Social Care Health Quality Assurance at the National Citizen Centre in Abuja, Nigeria, and former Director of Primary Healthcare Development Agency? in Nigeria.

"In response to this, the federal government ordered tests to determine the safety of the vaccines. Similarly, Kano, Kaduna, and Zamfara states conducted their own separate investigations. Tests carried out at the National Hospital Abuja and a laboratory in South Africa, as requested by the federal government, proved that the vaccines were free of any suspected chemical and biological agents. However, the Kano state government claimed that their tests revealed the presence of estrogen levels in the vaccines that could potentially lower fertility in women."

Meanwhile, despite polio being eradicated in almost all of Nigeria except for Kano state, the last known reservoir, it had resurfaced.

"Nine years later, in 2012, the government of Nigeria, through then Nigerian Health Minister C.O. Chukwu, decided to involve more women as leaders in polio eradication, VCMs, and women led CSOs like Muslim religious leaders and the Federation of Muslim Women Association in Nigeria (FOMWAN),"?

Despite their significant contributions to polio eradication in Nigeria, women hold only 25% of leadership positions in the health sector, which has impacted health efforts, including immunization.

In Nigeria, women face a 'glass ceiling' when it comes to reaching the most senior roles. While approximately one third of leadership positions in health organizations are held by women, the same cannot be said for national ministers or commissioners, where only 5 out of 30 are women, or for Directors of Federal Medical Centers, where only 1 out of 28 are women. This significant gender disparity in higher-level positions has resulted in poor treatment of women in polio vaccination.

To address gender barriers to immunization, the Global Polio Eradication Initiative (GPEI) launched its comprehensive Gender Equality Strategy in 2022. The strategy aims to address gender-related obstacles to immunization and improve the representation of women at all levels of the polio program.

This includes focusing on recruiting and training women for frontline eradication efforts, promoting a gender-responsive organizational culture, increasing ownership and accountability, ensuring a safe work environment, enhancing data collection and analysis, fostering partnerships, and allocating financial resources.

The program seeks to involve women more actively while considering their specific needs and profiles, recognizing their crucial role in the delivery of polio vaccines.