Jail threat for polio vaccination refuseniks

Authorities in Kano, Nigeria, recently announced people would be jailed or fined for refusing to immunize their children against polio, as cases increase in the northern state, but it is unclear whether this approach is working.



Nigeria, one of four countries that remain polio-endemic, has historically been “a global epicentre of transmission”, according to Oliver Rosenbauer, spokesman for the World Health Organization’s polio eradication group. Twenty-four polio cases were reported in Nigeria between 1 January and 27 July 2011, compared to six during the same period last year.



Kano authorities put parents on notice as health workers on 28 July launched a four-day

immunization drive targeting six million children in the state.



Prosecutions for refusing polio vaccination would be under an existing law forbidding parents from barring access to health care for their children; the law has been extended to cover immunizations from deadly diseases, according to Tajuddeen Gambo, permanent secretary of Kano State’s health ministry. Health workers who fail to report refusals, or who falsify data about coverage, would also be prosecuted, Gambo said.



“The surge in polio cases is due partly to lingering resistance of parents in giving their children the polio vaccine,” said Danjuma Al-Mustapha, a monitoring and evaluation officer with the UN Children’s Fund (UNICEF) in northern Nigeria.



Kano State immunization coordinator Abdurrahman Yakubu said in the recent immunization round “fear of arrest and prosecution” had drastically reduced refusals. He said three parents who initially refused relented after being taken to the police.



But Mohammed Zango, Kano State coordinator of Journalists Against Polio, said there was no change in the number of refusals. "We have recorded over 200 cases of rejection.”



Gambo said official figures do not yet exist. He said a list of children missed in the recent round was still being compiled, and the reasons they were missed were not yet clear.



Not the main problem



WHO’s Rosenbauer said vaccination refusals are “not the only problem and not the main problem” in fighting polio.



In 2008 up to 50 percent of children were missed in eradication campaigns in Nigeria “due to poor operational planning”, he said, pointing to lack of resources, problems with cold chain storage of the vaccines, and people simply being missed by health workers.



Rosenbauer said gains had been made since then through engagement of local leadership and pre-immunization community meetings. Polio cases dropped 95 percent in Nigeria from 2009 to 2010, and despite the current spike in cases the situation is still better than a few years ago. Rosenbauer said these days 5-20 percent of children were usually missed in vaccine drives, varying by region, and that gaps “need to be urgently addressed”.













Towards eradication
Polio spread from Nigeria to 20 other African countries from 2006 to 2010, according to the July 2011 report of the Independent Monitoring Board of the Global Polio Eradication Initiative (GPEI). The report pointed to Kano in particular as a “major worry” with “low routine immunization coverage”.



Globally, polio cases dropped 99 percent between 1988 (when the GPEI was founded) and 2000, from an estimated 350,000 cases. But the last 1 percent is proving the hardest and progress has halted in the past decade.

The other three endemic countries are Afghanistan, India and Pakistan. In 1988 polio was endemic in more than 125 countries.

In 2003 polio immunization programmes were suspended in Kano for over a year after religious leaders told people the vaccine could cause infertility, HIV and cancer.



Attitudes evolving



While resistance persists, for some attitudes have evolved. Aminuddeen Abubakar, a Muslim cleric in Kano, said he opposed polio vaccinations in the past due to “genuine fear”, but now he had changed his mind. “In fact, with the proof that [polio] vaccine is safe for children, it is a religious and moral obligation of clerics to support and facilitate polio immunization.”



Lawal Hamisu, a father in Kano, said: “I believed the claim that polio vaccine was harmful to children and I would not allow my three under-five children to be immunized… I was lucky none of my children got infected.”



Kabiru Maishanu’s son has been diagnosed with polio. “I feel guilty for my child’s deformity, [I refused] polio immunization due to the claim that polio vaccine could harm children. I chased away vaccinators whenever they came to my house.”



Health workers say refusals now tend to be a reaction against what people see as skewed government priorities.



"Resistance is a result of social frustration created by lack of basic amenities, especially lack of health care facilities in public hospitals,” UNICEF’s Al-Mustapha said. “Parents are frustrated by government insistence they immunize their children against polio while drugs for more rampant diseases like malaria and cholera are lacking in public hospitals.”



Yakubu said some people also used immunizations as “blackmail”. “They insist on being provided with some amenities like water, fertilizer and clinics in return for allowing their children to be immunized.”



A legal approach to immunization campaigns is not new. Parents in other parts of Nigeria have previously been fined or arrested under existing laws for refusing vaccinations for their children, said Emmanuel Abanida, who works within the Health Ministry for polio eradication.



Kwara State and Niger State have laws specific to immunization, and parents who do not allow their children to be vaccinated against deadly diseases can face fines and imprisonment, Abanida said.



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