The polio vaccine boycotts in Nigeria

Poliomyelitis, or polio, is an acute viral infectious disease. While around 90 to 95% of polio infections cause no symptoms, in about 1 to 3% of cases the virus enters the central nervous system, infecting and destroying motor neurons [1]. Depending on the nerves involved, different types of paralysis can occur. Polio is highly contagious and spreads easily by human-to-human contact, most commonly via the fecal-oral route (i.e. ingesting contaminated food or water). It mainly affects children under the age of five, and if contracted, can cause a person to be disabled for life [2].

Although there is no cure for polio, vaccines have been developed to prevent it. There are two types of vaccines, one administered by injection, and one taken orally. In the WHO’s global polio eradication efforts, the oral polio vaccine (OPV) is used because it is inexpensive and easier to administer. It is estimated that polio eradication will prevent 855,000 deaths, 4 million cases of paralysis, and 40 million disability-adjusted life-years (DALYs) during the period from 1970 to 2050 [3].

To date, about 10 billion doses of the vaccine have been administered [4]. It is estimated that eradication efforts, started in 1988, have reduced the number of annual diagnosed cases of polio by 99%--from about 350,000 cases in 1988 to about 1,300 cases in 2007 [5]. As of 2008, however, polio still remains endemic in four countries: Afghanistan, India, Pakistan, and Nigeria [6]. Nigeria is an area of major concern, as 82% of global cases of polio reported have been within the country [7].

In 1996, President Nelson Mandela and 45 other heads of state in South Africa launched the Kick Polio Out of Africa campaign, leading every country to have introduced key eradication strategies by the year 2000 [8]. It was reported that the number of cases of polio in Nigeria had decreased from about 990 in 2000 to 300 in 2002 [9]. However, in mid-2003, eradication efforts were derailed when several communities decided to postpone vaccinations. In the largely Muslim northern part of the country, states such as Zamfara, Kaduna and Kano refused to take part in the immunization drive.

A Muslim organization, the Supreme Council for Sharia, claimed that it had evidence to show that the vaccine was unsafe [10]. The President of the Supreme Council, Dr. Datti Ahmed, stated that “there were strong reasons to believe that the polio immunization vaccines was contaminated with anti-fertility drugs, contaminated with certain viruses that cause HIV/AIDS, contaminated with Simian virus that are likely to cause cancer” [11]. Some even went as far to say that the vaccine was a Western plot to make Muslim women infertile; they claimed that the immunization campaign was part of a U.S. plot to depopulate Muslims [12]. Kano state’s Governor Ibrahim Shekarau said that it was “a lesser of two evils to sacrifice two, three, four, five, even 10 children [to polio] than allow hundreds of thousands or possibly millions of girl-children likely to be rendered infertile” [13]. The Council asked the Nigerian government to suspend the immunization program and to have the vaccines checked for safety.

The tests initiated by the Nigerian federal government and the South African federal government concluded that the vaccines were free of harmful substances; despite these findings, Muslim groups rejected the results. Kano state officials said that their own scientists tested the vaccines and found trace amounts of estrogen and progesterone, which they feared would cause infertility. Another influential Muslim group, Jama’atu Nasril Islam, said that it sponsored its own tests in Britain and India, and got similar results. Such test results may have been false positives, which arise from improper testing methods or the mixing of foreign materials during testing. Even so, the WHO has said, the hormones found at the levels indicated by the Muslim scientists were of “absolutely no health consequence” and amounted to even less than the amount found naturally in mothers’ breast milk. [14]

Eventually, it came down to negotiation. The Nigerian federal government and religious leaders met in conjunction with the WHO and UNICEF to reach a solution. In early 2004 it was decided to test the vaccine independently in other Muslim countries. Both state and religious representatives were sent to South Africa, Indonesia, and India to observe vaccine testing and to bring back the results. The Kano state team returned with approved test results from the Indonesian company Biopharma. In mid-2004, vaccination was resumed in Nigeria. [15]

The concern for the safety of the polio vaccine is understandable. In 1 case per 750,000 vaccine recipients, the virus in OPV does cause paralysis in the patient [16]. But indications that the vaccine caused infertility, HIV/AIDS, or cancer were largely unfounded. The short span of 11 months during which immunization efforts were postponed due to the boycott had great implications. In the wake of the allegations against the polio vaccine, the disease continued to spread. The virus not only spread within Nigeria, but into 20 other previously polio-free countries as well over the period of 2003 to 2006 [17]. This resulted in over a third of the world’s cases of polio in 2004 being the result of the vaccine boycott in Nigeria [14]. And it goes without saying that eradication efforts were set back significantly.

“Since September 11, the Muslim world is beginning to be suspicious of any move from the Western world,” a spokesperson for Governor Shekarau had said in defense of Kano’s resistance against the vaccine. Actually, Kano’s concerns with vaccine initiatives have existed since 1996, when the state accused Pfizer Inc. of using an experimental meningitis drug on patients without fully informing them of the risks, causing at least 20 Nigerians to become disabled. “So many families won’t go to hospitals again. They prefer to die,” said Zubairu Shaba, who lobbied the Nigerian government for compensation on behalf of Pfizer patients. Sentiments such as these, derived from historical distrust of Western medicine, further escalated when Dr. Ahmed spoke out against the polio vaccines and said they were “corrupted and tainted by evildoers from America and their Western allies.” [14]

The boycott should also be considered in its socio-political context. At the time, Nigeria’s transition from a northern-led military regime to a southern-led democracy contributed to political tensions between the two factions. The religious leaders in the northern states may have felt that the southern-led government was acting in the interest of Western powers [15].

After immunization efforts were resumed, the Nigerian government launched large-scale rounds of emergency polio vaccine administration in the north. Despite their efforts, the number of cases of polio in the country has gone up from 175 cases in 2007 to 612 cases in 2008 [18]. This can probably be attributed to low immunization coverage in the affected areas, with more than 20% of children remaining unvaccinated, as well as limited acceptance of the vaccine due to lingering suspicions.

With this increase in virus transmission in 2008, it is even more urgent that Nigeria bring their polio situation under control. There are a number of suggestions to ensure future success in the fight against polio. First is that uptake of the vaccination does not only depend on provision of services, but also on the knowledge and attitude of the mothers of children who should be receiving the vaccine [19]. Second, there should also be careful global surveillance of refugee children, whose migrant lifestyle makes them naturally more difficult to systematically track down and vaccinate. This may help reduce the gaps in immunization that, when untreated, inevitably lead to an increase in the number of outbreaks.

Most importantly, as evidenced by the Nigeria boycott, a partnership and trust needs to be cultivated not just between participating national governments and the NGO’s and global governance system, but also with the leaders of communities. Dr. Bruce Aylward and Dr. David Heymann of the WHO Polio Eradication Initiative suggest that the success of the newly-intensified polio vaccination effort in Africa will strongly depend on direct oversight by all political, traditional, religious, and community leaders in each area to ensure that every child is reached.

References
1. “Polio - A devastating disease.” VaccinePlace.com. 16 May 2008. Sanofi Pasteur Inc. 4 Feb. 2009.

2. “Poliomyelitis.” Jan. 2008. World Health Organization. 5 Feb. 2009.

3. Krym, Valerie F., and Russell D. MacDonald. “Global efforts to eradicate polio.” Canadian Medical Association Journal 170 (2004): 189-90.

4. Lahariya, Chandrakant. “Global eradication of polio: the case for ‘finishing the job.’” Bulletin of the World Health Organization 85 (2007): 487-492.

5. “Succes in global polio eradication hinges on four countries and $440 million.” UN News Center 13 Oct. 2006. United Nations. 5 Feb. 2009 http://www.un.org/apps/news/story.asp?NewsID=20248&Cr=polio&Cr1=.

6. Wakabi, Wairagala. “Opponents stymie fight against polio in Nigeria.” Canadian Medical Association Journal 179 (2008): 891.

7. “Vaccine ‘could end Nigeria polio’” BBC News 16 Oct. 2008. 6 Feb. 2009 http://news.bbc.co.uk/2/hi/health/7671070.stm.

8. Aylward, R. B., and David L. Heymann. “Can we capitalize on the virtues of vaccines? Insights from the Polio Eradication Initiative.” American Journal of Public Health 95 (2005): 773-777.

9. “Progress toward poliomyelitis eradication --- Nigeria, January 2000 – March, 2002.” Centers for Disease Control 51 (2002): 479-481.

10. Raufu, Abiodun. “Nigeria postpones programme of polio immunisation.” BMJ.com News 29 May 2004.

11. Chen, Cecilia. “Rebellion against the polio vaccine in Nigeria: implications for humanitarian policy.” African Health Sciences 4 (2004): 205-207.

12. Associated Press. “Nigerian state balks at polio campaign.” 21 Mar. 2004. Global Health Council. 5 Feb. 2009 http://www.globalhealth.org/news/article/4288.

13. “Polio boycott is ‘unforgivable’” BBC News 26 Feb. 2004. 5 Feb. 2009 <>.

14. Associated Press. “Vaccine boycott spreads to polio.” News24.com 2 Nov. 2004. 5 Feb. 2009 http://www.news24.com/News24/Africa/Features/0,,2-11-37_1481952,00.html.

15. Clark, Sarah. “What led to the Nigerian boycott of the polio vaccination campaign?” Bio-Medicine 19 Mar. 2007. 5 Feb. 2009.

16. “Rationale for OPV Cessation.” Global Polio Eradication Initiative. World Health Organization. 5 Feb. 2009.

17. “Progress toward poliomyelitis eradication --- Nigeria, January 2007 – August 12, 2008.” Centers for Disease Control 57 (2008): 942-946.

18. Desai, Shalini; Pelletier, Louise; Garner, Michael and John Spika. “Increase in poliomyelitis cases in Nigeria.” Canadian Medical Association Journal 179 (2008): 930.

19. Odusanya, Olumuyiwa O.; Alufohai, Ewan F.; Meurice, Francois P. and Vincent I. Ahonkhai. “Determinants of vaccination coverage in rural Nigeria.” BioMedical Central 8 (2008): 381-890.