This past summer the World Health Organization (WHO) announced a dire reality – polio is making a comeback. Despite the WHO’s 1988 Global Polio Eradication Initiative to eradicate poliomyelitis in the world by 2006, the northern states of Nigeria have recently experienced a relatively large polio outbreak. Polio infection rates have skyrocketed nearly 800% in 2009 when compared to the same time period in 2008.

The cause of these reinfection rates are attributable to two things: 1) a rare case of faulty vaccine and 2) local rumors. The vaccines used in Nigeria are weakened versions of the polio virus and can spread from person to person.

This isn’t necessarily that dangerous unless the infectee in not immunized. If a child has not received a vaccine, this virus can mutate into a more dangerous strain and cause a massive outbreak. This wouldn’t be so much a problem if everybody had received a vaccine – but they haven’t. And it is the presence of local misconceptions that are associated with low immunization rates.

Cited: Diplomacy and the Polio Immunization Boycott in Northern Nigeria

This is not to say the WHO has been unsuccessful in eradicating polio in other parts of the world. Back in 1988, polio was endemic in more than 125 countries and spreading at a rate of nearly 1000 infections per day. This outbreak, however, signifies that discrepancies in available medications can lead to unanticipated outbreaks in countries that cannot afford safer vaccinations.

Additionally, this current outbreak harkens back to a time in Nigeria when immunization efforts were suspended in 2003 - consequently leading to a small polio outbreak. That time, the small ‘blip’ was important because it signified that new technologies and advancements in health care were not strong enough to trump local myths and perceptions about vaccines.

In this discussion we will look at the local perceptions of vaccines in Nigeria and also broaden our scope to other unique outlooks in the non-Westernized world. We will continue to analyze why these rumors dismantle modern eradication efforts and how intervention efforts have been and can be tailored to work alongside these rumors, rather than clash with them.

Epidemiological History of Polio in Nigeria

Since the late 20th century, Nigeria has been one of the few countries to suffer from cases of polio. In 2003, the immunization program was shut down because safety questions about the polio vaccine arose. This arrest led to a new outbreak of polio. The virus reinfected polio-free areas within Nigeria, and also spread into eight polio-free countries in the surrounding area.  2004 – The Minister of Health in Nigeria publically committed to bolstering immunization initiatives in hopes to eradicate malaria by signing the Geneva Declaration for the Eradication of Poliomyelitis. Impressively, that year on July 31, polio campaigns resumed in Northern Nigeria after a 12 month hiatus. Nigeria was able to hold the infection rate relatively steady between 2004 and 2006 but since then has allowed it to grow out of control.

Nigeria, along with several other poor nations, uses an oral polio vaccine (OPV) as the standard immunization procedure because it’s more affordable, more accessible, and can protect entire villages. This OPV, though, is made from a weakened version of the polio virus which carries risk in itself. Wealthier nations can afford another version of the vaccine which is given intravenously rather than orally. This inferior version of the  virus may cause polio in .000001% of immunizations or, in a worse-case-scenario, mutate into a more lethal version of polio.

Since May 2006, “Immunization Plus Days” (IPDs) have been implemented as to improve eradication efforts. These days offer substantially beneficial health interventions to increase the uptake of OPVs. Studies have shown that quality of these IPDs have made significant improvements in the uptake of OPVs over time. For example, the number of ‘missed children’ in the latest IPD in 2006 was only 12% whereas the first IPD effort was noted at 40%.

Local Perceptions

In 2003, the Nigerian government responded to community pressures by arresting all polio eradication efforts. Both socio-political and cultural beliefs lent to a unfavorable perception of the vaccine. On the most basic level, there was speculation that the polio vaccine was contaminated with antifertility drugs so that young Muslim girls would be unable to reproduce.

Politics was involved within this speculation as a result of the recent elections. In the April 2003 election, a southern Baptist General, Olusegun Obasanjo, was reelected as president and defeated a northern Muslim General, Muhammadu Buhari. In addition, the poorer quality health outcomes in the North aggravated tensions between these geographical and religious groups.

In July of 2003, a northern umbrella group of Muslim organizations called the Jama’atul Nasril Islam (JNI) called for a suspension of the use of OPVs. This suspension was fueled by a memo from one of the Muslim Emirs who said his people were concerned that the vaccine was ‘being used for the purpose of depopulating developing countries, and especially Muslim countries.’ The US ambassador at the time perceived this announcement as a reflection of overall dissatisfaction of Northern Nigeria, especially from the largely Muslim state of Kano, with the current Obsanjo government, which then attached itself to the idea that these immunizations were to blame – almost like a scapegoat.

Although UNICEF and other organizations thought this rumor would be easy to dismiss - they were proven wrong. The rumor itself was viral. At this point in time, the six remaining polio-endemic countries (Nigeria, Niger, Egypt, India, Pakistan, and Afghanistan) all harbored significant numbers of Muslims. Now it is easy to trace how this epidemic of 2003 spread so voraciously. 1) Existing health disparities in Northern Nigeria, exacerbated by a northern loss in the presidential elections spurred rumors made the northerners feel disposed and targeted 2) Rumors arose to substantiate the feeling of dissatisfaction and give a face to the blame. 3) Since the northern regions of Nigeria were majority Muslim, it therefore became a ‘Muslim’ problem and 4) the associative rule that since “I am being targeted with contaminative vaccine and I live in Northern Nigeria” and “I live in Northern Nigeria and am Muslim,” thus forth ”If I am Muslim, I could be targeted with a contaminated vaccine’ regardless of the country one lives in.

These rumors circulated through the region until the Global Polio Eradication Initiative (GPEI), the OIC secretariat and the regional director for WHO convinced religious leaders to speak out on issues of polio eradication. Fatwas, Islamic religious rulings, were issued to speak about polio vaccines in general. It wasn’t until there fatwas were issued when rumors about a Western plot to wipe out Muslims began to dispel.

Furthermore, these fears were brought to the public consciousness when a respected doctor, Dr. Datti Ahmed, claimed suspicion that the vaccine was contaminated with HIV/AIDS virus, anti fertility-substances, and other dangerous elements. These suspicions were more so caused by a cultural misperception than a political one. If local populations are given a poor understanding of the vaccine itself and the kinds of disease it prevents, then they can create unrealistic expectations of this vaccine.

For example, vague health messages can lead to local mothers to believe that “vaccines are good for the health of the child” and that “vaccines protect against serious illness.” But that’s about it. If a child were vaccinated with the polio vaccine and fell ill with malaria, the mother might be convinced that the vaccine did not do its job because the child still got sick. This misunderstanding is not necessarily the fault of the mother but a symptom of the reality of IPDs. Often, healthcare personnel are only able to give a quick explanation of the vaccine’s intentions and are not there to address concerns after the vaccination period.

With this in mind, it’s a bit easier to see how people can misattribute disease symptoms as a cause of the vaccination. In Nigeria, the HIV/AIDS infection rate is relatively sizeable and the infant mortality rate is one of the highest in the world. When the common expectation (while ill-conceived) is that vaccines protect against all diseases, including ones they are not meant to prevent – expectations are highly overinflated. Additionally, vaccines are sometime perceived to promote growth and increase a child’s weight. When a child gets sick or fails to grow, the perception is that these vaccines are ineffective and thus, rumors are spawned after crushed expectations.

One of the only ways to remediate this problem is to address the misinformation as efficiently as possible. How to do this? Raise general awareness. Sometimes this is difficult. Once immunization programs begin to take effect and infection rates are lowered, popular perceptions of the disease and their associated risks fade. With lack of general awareness, people are more prone to pick up on the adverse effects – as we’ve seen before.

Public awareness about the risk/benefits and the specific use of vaccines is imperative so that people with not misattribute outlying illness as a symptom of the vaccine. These messages need to be concise, yet accurate, correct, yet simple. Health care providers or even better, community health advocates, must be able to communicate with patients over concerns of adverse effects. They also must differentiate between direct effects of the vaccine and ailments that are not associated.

Some advocates want to bolster health education programs to introduce new information, sensitive to cultural surrounding, that complement the popular ideas of the community including a immunization education course that one needs to ‘pass’ before enrolling in school. It’s a good idea to ‘catch’ those children who have missed their vaccine but, asssumingly, not too cost-effective.

Other Examples

The northern state of Nigeria is not the first, nor the only country to experience outbreaks of disease as a consequence of bad-mouthing vaccines. Egypt has faced similar consequences after false claims were made against the polio vaccine in 2002. In Alexandra Coptic Christians (who represented 11-12% of the population) believed the vaccine was toxic. It just so happened that this ethnic group has a long history of distrust with the majority ethnic group in Egypt, the Muslims. Like the 2003 Nigerian experience, these rumors were only dispelled when religious/ethnic leaders stepped in. In Alexandria, the vaccinations were performed within churches before the people could begin trusting the safety of these vaccines.

In certain Asian countries, conspiracy theories impress the idea that foreign Christian countries are trying to convert the local population and finding a way to do so through the administration of vaccines. Here, medicine was used as an vessel of ideology and a system of beliefs (and in no way medically related).

Even earlier this year in a relatively well-educated country, vaccines were refused. A scare about adverse effects of many vaccines erupted in Ukraine and threatens to lead to disease outbreaks. In this case, the rumors appear to stem from government mismanagement and irresponsible media coverage after an extremely rare case of death in a 17-year old who had received vaccine injections for both measles and rubella. So far, the country has witnessed a 10% drop in vaccination rates. The decrease is so significant that the U.N. sponsored campaigns funded by USA dollars is being dropped.

Finally, we can look at the United States and we ourselves are guilty of allowing rumors to dissuade us from using vaccines. Yes, our own relatively well-off, well-educated, and well-cared-for population is at fault for the same reasons as Nigeria. As rumors about autism and its association with vaccines spread, many women are withholding vaccinations from their infants. This is dangerous because not only are these children infection-prone, but if they ever contract the disease, they can become vectors and infect others around them.

Where we are today

Now Nigeria is facing a similar problem that it did six years ago. Low immunization rates have put the country at an increased risk of an epidemic. And it is local rumors that often contribute to these low rates. If these rumors perpetuate, it would endanger both the Nigerian population and surrounding

19-20/12/98, Freetown, Sierra Leone, N.I.D. Photograph: Jean-Marc Giboux

countries, as it did last time. What must be done incorporates local, national, and international forces to coordinate activities so that the populace is well educated and well covered. National and international organizations must convince the smaller, more local religious and ethnic leaders to support the vaccination campaigns. The locals will trust these more personal figureheads – not the big, ‘looming’ superpowers of the world whom appear to want to domesticate all inferior countries.

Other experts urge the discontinuation of OPV use because the very minimal risk of mutant strains still causes apprehension. But this would call for the intravenous vaccines to decrease in price and increase in availability. Such efforts to lobby for lower prices may require incredible force with little result. Implementing a campaign that emphasizes education and awareness may be more cost effective and sustainable. Community health workers could be trained to dispense advice throughout the community incase a doctor or licensed health worker is not available. Such programs could also be crafted to compliment local values. Besides, even if OPVs were eliminated, the misconception about vaccine as being a panacea for all disease would still exist. Another ‘vaccine boycott’ would still be possible as long as rumors fly.

The truth of the matter is that changing the type of vaccine will not eliminate these reoccurring boycotts. And these boycotts are not just a local matter because the health of one community jeopardizes the health of the surrounding regions, as previous polio outbreaks have shown. With support and direction coming from international forces, local leaders can lead communities into an era of heightened awareness and educated decision making.

References:

http://www.polioeradication.org/content/factsheets/Nigeria_12Oct06.pdf

Hiel, Betsy. Eguypt remains committed as it closes in on becoming polio-free. Pittsburgh Tribune-Review. 3 April 2005. Accessed 18 August 2009 at http://www.pittsburghlive.com/x/pittsburghtrib/news/specialreports/unfinishedmiracle/s_319389..

Mutant polio virus spreads in Nigeria. CBS News. 14 August 2009. Accessed 19 August 2009 at http://www.cbsnews.com/stories/2009/08/14/health/main5242168.sht.

U.S. Pharmacopeia. Poliomyelitis, OPV, and Misconceptions on Vaccinations. USP Information. 9 May 2000. Accessed 19 August 2009 at http://www.usp.org/pdf/EN/dqi/polioTechnicalReportEnglish.pdf

Kaufmann JF and J Feldbaum. Diplomacy and the polio immunization boycott in Northern Nigeria. Health Affairs. 28 (4) 2009: 1091-1101.