The battle to stop measles

Ene Ngbede rides in the arms of her father all through. The registration at Comprehensive Health Centre in Kaita, Katsina doesn’t take long.

But she cringes when it is time to get her shot. The two-year-old buries her face in her father’s biceps as the syringe comes toward her arm. Her father, Sunday Ngbede, adjusts her for comfort on his lap, helps hold out her arm.

The vaccinator swabs the spot on the girl’s arm with methylated spirit. Then the syringe finds its mark and pushes, emptying a single dose of measles vaccine into Ene.

Her cry is only momentary; she quiets as soon her father rises with her. But now he’s sure his daughter, the last of four children yet, is protected from one more deadly killer of children her age.

Millions of children her age, born after the last vaccination campaign against measles in 2013, have never been vaccinated against measles.

Those who have never taken routine immunisation are even at more risk of contracting the disease.

That’s the prompt for a vaccination campaign against the disease across the country—to vaccinate a record 33 million children aged nine months to five years between November and next February.

Teams work in sixes–a vaccinator, supervisor, 2 recorders, crowd controller and town announcer Dankatu, with the bullhorn

Reports and cases

Katsina hopes to have vaccinated 1.8 million like Ene by the time the campaign winds up. A first phase is for 22 local government areas of Katsina; a further 12 council areas make up the second phase.

At the health centre, vaccinators target at least 154 children every day. Similar target is at health centres across Katsina in hopes of stemming possible outbreaks.

The campaign nationwide has had to overcome possible failure after rumours of “forced vaccination” took root in the south east, forcing parents to keep back their children and refuse vaccines.

But the sheer numbers in terms of measles meant the campaign went ahead.

In 39 weeks of reporting entering this year, more than 18,000 cases of measles have been reported; in 105 cases, the children died of the disease, according to the Nigeria Centre for Disease Control which tracks priority diseases

By contrast, some 14,000 cases of measles were recorded in 2010.

The National Primary Health Care Development Agency, which coordinates routine immunisation and is pushing the ongoing measles vaccination campaign, says outbreaks of the disease topped 183 in 2016, up from 166 in 2015.

This year alone, more than 16,343 cases of measles have been recorded, meaning nearly every one of Nigeria’s council areas has had a case.

A vaccinator marks the left thumb of a vaccinated child. Monitors have helped correct wrong finger marking

Political will

It has taken much political will to get the campaign off the ground. Top government officials appeared at the official start of the campaign in Batagarawa to whip up support for measles vaccination.

Women and healthworkers rallied in the streets, carrying banners calling on parents to take their children to health centres to be vaccinated. Young men and boys wrapped themselves in the banners and marched through streets.

At birthdays and naming ceremonies and in mosques, prayers take regular breaks for announcement about the ongoing vaccination, according to Umma Mahatu, head of Kaita’s local government administration.

Vaccinators are meant to work at fixed posts. But expedience calls for exceptions: they move out into communities when parents don’t show up at health centres; the stage a mobile post at schools and centres for Islamic education.

Vaccinators work in teams of six in each centre. One supervises, one injects the children, two people document, one more person controls the crowds and a last person is the town crier speaking through a bullhorn.

Abdul Dankatu is the announcer attached to his six-man team. His voice is firm and carries far over a bullhorn once he begins his broadcast.

“When I enter town, I greet everyone and I have to tell them health workers are starting vaccination for children. The venue is the health centre. Women, gather your children and take them where it is happening,” he says.

The announcement brought out Aisha Danjuma, with her two children. She has no problems with the vaccine, she says over the top of her younger son’s head as the vaccinator jabs the needle in.

The boy cries and she passes him to one of the two women documenting her children’s vaccination. She grabs her older son and clasps him into position, baring his left bicep. A jab and the boy winces.

By routine, the supervisor on the vaccination team “educates” mothers on what to expect after a measles vaccination. After effects range from fever to a rash up to hours or days after vaccination.

Danjuma has to wait at least 15 minutes to be sure her children aren’t immediately reacting to the vaccine before she leaves the centre.

The 15-minute wait is “just to observe,” says Ibrahim Galadima, who supervises the team that injected Danjuma’s two sons.

“But when they see something else after going home, they come back here. That’s what we tell them, but none has.”

Each vaccination team doesn’t have just syringe and vaccine doses. They also carry a special kit  to deal with after effects following immunisation.

The kit contains adrenalin, hydrocortisone, intravenous fluids, paracetamol, all of which are critical to managing children reacting to the vaccine.

The setup for the vaccination is to send serious cases to a referral unit where doctors can take charge.

Each vaccination team’s supervisor must take part in a review meeting at the end of the day’s work. The report goes to a ward level with a district head present, where ward reports are collated for a council-level meeting. To show political will, heads of local government administration like Mahatu are required to attend the review meeting—and help sort through the day’s challenges and prepare for the next day of vaccination.

Officials pore over statewide vaccination progress in a command-central styled review

Data, data and more data

On first day of vaccination, only three administrators in Matazu, Musawa and Batagarawa attended. It came as the reports from 22 local government areas flowed by mail to a command centre in the capital Katsina.

The emergency operations centre for polio doubles as a command centre for measles vaccination. Its grounds are stacked with large consignments of auto-disposable syringes shipped in via Apapa Quays and bearing the logo of the United Nations Children Fund.

Workers from UNICEF, the World Health Organisation and e-Health share the space, poring over close to real-time data and running reports.

Data flow is crucial to the success of the campaign. It isn’t live, but close to real time as it can get.

Campaign vaccinators, monitors—just about anyone involved—can use an app, Open Data Kit, to track and report findings. Monitors sampling children vaccinated use it to report missed children, discrepancies in documentation or attitude of vaccination teams. They also share findings in photos and text at the swipe of a mobile phone touchscreen on a WhatsApp group.

Open data flow has helped the emergency operations centre correct vaccinators marking the left middle finger of children vaccinated, instead of their thumb in Ingawa council area and the tallying of 223 doses of measles vaccine from 16 vials of 10 doses each.

In Rogogo ward, Zangi council area, monitors found 19 of 27 children were unvaccinated after a sample.

Eight of 12 teams in Mani did not get an AEFI on their first day of work.

Katsina is the second biggest user of the app after Kaduna. ODK uses GPS coordinate to locate the position in question.

Charts alter with each new data is plugged in; reasons for the changes are debated. Decisions are reached. Appropriate response is communicated.

Ngbede is about the only man at the centre to bring his daughter to be vaccinated.

“Her mother is off to the market, so I felt the need to bring her myself,” he says.

“I saw the message, and I knew this is one of the vaccination points. It is just to prevent measles, and you know measles is a deadly disease.”