By Erin Biba Photo by Andrew Esiebo
 
For a 13-month-old boy whose family lives in northeastern Nigeria, escaping Boko Haram was only the beginning of a long, difficult journey.
 
When his family finally arrived at the Muna Garage camp for internally displaced people (IDP), they had walked more than 130 miles in three days. They were starving, and the camp was only a temporary setup with inadequate facilities, housing more than 15,000 people. But the worst news was yet to come. Health officials in the camp determined the baby had polio.
 
“It was heartbreaking,” says Tunji Funsho, chair of the Nigeria PolioPlus Committee and a member of the Rotary Club of Lekki Phase I. Funsho met the boy on a trip he took in August to three of the country’s IDP camps. “At least (the family was) able to escape Boko Haram. The child was able to walk but with a limp, and was quite malnourished.”
If it weren’t for the polio surveillance system that the World Health Organization (WHO) has in place at every one of Nigeria’s IDP camps, Funsho says, the boy’s polio could have easily gone unnoticed. In fact, it was a shock to the entire polio eradication effort in the country that a case existed at all.
 
An estimated 15,000 people live in the Muna Garage camp, an informal settlement on private land.
 
The country hadn’t had a case since July 2014 and had been removed from the list of polio-endemic countries. But in August 2016, routine surveillance methods, which include sampling of sewage and wastewater to look for viruses circulating in the wild as well as monitoring and investigating all cases of paralysis in children, discovered two cases of polio in Borno state – one of them the 13-month-old. (Two more cases were subsequently reported.) Polio wasn’t gone from Nigeria after all.
 
“The new cases devastated us. Even one case is unacceptable. It’s very unfortunate we are in this position, but we are recalibrating our efforts to end this disease,” Nigeria’s health minister, Isaac Adewole, told Rotary leaders during a meeting at Rotary International World Headquarters at the time. “We consider this situation a national emergency.”

The importance of surveillance
 
The polio surveillance system, carried out mostly by WHO and the U.S. Centers for Disease Control and Prevention (CDC), two of Rotary’s partners in the Global Polio Eradication Initiative, consists of several parts. First, doctors and other community health workers such as healers and traditional birth attendants monitor children for paralysis. “Most times cases are not discovered at a medical facility – they’re discovered at home by the volunteer community mobilizers and people who are paying regular visits,” Funsho explains. “They find a child that is limping or unable to use a limb they’ve used before. They’re trained and they know the questions to ask.” If they discover a paralyzed child, the health workers report the case to WHO, which sends a surveillance team to collect stool samples from the child and his or her siblings for testing.
 
The second part of the surveillance process involves local authorities collecting samples from sewage systems or, in places that don’t have adequate sanitation facilities, rivers and bodies of water near large settlements. The samples are sent to a lab, one of 145 in the Global Polio Laboratory Network, which looks for the poliovirus. If it is found, the samples go on to a more sophisticated lab where scientists perform genetic sequencing to identify the strain and map where and when it has been seen before.
 
The worldwide scale of these surveillance efforts is massive and costs roughly $100 million every year. For the most part, these activities take place only in countries that don’t have adequate health systems already established. In the U.S., for example, if a child showing signs of paralysis visits the doctor, the necessary tests for polio are already a part of the working health system. But in countries that don’t have such a robust system, WHO takes on that responsibility. That means investigating more than 100,000 cases of paralysis around the world every year to rule out polio.
 
In Nigeria’s IDP camps, surveillance is more complicated. Before people enter, they are screened by security agencies (there have been several cases of suicide bombers trying to infiltrate the camps). Next, at the camp’s health facility, doctors evaluate the new arrivals’ overall health and screen them for polio. Volunteers then document what villages they have traveled from, using the information to track who is in the camp, where they are within the camp, and who their family members are.