Kenya - Background - Combatting Antivaccination Rumours: Lessons Learned from Case Studies in East Africa

Kenya - Summary Points

• Geographical focus in Central Province, the heartland of the political opposition
• Religious opposition from Catholic bishop of Nyeri, not under control of his superiors
• Temporal coincidence of polio NIDs and national AIDS campaign, an unfortunate timing in retrospect
• No perceptible effect on routine EPI, and no reintroduction of wild poliovirus
• House to house vaccination seems to have blunted the impact of the rumours.

In Kenya, anti-NIDs campaigns started in the final stage of the country's successful campaign against polio, and after polio had faded from the headlines. They were focused in Central Province, the heartland of the political opposition, and especially in Nyeri, where a militant bishop, unsupported by his superiors, led a campaign from the pulpit against the polio NIDs. Other factors also intervened. In retrospect, the rumours might have had less impact on coverage if the NIDs and the national AIDS campaign had been launched consecutively, and not at the same time. One notable feature of the Kenyan campaigns is that they had no perceptible effect on the routine EPI. In Kenya, as elsewhere, vaccination campaigns have provided a more attractive target for critics than has the routine vaccination programme.

The Kenyan anti-vaccination campaigns, though successful in lowering NIDs performance, did not lead to reintroduction of polio. Central Province of Kenya has high routine coverage, and it does not border on polio endemic areas. After the initial shock of 1996, the government and agencies responded with public information campaigns which blunted the edge of the attacks. By the year 2001, a prominent opposition politician was willing to appear in public with government and UNICEF staff, administering OPV on camera on the grounds of a Catholic church.

Background

The Ministry of Health launched Kenya's Expanded Programme on Immunisation (KEPI) in 1980. The main purpose of KEPI has been to assure that all children are immunised against six childhood diseases before their first birthday: tuberculosis (BCG), given at birth; diphtheria; pertussis; tetanus; poliomyelitis; and measles. The six antigen programme will add hepatitis B and Haemophilus influenzae B vaccines in 2002.

KEPI is also committed to the global Polio Eradication Initiative and has been conducting National Immunisation Days since 1996. From 1996 to the present period, over 20 million children less than five years were given polio vaccines. According to health officials and statistical data, coverage for both rounds of NIDs stood around 81 percent except in 1999 and 2000, when it rose above 90 percent.

As eradication programmes enter their final phase, the target diseases become less and less common, and their importance declines in the eye of the press and the public. Doubts about vaccines and vaccination, previously disregarded when the diseases were common, rise to the surface, and programme communication becomes more common.

Programme communication is widely recognised as an important component of immunisation programmes. It gets lip service in all documents about immunisation and campaigns, and every individual interviewed said the same thing. However, in practice, communication does not always get the respect, priority and funding that it deserves. This report documents the tendencies to implement communication activities in a haphazard and unfocussed way, implementing social mobilisation activities too late to be effective, and the failure to communicate the purpose of repeated NIDs to opinion, religious, and other grassroots leaders and mothers/caretakers.

Historical Situation Analysis of NIDs

Before examining rumours during NIDs and looking at their impact on immunisation rates, an analysis of Kenya as a nation and the Central Province is needed. This will show national trends for the five years NIDs were conducted throughout the country, along with routine vaccinations.

1996

Records and reports on National Immunisation Days for polio start with 1996 when the first NIDs were conducted. In these reports, mention of rumours or questions is very frequent.[2]

In the first NIDs in 1996, Central Province was recorded as having the lowest coverage in Kenya. Central Province recorded an overall coverage of 60.3 percent during the first round and 51.2 percent in the second round. Within Central Province, Nyeri district coverage was 40 percent, far below the average for the province as a whole. According to the same report, these were unexpected results considering the fact that the province has always reported high OPV coverage in the past, as verified by immunisation coverage surveys and routine immunisation data.

1997

In the 1997 National Immunisation Days Report for Kenya, KEPI states that false rumours related to the polio campaign had a negative effect on NIDs coverage in certain parts of the country. Fears were aroused because of controversies about the safety of the vaccines and whether they were laced with contraceptives and HIV. Another fear was that overdoses might occur from extra doses. People felt that there were more important public health problems, such as malaria and typhoid; thus, polio spending could not be justified. [3]

In 1997, as the following table shows, the Central Province had the biggest drop in coverage in both rounds compared to 1996 -- a 15 percent drop in round one and about a five percent drop in Round Two.

Source: National Immunisation Days Report - 1997

1998

In the 1998 NIDs, all provinces registered 70 to 90 percent in OPV coverage with the exception of Central Province, which was below 70 percent. Yet while Central Province NIDs were lowest in the country, routine immunisation was highest, with 70 percent fully immunised. (DPT3 coverage was at 97.2 percent.) [4]

1999-2000

Results for 1999 NIDs were almost identical to those in 1998 for the Central Province but with an increase in those fully immunised at 84.8 percent. (DPT3 coverage was again 97.2 percent – the highest in the country). At the same time, Central Province coverage in the NIDs for polio was still the lowest in the country. [5]

The following table shows the routine immunisation rates for Kenya.

cont....

Source: Kenya Demographic and Health Survey

*North Eastern Province is not included.

According to the 2000 Report on National Immunisation Days, Central Province, which had lagged behind in NIDs since 1996, finally caught up with the rest of the provinces. Many of the interviews conducted in Nyeri in the Central Province concurred that NID participation improved where house-to-house immunisations were done.

What accounts for low coverage in Central Province during NIDs compared to its high routine coverage? This report will answer that question as it focuses on the Nyeri District, the centre of many rumours.

Nyeri Profile[6]

Nyeri district is one of the seven districts in Central Province, covering an area of 3,284 square kilometers. Nyeri itself has seven divisions: Mukurweini, Mathira, Kieni East, Kieni West, Tetu Municipality, and Othaya. Physical features of the district are Mount Kenya to the east and Aberdare Ranges to the West.

The people of Nyeri appear to be very religious, predominantly literate and aware of the health needs of their children, particularly immunisations. This is evident in the continuing high level of routine immunisations, the highest in Kenya. It is also evident to any visitor to Nyeri that family planning has been widely accepted. Advertisements for condoms are everywhere: "Let's talk," the slogan of Trust condoms, is apparent on buildings and kiosks even in the smallest villages.

Immunisation services in Nyeri district are provided at 59 service delivery points. Forty-four of the facilities are operated by the government of Kenya, eight are private, and seven are church run. Four outreach clinics are conducted monthly for communities not able to access health facilities. The majority of the facilities give vaccinations on a daily basis.

The following table shows crude routine coverage statistics from the 2000 Immunisation Coverage Survey – Nyeri District. These statistics are based on information recorded on immunisation cards or information given by the mother if the card was not available. The survey confirms high routine coverage for Nyeri.

In this survey, immunisation card retention rate was 80.1 percent, an indicator of how mothers regard the importance of child vaccinations. The survey analyses immunisation coverage by card alone and by verbal history.

Source:Immunisation Coverage Survey, Nyeri District: Results 2000

In this same study, a comparison between routine immunisation and survey coverage shows a close correlation and similar results between the two methods of evaluating immunisation coverage. In both methods, immunisation coverage was above 80 percent for most antigens in both 1998 and 1999.

This survey also gives a strong indication as to why mothers chose not to participate in NIDs in Nyeri district.

Source: Immunisation Coverage Survey, Nyeri District: Results 2000

As shown in the table above, the main reason for mothers' not taking their children to NIDs to get OPV is that their children were already fully immunised. Religious influence accounted for 17 percent of those not participating in NIDs, while negative rumours concerning the vaccine accounted for eight percent of those not responding to NIDs. Thirty-six percent of those not responding to NIDs could not be specified as to reason. Of those reporting rumours as the reason for not participating, the rumour most often cited was that the vaccines were laced with contraceptives.

KEPI and UNICEF have commissioned a number of studies over the past five years to determine why participation in NIDs has been so low in Central Province compared to other Provinces, and why routine immunisation is the highest in the country -- a contradiction noted in some of those studies.

For several years, officials outside Central Province have assumed that rumours kept mothers away from NIDs. In fact, while many rumours were circulating, closer examination reveals that many other trends and factors may have converged to subvert participation in NIDs.

6 Information in this section taken from: Immunisation Coverage Survey, Nyeri District: Results 2000. 2001. Ministry of Health, Kenya by Kenya Expanded Programmeme on Immunisation.