Why Nigeria has one of world’s worst vaccination rates

• 3 million children have never received a dose of vaccine, says UNICEF
• Says country has highest measles outbreak with more than 14,000 children infected, 60 killed in recent outbreak
• Country ready to rollout cervical cancer vaccine by August 2022, plans to introduce malaria jab, says UNICEF
• Only 19.3m of 111.7m persons targeted in Nigeria have been fully vaccinated against COVID-19, says NPHCDA

Rekia Auwal was nine months old. Her parents were displaced from a remote village in Borno, after an attack by insurgents. Rekia died after having fever and skin rashes for days, without medical intervention.

Musa Ndanusa, six years old, native of Sabon Gari in Kano, cannot walk. He was crippled by the wild polio virus (WPV). Nnenna Oguwoke struggled to attain 52 years. She was diabetic and hypertensive. She died of complications arising from COVID-19.

Rekia, Musa and Nnenna belong to the over three million Nigerians that have never had a single dose of vaccine; while some lost their lives, others are maimed for life.

Rekia and Nnenna would have lived, if they were fully vaccinated against childhood preventable diseases and COVID-19. Musa, on his part, wouldn’t have lost the use of his limbs, if he had the oral polio vaccine or injectable polio vaccine.

Some of the diseases that can be prevented with vaccination include the following: measles, Yellow fever, meningococcal disease, pneumococcal disease, hepatitis A, hepatitis B, tetanus, diphtheria, Haemophilus influenza b and HPV (Human Papillomavirus). Others are polio, rotavirus, mumps, rubella, whooping cough (pertussis), chicken pox, typhoid fever, malaria, tuberculosis, rabies, cholera, and flu (Influenza).

COVID-19 vaccines are also now available to prevent and reduce the severity of infection. Indeed, vaccine preventable diseases are still the most common cause of childhood mortality, with an estimated three million deaths every year, mainly in Africa and Asia.

According to a study, titled, ‘Factors influencing childhood immunisation uptake in Africa: a systematic review’ and published in the journal BMC Public Health, an estimated 29 per cent deaths among children aged zero to 59 months were due to vaccine preventable diseases.

Immunisation is considered one of the most successful and cost-effective public health sustainable interventions for human beings against diseases. In fact, routine immunisation plays a key role to significantly reduce child mortality due to vaccine preventable diseases.

According to the World Health Organisation (WHO), immunisation has been estimated to prevent three million deaths, globally, every year. Between the years 2000 and 2016, a decrease of 84 per cent in the measles mortality rate was recorded worldwide due to measles vaccination. Likewise, a reduction in pertussis mortality was also recorded globally from 390,000 deaths in 1999 among children younger than five years of age to 160,700 deaths in 2014 as a result of vaccine effectiveness against pertussis.

According to the Expanded Programme on Immunisation (EPI), every child in Africa must receive one dose of Bacillus Calmette Guerin (BCG), Oral Polio Vaccine (OPV0) and Hepatitis B Vaccine (HBV1) at birth, Penta1 & OPV1 at six weeks of age, Penta2 & OPV2 at 10 weeks of age, Penta3 & OPV3 at 14 weeks of age and measles and yellow fever at nine months of age.

DESPITE the benefits of childhood immunisation, routine vaccination coverage for all recommended EPI vaccines has remained poor in Africa with countries such as Nigeria remaining at 31 per cent, 2018; Ethiopia (43 per cent; 2019), Uganda (55 per cent; 2016) and Ghana (57 per cent; 2014). The coverage is higher in countries such as Tanzania and Kenya, where in 2016 and 2014, it was 75 and 78 per cent, respectively.

Diphtheria Pertussis and Tetanus (DPT3) coverage is also low in Africa. Nigeria has attained only 50 per cent coverage.

Chief of Health and Human Immuno-deficiency Virus (HIV) /Acquired Immune Deficiency Syndrome (AIDS) at the United Nations Children Fund (UNICEF), Eduardo Celades, in a chat with The Guardian: “We are seeing over the last few years that the country has improved by two per cent a year, however, this isn’t enough. We need to really accelerate the growth. What has happened over the years, the COVID pandemic that has of course affected vaccination and most especially the capacity of our weak in-house system to deliver the services that the people need. So it is like we are seeing progress but there is insufficiency.”

Celades added: “Also, what we are seeing is the huge inequalities within the different regions and within the states. For example, in Sokoto in the North only 11 per cent of the children are immunised against Penta 3, the national average is 56 per cent so this is a huge gap. Same way, we compare for example the North West with the South East. In North West the coverage of Penta 3, which is the best vaccine we use, as proxy for vaccination coverage is 29 per cent, which is one out of every three children is vaccinated. In the South East, it is the opposite; it is 81 per cent. So inequality is a big problem.”

The UNICEF chief said another big issue that the country is facing is the large number children that have never received a single vaccine and Nigeria has one of the highest number of seed adult children and this is not only the North West, it is also in the big urban cosmopolis like in Lagos and “for us this is one of the priorities we should be focusing from equity lenses.”

On what can be done to locate these children that have never received a single vaccine, Celades said: “Many of them are in areas affected by violence and the percentage of such children is 29, which is very massive. It is roughly three million children. The issues are that they live in conflict-affected areas in the North East and those are the poor rural areas. We believe we need to capture these data to be able to track these children. Informed data to be able to get targeted support like what we are trying to do with NPHCDA and as well as the Federal Ministry of Health to really identify these children and do a full outreach to get to the places where people normal don’t get access to healthcare.”

He, however, said Nigeria has been making progress in vaccination. “Demonstration coverage that we have on Penta 3, which is the best indicator we have is 56 per cent compared to 2018 that we had 50 per cent,” Celades said.

A pentavalent vaccine, also known as a 5-in-1 vaccine, is a combination vaccine with five individual vaccines conjugated into one.

Pentavalent vaccine frequently refers to the 5-in-1 vaccines protecting against diphtheria (DPT), tetanus, whooping cough, hepatitis B and Haemophilus influenzae type B, which is generally used in middle- and low-income countries, where polio vaccine is given separately.

Another pentavalent vaccine is the 5-in-1 vaccine that protects against diphtheria, tetanus, whooping cough, polio, and Haemophilus influenza type B, which was used in the United Kingdom (UK) until 2017, following which a 6-in-1 vaccine became available containing the additional protection against hepatitis B.

On the benefits of routine immunisation and diseases that can be prevented from routine immunisation, Celades said: “Since vaccines were invented almost a hundred years ago, it is the most effective way to save lives and at this moment the country has 14 different vaccine-preventable diseases. So with the COVID-19, we have four antigens for COVID-19. So many diseases can be prevented like measles, which at the moment Nigeria has the highest outbreak. More than 14,000 children has measles in this current outbreak and I think more than 60 children have passed away due to this disease, which would have been completely prevented with measles vaccine; the same with Yellow fever, cholera, polio, typhoid vaccine. Penta has five different antigens; so we have different diseases that can be prevented by vaccination, which are cheap, most effective, and safe. For us, we believe vaccinating your children is a way to show respect for your neighbours, your community and to show love to the children because you are protecting them and the next generation. I can’t think of any other public health intervention that is more effective than vaccination.”

Why mothers are not disposed to immunisation
SPEAKING on reason many mothers are not disposed to taking their children for immunisation despite the benefits, the UNICEF Chief said: “I would say the biggest problem we are facing in Nigeria is having a functional primary healthcare system and easy access, especially for children. We don’t have enough doctors and nurses in primary healthcare centres. The country has 110,000 nurses but we need four to five times more to be able to deliver the services that we need. For doctors, we have about 25,000 in the country and we need three times more than the present number. We need good financing for the healthcare system, we need good data, we need good supply logistics, good call chain etc. We need good access for everyone; it is safe for him or her to visit, it is affordable etc. Only when you have a good service delivery and good access then you have vaccine access. But I don’t think it is a problem for only children; COVID-19 is a new vaccine for adult and that survey is showing that more than 60 per cent of Nigerians are yet to receive the COVID vaccine if it is readily available for them. So, I don’t think that is the main issue but I believe our efforts need to be addressed to strengthen the distribution.”

On what can be done to ensure that those children that missed out on vaccination during the lockdown are immunised, Celades said NPHCDA and the Federal Ministry of Health are working on this with the support of UNICEF and WHO and other partners are trying to do some campaigns to reach the children they missed during the lockdown. What they are doing, he said is to integrate the campaigns. “So on the June 17, an integrated company of measles, yellow fever and COVID-19 is going to be launched in three states- Gombe, Lagos and Ogun. In October more than 10 campaigns would be integrated as planned, including measles and COVID etc. Many people missed opportunities over the past couple of years, so we need to recover the time that we lost so that these children wouldn’t remain unvaccinated. So, we are trained to intensify routine immunisation but also to do campaign to reach the ones that haven’t been reached and we believe with this approach, measles vaccine for example would be offered to the children and as well COVID vaccine would be offered to the caregivers. That would be a way forward to reaching children,” he said.

On doubts over safety of vaccines, he said: “Of course, vaccines can have adverse effects but most of the cases are very mild. Maybe you can have a little fever after a shot of vaccine, very mild. What we know is that vaccine has the potential capacity to save lives and the positive effects outweigh side effects.”

A PUBLIC health specialist and Executive Director (ED)/Chief Executive Officer (CEO) of NPHCDA, Dr. Faisal Shuaib, said: “Immunisation is important because vaccines are used to confer immunity against specific diseases or infections. Vaccines train the body’s immune system to develop antibodies against diseases and strengthen the immune system. It works to stimulate the immune system to develop defence mechanisms (antibodies) to prevent severe infections.

“Immunisation saves lives. It protects an individual, the family and the community from becoming ill with unpleasant and serious infectious diseases, which have a risk of complications and long-term side effects. If vaccinated persons get infected, they do not usually come down with severe infection or illness. The more people are vaccinated, the fewer otherswill be infected, and the less widely a disease can spread. Immunisation also helps to protect future generations by eradicating diseases. So, many people are being vaccinated to try and wipe out as many infectious diseases as we can everywhere in the world, though new infectious diseases are appearing around the world.”

Shuaib, who served as the Incident Manager/Head of the Nigeria Ebola Emergency Operation Centre during the July – October 2014 outbreak of Ebola Virus Disease, said there has been very significant improvement in the routine immunisation performance in the country.

Shuaib, in addition to serving as a Senior Technical Advisor to the Minister of State for Health on Immunisation and Polio Eradication, was also the Chief Operations Officer/Deputy Incident Manager of the National Polio Emergency Operation Centre.

He said there has been an improvement in average national Penta3 routine immunisation coverage from 33 per cent in 2017 (Multiple Cluster Indicator Survey/National Immunisation Cluster Survey – MICS/NICS) to 71 per cent in 2019 (SMART Survey) and 56.4 per cent (2021/2022 MICS/NICS) in spite of the COVID-19 pandemic. Shuaib said the Global Vaccine Alliance (GAVI) High-Level Mission to Nigeria in February 2022 applauded this performance in the routine immunisation. He said a lot of efforts are ongoing through the National Emergency Routine Immunisation Coordination Centre (NERICC) to sustain the achievements made.

For the COVID-19 vaccination, Shuaib said about 31,286,532 (24.4 per cent) of the 111.7 million persons targeted in Nigeria have so far received the first dose of COVID-19 vaccines; 15,214,480 have received second dose and 19,272,722 (17.2 per cent) have been fully vaccinated, as at June 4, 2022. And, this performance is higher than the less than 10 per cent Nigeria COVID-19 vaccination being reported by WHO Global.

Shuaib said the coverage is below the earlier set COVID-19 vaccination target of 50 per cent by June 2022 for several reasons. “First, were the difficulty in getting adequate vaccines at the commencement of the vaccination exercise in 2021 and then the misinformation, myths and rumours about COVID-19 disease and vaccination pre- COVID-19 vaccines rollout in the country. Again, most of the vaccines available in Nigeria are two doses vaccines when some other countries are using the single dose vaccine and so no challenge of getting them to return for a second dose. The main challenge the team is facing now is the believe by most Nigerians that there is no more COVID-19 and the perceived low risk of the disease in the country; and this is contributing to the current hesitancy and resistance to the COVID-19 vaccination,” he said.

He said there has been recent engagement with the Global Manufacturers of the Human Papilloma Virus (HPV) vaccine and there are very strong commitments for the vaccine to be delivered to Nigeria for introduction in 2023. “So, HPV vaccines will be introduced in phases into the routine immunisation schedule for girls at nine years from May 2023,” Shuaib said.

Shuaib said adverse event following immunisation (AEFI) is a medical occurrence following immunisation, and not all persons have AEFI after vaccination. He said it is the body’s response while stimulating the immune system to produce antibodies that help to fight diseases.

The public health physician said common AEFI seen following COVID vaccination and most other routine vaccines for children and adults, include the following: mild fever, headache, mild body weakness, cough, heaviness of the arm, pain at site of injection, swelling at the site of injection. He said these usually resolve within 48 hours after administration of the vaccine. Severe reactions following immunisation are extremely rare.

The public health physician said there might be adverse effects following immunisation, just as may be observed after taking some other drugs. He, however, said from research, the AEFIs associated with all brands of vaccination is usually very minimal and severe reactions are very rare. “It is not possible to predict every individual who might have a mild or serious reaction to a vaccine, although there are a few contraindications to some vaccines. By following contraindications the risk of serious adverse effects can be minimised,” Shuaib said.

Director of the Africa Centres for Disease Control and Prevention (ACDC), an institution of the African Union (AU), Dr. John Nkengasong, said only about 15 per cent of the population in Africa has been fully vaccinated. “Because of this, the trajectory of the pandemic on the continent remains unpredictable and uncertain. With low vaccination rates, we run the risk of being hit by new variants that may severely impact the effectiveness of vaccines globally and limit people’s lives once again,” he said.

WHO Regional Director for Africa, Dr. Matshidiso Moeti, said: “Having been beset by poor access to doses, costly delays and shortfalls, Africa’s COVID-19 vaccination progress so far is no mean feat.

“Africa’s youthful population has helped the continent weather the COVID-19 pandemic. While protecting young people at high-risk of COVID-19 paramount, focusing efforts on vaccinating older people, health workers and other vulnerable populations will ensure we stay a step ahead of the virus.”