A presentation on the Challenges faced on Immunization in Nigeria

1. CHALLENGES OF ROUTINE
IMMUNIZATION SERVICES IN
NIGERIA
PRESENTED BY DR. OLUBIYI O.A
SUPEVISED BY PROF. MUSA O.I

2. Outline
• Introduction
History of immunization
Definition of terms
• Overview of Routine Immunization in Nigeria
• Strategies for Routine Immunization
• Immunization coverage in Nigeria
• Challenges
• Conclusion
• Recommendations

3. Introduction
• Immunization is defined as the process by which a person is
made immune or resistant to an infectious disease by the
administration of a vaccine.1
• Vaccines stimulate the body’s own immune system to protect
the person against subsequent infection or disease.1, 2
• Inoculation is the introduction of the causative organism of a
disease into a living body to stimulate the production of
antibodies.3
• Immunization has been identified as one of the most powerful
tools for the prevention of infectious diseases in the past 100
years.4
• In fact it is one of the eight major public health successes of
the twentieth century, second only to the control of infectious
diseases.5

4. History of Immunization
• The Chinese were known to be the early pioneers
of immunization
• This dates back to 2700BC.6
• To prevent small pox, they practiced variolation.
• The Egyptians also practiced a form of
immunization as healthy individuals inhaled dried
pus from small pox patients about 3000BC.7
• Immunization was however scientifically done
when Edward Jenner in 1798 discovered the
small pox vaccine using cowpox virus as a
stimulant.7

5. Definition of terms
• NATURAL IMMUNIZATION: This occurs when an individual acquires
active immunity from infections like measles, chicken pox and
yellow fever or passively as in the case of breastfeeding in which
the mother’s antibodies are passed to the baby.
• ARTIFICIAL IMMUNIZATION: This is done actively by the
administration of vaccine to induce immunogenicity while the use
of immunoglobulins as in the treatment of snake bite is passive
immunity.7
• ACTIVE IMMUNITY: this occurs when on exposure to antigenic
organisms; the host produces its own corresponding antibodies e.g
administration of vaccines.
• PASSIVE IMMUNITY: this occurs when readymade antibodies are
administered to individuals especially hen antigens need to be
neutralized immediately. E.g. Immunoglobulins

6. Definition of terms
• COVERAGE RATE: This is a measure of the utilization of
health services by the community
Total number of infants immunized x 100
Total number of infants in the target area
• DROPOUT RATE: It is a measure of accessibility of health
services, quality of service and personnel attitude to client.
WHO considers drop-out rate of more than 10% as a
problem.8
• It is the single most reliable (and revealing) indicator of
immunization Programme management.10
PENTA1-PENTA 3 X 100
PENTA 1

7. Definition of terms
• VACCINE WASTAGE: In immunization program, the number of vaccine
doses used is always higher than the number of beneficiaries actually
immunized.10 This excess number of vaccine doses which remain
unutilized contributes to vaccine wastage at service delivery level.
Vaccine usage rate (%) = Number of doses administered x 100
Number of doses consumed
Vaccine wastage (%) = 100 – Vaccine usage (%)
• MISSED OPPORTUNITY: This occurs when an infant or woman of
reproductive age in need of immunization gets in contact with health
facility rendering the services but fails to get the immunization as at when
due.7
• ADVERSE EVENT FOLLOWING IMMUNIZATION: An Adverse Event Following
Immunization (AEFI) is a medical incident that takes place within one
month after an immunization and is believed to be caused by the
immunization.11

8. Definition of terms
• THE COLD CHAIN SYSTEM: This is a system
involved in the storage and distribution of
vaccines at acceptable cold temperatures from
the point of manufacture to the point of
administration to the client.7

9. Types of vaccines
• There are five types of vaccines namely;
• Live attenuated vaccines examples of which are BCG,
Yellow Fever, Oral Polio and Measles vaccines
• Killed/Inactivated vaccines, e.g Pertusis Cholera,
Typhoid and Inactivated Polio Vaccines
• Toxoids e.g Diphtheria and Tetanus
• Conjugate vaccines e.g. Pneumococcal Conjugate
Vaccine
• Recombinant Vaccines. e.g. Hepatitis B And Human
Papilloma Virus vaccines
•

10. BENEFITS OF IMMUNIZATION
• The benefits include;
• It confers immunity or resistance to infectious diseases
when administered.
• It has proven as a tool for controlling and eliminating
life threatening infectious diseases e.g small pox
• Protection of others as in herd immunity.
• It is estimated to avert between 2 and 3 million deaths
each year Worldwide.8
• Immunization has been the most cost effective strategy
for disease prevention globally.4, 9

11. OVERVIEW OF ROUTINE
IMMUNIZATION IN NIGERIA
• Immunization is an important child survival strategy
especially in the developing countries.
• Therefore the WHO launched the Expanded Program
On Immunization in 1974.7
• This was aimed at reducing morbidity and mortality
from vaccine preventable diseases.
• The EPI was eventually launched in Nigeria in 1979 and
revised in 1984.
• It was later renamed in 1996 by the Nigerian
government to demonstrate ownership of the program
to National Programme on Immunization(NPI).9

12. OVERVIEW OF ROUTINE
IMMUNIZATION IN NIGERIA
• The optimum level of success by EPI was recorded by
the early 1990s with the country achieving universal
childhood immunization coverage of 81.5%.
• But since that period of success, Nigeria has witnessed
gradual but consistent reduction in immunization
coverage.
• By 1996, the national data showed less than 30%
coverage for all antigens, and this decreased to 12.9%
in 2003.9, 12
• It is one of the worst in the West African sub region,
only better than Sierra Leone.

13. GROUPS TARGETED FOR
IMMUNIZATION
• The following groups have been targeted for
immunization11:
Children 0–11 months
 Children 0-59 months
 Women of child bearing age 15–49 years
 Other at-risk groups especially in outbreak situations
and those traveling to endemic areas.
 International travelers
• As a rule, no eligible person shall be denied
immunization unless there are medical
contraindications

14. Vaccination Programmes in Nigeria
• Routine Immunization
• Supplemental/ Catch–up Campaigns
• Vaccines For Out-break Control And Special Groups
• In addition to these, children can also be given some other vaccines
that are not yet included in the routine immunization schedule. These
include;
 Td given every 10 years, Tdap to children 11-12 years of age13, rotavirus
vaccine, typhoid vaccines.
 Rotavirus vaccine (Rotarix): There are plans to introduce Rotavirus
vaccine into the Routine immunization schedule in Nigeria by 2017.8
Rotaviruses infect nearly every child by the age of 3–5years and are
globally the leading cause of severe, dehydrating diarrhoea in children
aged <5 years.14
 Typhoid vaccine.

15. RI Schedule in Nigeria
• Note:
* OPV0is only given within the first two weeks
of life.
**HBV0 is given only within the first 24 hours of
birth.
• All children who present to the health facility
should be adequately immunized to avoid
missed opportunity.

16. Table 1:Routine Immunization Schedule In Nigeria
Contact Min. Age
Of Child
Type Of Vaccine Dosage Route of
Admin.
Site
1st At birth BCG 0.05ml Intra dermal Left Deltoid
*OPV0 2 drops Oral Mouth
**HBV0 0.5ml intramuscular Thigh
2nd 6 weeks Pentavalent1
PCV1
0.5ml
0.5ml
Intra muscular
Intramuscular
Thigh
Thigh
OPV1 2 drops Oral Mouth
3rd 10 weeks Pentavalent2
PCV2
0.5ml
0.5ml
Intramuscular
Intramuscular
Thigh
Thigh
OPV2 2 drops Oral Mouth
4th 14 weeks Pentavalent3
PCV3
0.5ml
0.5ml
Intramuscular
Intramuscular
Thigh
Thigh
OPV3 2 drops Oral Mouth
IPV 0.5ml Intramuscular Thigh
5th 9months Measles 0.5ml Subcutaneous Left Deltoid
Yellow Fever 0.5ml Subcutaneous Right Deltoid

17. Strategies For Routine Immunization
• To strengthen routine immunization systems
and improve coverage, some strategies have
to be put in place.15
• The four main approaches are (4Ms)
Maximising reach
Managing the programme
Mobilising people
Monitoring the Progress

18. Maximising Reach
• Detecting and Reaching the Unreached
• Designing Services to reach all equitably
• Building Capacity of Vaccinators and Managers
• Ensuring Vaccine Quality and Availability
• Creating Synergy with special vaccination
efforts
• Integrating Immunization efforts

19. Managing the Programme
• Securing Political commitment and
Partnerships
• Planning, Budgeting and Mobilizing Resources
• Ensuring Excellence in National leadership
• Setting Programme Policy and Guidance

20. Mobilizing People
• Engaging communities and creating Demand
• Mobilizing and Communicating for vaccination
• Addressing vaccine hesitancy and false
perceptions

21. Monitoring Progress
• Monitor Programme performance and disease
occurrence
• Evaluate the programme through surveys and
Reviews

22. Important Milestones of Routine Immunization
in Nigeria
• Interruption of polio transmission in Nigeria. WHO on September
25th 2015 removed Nigeria from polio endemic list.
• Nigeria switched from tOPV to bOPV on 18th April 2016.
• Commencement of Pneumococcal vaccine in July, 2016. It was
commenced on 22nd July, 2016 in UITH Ilorin.
• Shortly after celebrating interruption of polio in Nigeria for two
consecutive years, and awaiting certification of Nigeria as a polio
free country by WHO, the country recorded two (2) new cases of
Polio in the war torn Northeast Nigeria on 11th August, 2016.
• There is an ongoing prospective cohort study at the Maternity wing
of UITH on OPV-IPV administration to a cohort of newborns that are
then followed up for 22 weeks. The aim is to study the
seroconversion of IPV in the cohort as well as incidence of AEFIs.
The study is sponsored by WHO, PAN and NPHCDA

23. Immunization Coverage In Nigeria
• Despite all the measures put in place to promote
immunization, Nigeria has one of the lowest
vaccination rates in Africa9
• Infant Mortality Rate of 69/1000 live births in 201516
• Under-five mortality rate of 109/1000live births.
• From these mortality rate estimates, vaccine-
preventable diseases account for approximately 22% of
childhood deaths, per year.8
• It has also been estimated that out of the six million
Nigerian children born every year in the country, more
than1 million fail to get fully vaccinated by their first
birthday.8

24. Figure 1: Causes of child (under-five years old) mortality in Nigeria (2010).v
Source: National Routine Immunization Strategic Plan 2013-2015

25. Immunization Coverage In Nigeria
• In recent years, Nigeria’s coverage of Penta 3, a key indicator of a
country’s performance of routine immunization (RI), has fallen from
74% in 2010 to 52% in 2012.12
• This recent drop in immunization coverage in Nigeria has left more
than 3.2 million children
• Thereby adding to the existing large pool of susceptible under-fives,
which could lead to outbreaks of vaccine-preventable disease
across the country
• Fluctuations have also been observed in the coverage of other
antigens administered in the country.
• It has also been noted that variations exist in RI performance across
the country’s zones 12
• According to the National Immunization Coverage Survey (NICS), in
2012, only about 50% of Nigerian states had more than 80%
immunization coverage.12

26. Figure 2: Immunization Coverage Rates In States, 2012
Source: National Routine Immunization Strategic Plan 2013-2015

27. Figure 3: Immunization coverage rates by zone in 2010
Source: National Immunization Coverage Study, 2010

28. Routine Immunization In Kwara State
• Kwara state is one of the six states in north
central geopolitical zone of Nigeria.
• It has sixteen local government areas and has
a population of about 2.5 million people.17

29. Figure 4: Total number of immunized children in Kwara state in 2015
Source: WHO (Kwara state) 2016

30. Figure 5: Dropout rate in Kwara state in 2015
Source: WHO (Kwara state) 2016

31. Figure 6: Pentavalent 3 coverage rates per LGA for years 2014-2016
Source: WHO Kwara state 2016

32. Figure 7: Measles Coverage Rates per LGA 2014-2016
Source: WHO Kwara State, 2016

33. CHALLENGES
• LEADERSHIP: This is a major problem in Nigeria.
• There is lack of commitment to immunization policy
• Lack of foresight: The leaders are not usually proactive.
They only respond to issues as they occur, giving room
to inefficiencies.
• No effective monitoring and evaluation.
• Recently on August 11, 2016 the news of two new
confirmed cases of poliovirus was everywhere. This
was just a few days after the second anniversary of
Nigeria interrupting polio transmission. The virus was
closely related to the ones seen in 2011 which means
that the virus had been circulating undetected for five
years.

34. CHALLENGES
• HUMAN RESOURCES:
• Knowledge of health workers on the site of administration, dilution
etc. of vaccines. This is due to lack of training and retraining.
• This leads to poor vaccination techniques that cause abscesses or
other discomfort. Each vaccine has its route of administration which
has to be adhered to strictly. Failure to do so leads to complications
in form of abscesses etc.
• Unauthorized fees charged by health care providers. This
discourages some clients especially in the rural areas where the felt
need for immunization is low.
• Incessant strike actions by health workers leads to high dropout
rates in the health facilities. This affected the coverage rates in
Kwara State in 2015.

35. CHALLENGES
• VACCINE SUPPLY CHAIN AND LOGISTICS
Reduced or limited global production of vaccines
(particularly for DPT and yellow fever) in 201212 led to
shortage of vaccines in Nigeria.
• Frequent vaccine stock out due to poor forecasting. Some
states have excess while some do not
• Lack of support for vaccine distribution / outreaches
• Cold chain equipment failures and poor electricity supply
• Lack of funds at States and LGAs for service delivery and
supervision.

36. CHALLENGES
• Missed opportunity: The following are the causes of missed
opportunity;
 Inappropriate contraindication e.g sickness
 Refusal of health workers to open new vaccine vials for few
clients
 Controversy on vaccine safety e.g OPV and other vaccines
leading to client’s refusal of vaccine.
 Improper communication to mothers on next appointment
• Adverse events following immunization: any form of AEFI
discourages immunization especially in the communities.
• Overdependence on vaccine importation instead of local
production

37. CHALLENGES
• OTHERS
 Data handling and management:
– Lack of RI data tools leading to low quality data. The absence of data
collection tools at facilities can also result in poor data capturing.
– Data falsification to increase immunization coverage rate, reduce
vaccine wastage and reduce dropout rates. This is a very common
practice. It is due to the fact that the Monitoring and Evaluation
officers in each Local Government has a target that he has to meet, if
the actual coverage rates fall short of his target, he falsifies the data.
– Lack of vaccination cards for evidence in coverage survey. During
surveys, there is no way of cross checking if the data generated is
accurate because clients’ vaccination cards are not accessible. This
questions the quality of the data.

38.  Injection safety. This has to do with
o Dilution,
o Administration of vaccines
o And subsequent disposal of sharps.
o Incineration is the gold standard for the disposal of sharps
 Household immunization on NIDs: This gives parents and guardians a false
sense of being immunized. They assume that the children have been fully
immunized and so see no reason to visit health facilities.
 Hard to reach communities leading to poor immunization coverage
o as witnessed in a Lagos community recently with an outbreak of Measles.
o Due to logistic reasons, e.g lack of project vehicles, poor access roads,
rivers not dredged, collapsed bridges, some communities especially
riverine areas are not accessed
o This is a major setback in the routine immunization coverage.

39. Hostilities such as war and terrorism
o leading to poor immunization coverage in
northern Nigeria.
o terrorism has led to displacement of millions of
people both within and outside Nigeria.
o For the internally displaced people (IDPs), their
basic needs become paramount.
o Immunization is only secondary.
o The Government and donor agencies also meet
the basic needs of those in IDP camps.

40.  Rumours and misconceptions about immunization:
Examples of such rumours include:
o Childhood vaccinations must start with BCG
o Premature children should not be vaccinated
o OPV contains contraceptives, sterilization and cancer
agents
o There is no need to vaccinate children as there are potent
herbs to take care of sicknesses.
o Measles vaccine kills while drinking coconut water prevents
measles
o Different vaccines given at the same time weakens the
child’s immune system
o Many vaccinated children still fall ill and die
o Natural immunity is better than vaccinations. Eating good
food boosts immunity.

41. Recommendations
• THE FEDERAL GOVERNMENT
• To demonstrate ownership of immunization programmes and avoid donor-
dependency.
• To conduct a census so that accurate figures can be used to determine the
target population of children for to be immunized
• To ensure adequate provision of vaccines
• Training and retraining of health workers
• To address the issue of insecurity in Nigeria especially the northern states
• To provide more information through the Ministries of Health and
Information on the benefits of immunization as well as work with the
village and religious heads to improve immunization coverage.
• Demonstrate the political will to adequately run all the operations
involved in immunization such as cold chain and logistics, prompt payment
of workers’ salaries and entitlements.

42. Recommendations
• THE STATE AND LOCAL GOVERNMENTS
• To show interest in Primary Health Care activities
• Prompt payment of workers’ salaries
• THE COMMUNITY
• To be more involved in immunization
programmes
• To get information on immunization from the
right source

43. Recommendations
• TO THE HEALTH WORKFORCE;
• To attend training and retraining programmes
• To improve their attitude and relate well with
clients
• Reduce industrial actions and embrace dialogue
• All AEFIs from whatever cause, should be
reported using standard reporting forms and
investigated to increase public confidence and
acceptance of immunization and help strengthen
the immunization system.

44. CONCLUSION
• Immunization is one of the child survival
strategies. Both government and the citizens
have a stake in the health of the children in
Nigeria. We should therefore work
harmoniously to ensure that every child is
adequately immunized.

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•