13 January 2016

Nigeria: Nation Faces Major Challenge to Vaccinating Children

guest column

As we look back on the public health issues that caught the world's attention in 2015, immunization stands out. Whether it was the measles outbreak in the US or the Ebola vaccine trials in Guinea, vaccines were top of mind throughout the year.

The annual Global Vaccine Action Plan (GVAP) Assessment Report, which was released at the end of the year, recaps some of these key moments and highlights some critical gaps in immunization coverage worldwide.

The GVAP, which was endorsed back in 2012 at the World Health Assembly, serves as a roadmap to achieve the "Decade of Vaccines" - a vision of universal access to immunization by 2020. Since then, the Strategic Group of Experts on Immunization (SAGE) has issued an annual assessment on GVAP progress and made recommendations to governments, international organizations, and development partners for actions required to meet the goals and objectives of the global vaccination plan.

This year's SAGE report emphasizes that countries, including Nigeria, are far off track toward reaching key targets.

What are the good, the bad and the ugly?

Focusing on Nigeria, halfway into the Decade of Vaccines the latest report highlights the country's achievements wiping out some diseases.

The country has not recorded a case of wild poliovirus in more than a year, and last September the World Health Organization announced the removal of Nigeria from the polio-endemic list.

The report notes that this success is the result of strong accountability and commitment. The country and its technical partners established and enforced clear accountability systems to measure results, reward those who achieved them, and discipline those who did not.

Unfortunately, Nigeria has not been able to translate its success against polio to other diseases. Despite being Africa's largest economy, Nigeria remains the country with the second largest number of unvaccinated or under-vaccinated children. Estimates based on the administration of three doses of the diphtheria-pertussis-tetanus vaccine indicate that in 2014 Nigeria had more than two million unvaccinated children. In the same year, more than three million Nigerian infants were not vaccinated against measles.

The report also tracks new vaccine introductions, and surprisingly notes that the "Ebola candidate vaccines were developed and tested swiftly with potential to protect against a terrible disease." However, the first batch of the GSK candidate vaccine meant for large-scale human trials was shipped to West Africa only in the last week of January 2015, after nearly 22,000 cases had been recorded in the epidemic, with nearly 9000 deaths.

Although Nigeria recorded only 20 cases of Ebola and eight deaths, those lives may have been saved if an effective vaccine had been available sooner. Forty years after the deadly disease was discovered, there are still no vaccines licensed for use in humans that protect against the Ebola Virus Disease.

Why are we off track?

In most countries where vaccination targets are not being met, large populations and weak vaccine programs have led to large numbers of unvaccinated children. Nigeria, like others, is beset by healthcare data quality issues due to a lack of governance, technical knowhow and infrastructure.

Political, ethnic and religious conflicts can also hamper vaccination efforts by disrupting health systems. Violent conflicts prevent the delivery of vaccines and displaced populations often struggle to receive basic services. This is the situation in northeastern Nigeria where Boko Haram is threatening immunization programs with ripple effects in neighboring Cameroon.

Funding is also a concern. Currently, there is an estimated funding gap of U.S. $130 million to rid the world of maternal and neonatal tetanus.

Compared to the $1.1 billion which GAVI, the Global Vaccine Alliance, spent in 2014 on its new and underused vaccine programs, this is a miniscule amount, but the funding is not getting to where it needs to go. This is all too familiar in Nigeria where the Business Anti-corruption Portal has noted that corruption risks are pervasive throughout all institutions, including the healthcare system.

What is the way forward?

This 2015 SAGE report rightly focuses on leadership and the accountability systems as two investment areas that can take the GVAP forward. But I believe that the factors highlighted in earlier SAGE reports - data quality, community involvement and vaccine supply - are still important to meet vaccination targets in countries like Nigeria.

The challenges to improving healthcare quality, including information and communication technologies, need to be addressed with legislation, better standards, greater investment and new infrastructure. A comprehensive approach that tackles poverty and the distribution of wealth is also needed to assure peace and security across the country.

Accountability and transparency at all levels of the vaccine procurement and distribution mechanism will help ensure the right vaccines are available at the right time and place.

The GVAP goal of freeing all children from vaccine-preventable diseases is an ambitious one. At this time we are far from meeting the set targets, but it is true that significant progress has been made. With greater government commitment, it can be hoped that this lofty goal will soon become an achievement for all of humanity.

Dr. Effiong is a Nigerian-born physician now working in the United States and a research scientist at the University of Michigan. He is also a New Voices fellow at the Aspen Institute. He previously worked as an internist for six years in Nigeria.

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