Immunisation is a clear success story and its value in preventing and curtailing infectious diseases cannot be overemphasised. It prevents an estimated 2 to 3 million deaths annually. What does immunisation have to do with preventing epidemics in Nigeria? Everything.
In June 2017, Nigeria conducted a Joint External Evaluation (JEE) to assess the country's capacity to find, stop and prevent threats of public health significance. According to preventepidemics.org, Nigeria scored 39% on the ReadyScore, a measurement of the country's preparedness to find, stop and prevent epidemics.
The low score indicated that gaps were identified in Nigeria's epidemic preparedness and an epidemic, should it break out in the country, would lead to a significant loss of life, both domestically and in neighbouring countries. At the 2019 Nigeria Health Watch Forum, themed "Prevent Epidemics: Immunise" participants discussed how immunisation can help prevent disease outbreaks in Nigeria. Deliberations at the forum also addressed challenges facing the distribution of vaccines across the country and how overcoming these challenges can fortify the nation from diseases.
In her welcome remarks, Ms. Adaobi Ezeokoli, Managing Director, Nigeria Health Watch, noted that while there are challenges facing the Nigerian health sector when it comes to immunisation, there are also incredible innovations and fantastic collaborations taking place in the space in Nigeria, and these have incredible ripple effects for our ability to control epidemics. "One way to prevent disease outbreaks is to ensure that our families are protected and this is where immunisation takes centre stage," she said.
Preventing epidemics through immunisation
Renowned virologist Professor Oyewale Tomori, Chair, Expert Review Committee for Polio Eradication and Routine Immunisation in Nigeria, in a riveting discourse on the sub-theme "Stronger together: Community sensitization improves herd immunity and changes behaviour," took the room back in time to the history of vaccination in Nigeria.
Born into a 'no-vaccine' era, he said he knew what it was like to live in a world where no-one was immune against infectious diseases. "We survived by chance, but you are alive today because of the choice made by your parents so you have the right to pass it on to your children and make sure that the choice your parents gave you, you also give it to your children", he said, adding that when 95% of a community is vaccinated, herd immunity is built and disease outbreaks are prevented. "The herd security of the future of this country depends on vaccinating the ones that are born now".
Government innovations to improve immunisation and stop epidemics
Dr. Yakubu Maigana, Head, Outbreak Prevention & Response Unit, Dept. of Disease and Immunization at the National Primary Health Care Development Agency (NPHCDA) said the 2016 Multiple Indicator Cluster Survey/National Immunisation Coverage (MICS-NICS) Survey was a shock to the agency, which prior to this had been operating under the assumption that Nigeria's immunisation coverage rates were high. The 2016 MICS-NICS Survey however revealed Nigeria's Routine Immunisation (RI) Coverage at a rather low 33%. He said one potential cause of this disparity could be poor data sent to the agency from states. As a result, the NPHCDA declared a state of emergency on Routine Immunisation, and now leverages on technology to address issues around the integrity of data.
Dr. Chizoba Wonodi, Country Director, International Vaccine Access Centre at John Hopkins School of Public Health (JHSPH), gave a detailed talk on exactly how the vaccination supply chain in Nigeria works and the improvements that Nigeria has made in distribution over the years.
Nigeria's vaccine distribution process is an untold success story. Dr. Wonodi detailed what innovative strategies the Nigerian government and partners have employed to address challenges in vaccine distribution. During her discussions on the sub-theme, "Beyond Vaccine Procurement: Maintaining the Cold Chain." This included innovations that redesigned the cold-chain equipment, learning from private companies like Coca-Cola how they distributed their product to the most remote areas, and repairing old equipment to increase saturation in Nigeria's over 9,000 wards from 17% to 66%. Power supply challenges were tackled by making equipment solar-powered in order to ensure proper data management. A supply chain dashboard was created and local government officers were trained on how to take stock and text the information weekly to the central server to ensure there were no vaccine stock-outs.
These interventions have increased stock adequacy and reduced stock out rates. Dr. Wonodi commended the NPHCDA for championing all these innovations. In addition, Zipline, an organisation that operated the world's first national-scale drone logistics network to deliver critical medical products to the most remote communities, is presently testing vaccine delivery in Ghana. Despite this, Dr. Wonodi pointed out that NPHCDA still has a lot of work to do because about 7 million children are born every year that need to be vaccinated.
Mrs. Elsie Ilori, Deputy Director at the Nigeria Centre for Disease Control (NCDC) mentioned that risk communications played an integral part in the agency's public health response, working with communities to prevent and reduce the spread of infectious disease outbreaks. This was done through public engagement and targeted messaging. Mrs Ilori mentioned that Rapid Response Teams (RRTs) visit different communities, carrying out research on behavioural norms, then developing messages that addressed those specific issues.
In November 2018, President Muhammadu Buhari signed a bill for an act to establish the NCDC in recognition of the importance of the agency to protect Nigeria's national health security. This will now ensure that there is a clear mandate to fund the agency in the 2019 budget. In addition to leading the national response, the NCDC also bears the burden of responding at the state level during disease outbreaks. "Some states are trying but for most of them, health is not on their priority list so most times when there is an outbreak, resources and supplies are provided from the national to manage the outbreak," Ilori said, bringing to light the need for local resource mobilisation to begin to fund preparedness for epidemics at the state level.
Local resource mobilisation for immunisation was also a key discussion point at the Nigeria Health Watch Forum. Professor Tomori made a case for effective investment of Nigeria's funds, especially recovered funds that may have been previously misappropriated. He said that if this is accomplished, Nigeria will not need funds from the Global Alliance for Vaccines Initiative (GAVI), as the country has enough resources to take care of its immunisation coverage needs.
How much exactly does Nigeria need to immunise the nation? Wonodi talked about a 10-year plan that has calculated what it will cost to run the nation's immunisation program. From 2018 to 2028, the Nigerian government is going to spend nearly N7 billion ($2 Billion) to buy vaccines. GAVI will support with about $700 million but the bulk of the financing must come from the Nigerian government. This means that when the country graduates from GAVI support, Nigeria will require around N106 billion ($300 million) every year to buy vaccines; "So, when we talk about beyond procurement, we are not yet beyond procurement; we still have to continue the advocacy to ensure that the procurement happens," she said.
Innovative approaches that can work
Mr. Oghenetega Iortm, Co-founder/CEO of GRICD, a cold chain technology solutions company said that most of the solutions behind refrigerating vaccines were very expensive, so their goal was to build affordable and smart equipment. Considering Nigeria's power problem, this innovation ensures the potency of vaccines are maintained throughout the entire process. Ms. Azuka Okeke, Regional Director, Africa Resource Centre, said her office works closely with the government to prioritise supply chain because it is not enough to get a vaccine into the system, but that the vaccines remain potent until it administered. She emphasised the need to improve the maintenance culture of cold chain equipment in order to ensure that we "vaccinate to immunise". Dr. Uchenna Igbokwe, Principal at Solina Health, said the focus should be on balancing vaccine distribution, because there was a lot of disparity in the vaccine coverage rate, however the plan should be to bring all the states to the same level of immunisation provision.
Do the little you can: #AdoptAPHC for immunisation
Puzzled by the low demand for vaccines in some areas in Nigeria, Mrs Chika Offor, Chief Oversight Officer at the Vaccine Network for Disease Control, said she decided to start a project called, "Adopt a community". She adopted Damangaza Angwa Usawa community, around Lokogoma, Abuja. In this community, they discovered that mothers didn't believe in immunisation because they didn't understand the need for it when you are not sick. After 5 years, through their advocacy and community engagement efforts, coverage in that community increased to over 90%. "We tried every strategy. The beautiful thing I took away from my time in the private sector is, innovation is anything that works. Do whatever it takes to make sure that the message gets to where it needs to go".
She added that, "To have an immunisation culture we should start a movement so that it becomes natural for someone to say they want to go for immunisation. Where you live there is a PHC and a community near you. Adopt a PHC, once in a quarter, go there and check. Is the water running? Are people coming for immunisation? Do they have antigens, do they have light? If we all ask questions, things will improve."
All agreed that funding for vaccines should be everyone's responsibility, from Federal and State Government, to the private sector. Health insurance programmes were one of the innovations touched upon that could be used to fund immunisation programmes and Dr. Wonodi said, "This is where we need to build bridges with other sectors to ensure that health insurance covers everybody and there is enough to cover the vaccine programs because that is how other countries who have done it have been able to achieve it".
As a nation, we must be willing to learn and adopt innovative procurement and supply chain strategies from the private sector just as we have adopted community sensitisation strategies. We must be willing to ask questions, of ourselves and of the government. What happens when the GAVI funding transitional period comes to an end in 2028? Where do we go from there?
Vivianne Ihekweazu, Director of Programmes at Nigeria Health Watch, put it aptly in her closing remarks; "Without health, we have no economy, we have no country. It is time that we begin to look internally to fund epidemics."
What plans do your states have to fund immunisation programmes? How much funding has been allocated to preventing, detecting and controlling the spread of infectious diseases in your states? It is time that we all start asking our state health representatives these questions.