Routine immunisation (RI) plays a critical role in reducing morbidity and mortality among children under five, as vaccine-preventable diseases such as tuberculosis, measles, and pneumonia are among the leading causes of mortality of under-five children in developing countries like Nigeria. With pneumonia alone claiming the lives of over 800,000 children annually, ensuring adequate RI coverage becomes critical in preventing these deaths. Therefore, prioritising and sustaining high immunisation coverage levels should be a fundamental goal for all health systems.
For decades, Nigeria has faced persistent challenges in achieving adequate RI coverage, which was further exacerbated by the COVID-19 pandemic. Experts attributed these challenges to a variety of factors, including ineffective supply chains, poor service delivery, inadequate human resources, low demand due to negative perceptions, religious and cultural influences, financial gaps, accountability issues, weak governance, and poor data quality.
Efforts to achieve and sustain high RI coverage rates before COVID-19
Since the early 1990s, when Nigeria achieved a universal childhood immunisation coverage of 81.5%, after the introduction of the Expanded Programme on Immunisation (EPI) in 1974, there has been a gradual but consistent decline in RI coverage. However, in collaboration with development partners, the government has formulated and implemented innovative strategies to reverse the decline and transform this situation.
In 2012, the number of states with less than 50% RI coverage increased from eight in 2011 to sixteen. Consequently, the number of unimmunised children rose from 2.5 million in 2011 to 3.2 million in 2012, contributing to 40% of all vaccine-preventable deaths among children under five in the same year. This prompted the development of the National Routine Immunisation Strategic Plan (NRISP) after the "Lafia retreat" in 2013, with the goal of lowering the number of unimmunised children by at least 87% and ensuring sustained national coverage by 2015.
According to Dr. Faisal Shuaib, Executive Director and Chief Executive Officer of the National Primary Health Care Development Agency (NPHCDA), the establishment of the National Emergency Routine Immunisation Coordination Centre (NERICC) in July 2017 improved Nigeria's RI landscape. As per Multiple Indicator Cluster Survey data, RI coverage for children age 12-23 months who received all vaccinations recommended by their first birthday witnessed a remarkable increase from 23% in February 2018 to 44% in August 2021. According to Dr Shuaib, "NERICC's strategic interventions are focused towards surpassing Nigeria's Strategy for Immunisation and Primary Healthcare System Strengthening (NSIPSS) projected average of 84% coverage in 2028," as outlined in the Strategy for Immunisation and Primary Healthcare System Strengthening (NSIPSS).
COVID-19 disrupted coverage and revealed vulnerabilities in the RI system.
A child is considered fully vaccinated by the Federal Ministry of Health if they have received tuberculosis, DPT, polio, and one measles vaccination in the five visits during the first year of life. All vaccinations must be received by children between the ages of 12 and 23 months.
However, the emergence of the COVID-19 pandemic exposed gaps in the health system, disrupting ongoing RI efforts and posing a significant risk of reversing the progress made. With intensified measures to combat the pandemic, including the implementation of non-pharmaceutical interventions and enforced lockdowns, there was a noticeable decline in immunisation coverage.
Between July 2019 and August 2020, the BCG coverage rate in Oyo State fell by 3.7%; yellow fever and measles coverage rates dropped sharply from 77.0% and 74.5% to 64.6% and 58.6% respectively, and Penta 3 coverage dropped by 16% nationwide.
In order to address supply chain challenges, the Federal Ministry of Health (FMoH) and the NPHCDA obtained flight waivers to ensure the timely arrival of vaccines. NPHCDA also held training sessions for health workers and issued directives to facilitate RI sessions, particularly outreach programmes. Furthermore, the use of dashboards at national and state levels enabled effective surveillance of RI gaps, which contributed to increased coverage rates.
A decline in funding support for RI
The Federal Government of Nigeria covers the full cost of traditional vaccines (such as BCG, Penta3, yellow fever, measles, etc.) and the Hepatitis B vaccine and co-pays for newer GAVI-supported vaccines. At the sub-national level, State and local governments are responsible for funding and implementing immunisation programs. However, DHIS2 data revealed a decline in funding support from state governments for conducting RI and PHC services declined from 31.8% in July 2019 to 24.6% in July 2020. Available funds were redirected towards the COVID-19 response, resulting in a decrease in routine immunisation and supportive supervision (RISS) visits.
To mitigate the funding problem in states during the COVID-19 pandemic, reprogrammed funds from partner earmarked funds, such as World Bank Multiphase Programmatic Approach funds (MPA) for PPEs, GAVI, and CDC were used to alleviate funding constraints in states, and have also improved access to available funds for RI.
Nigeria's Path to Progress in increasing RI coverage for all children
The benefits of vaccines are fully experienced when children receive all recommended vaccine doses in a timely manner. 64% of children aged 12-23 months did not receive all routine immunisations, with 46% being partially vaccinated, and 18% of children not vaccinated at all. Only 36% of children aged 12-23 months received all recommended vaccines in Nigeria. The southern zones have significantly more children that are fully vaccinated than the northern zones.
Due to the COVID-19 pandemic, an estimated 6.2 million children in Nigeria did not receive a single dose of their routine vaccines from 2019 to 2022. To reach these eligible children with life-saving vaccines, the government of Nigeria, through the National Primary Healthcare Development Agency (NPHCDA), in collaboration with the World Health Organization (WHO) and its partners, including Gavi, the Vaccine Alliance is intensifying various strategies to optimise the "Big Catch-up campaign" to improve immunisation coverage across the country. Nigeria has the willpower to cover 80% of the targeted zero-dose population by 2028. The goal is to reduce the number of zero-dose children in Nigeria by 15% by 2024, and 80% by the end of 2028 (the 2018 strategic document for 10 years).
It has become crucial for the government to devise mechanisms to ensure no child is left behind. Some of the measures to be implemented include improving the leadership, building the capacity of the leaders, increasing monitoring routine immunisation sessions and supervision, and improving accountability and integration of health activities to ensure encompassing health services. By implementing evidence-based policies and taking decisive actions, we can work towards enhancing and sustaining improved coverage rates for routine immunisation. This proactive strategy would be critical in effectively addressing future pandemics and their impact on immunisation programmes in Nigeria.
To achieve universal routine immunisation (RI) coverage in Nigeria requires a collaborative approach involving various stakeholders from the government, private sector, donors, financial institutions, research institutions, healthcare providers, and other relevant partners.
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The Big Catch-up" initiative: A call for collaborative action
"The Big Catch-up" campaign which aims to strengthen immunisation efforts for children, particularly in response to the declines observed during the COVID-19 pandemic, is a notable event that highlights the global commitment to vaccination efforts.
On 24th April 2023, global partners including WHO, UNICEF, Gavi, the Vaccine Alliance, the Bill & Melinda Gates Foundation, Immunisation Agenda 2030, and many other global and national health partners, joined forces to call for "The Big Catch-up", a targeted global effort to boost immunisation rates and ensure that children receive the essential immunisations they need for a healthy future.
"The Big Catch-up" initiative carries significant importance for Nigeria, as it will specifically target the 20 countries where the majority of children who missed immunisations in 2021 reside. To effectively capitalise on this opportunity, the Nigerian government, in partnership with the Federal and State Ministries of Health, must work closely with the involved stakeholders to strengthen the healthcare workforce, improve immunisation delivery systems, foster demand for vaccines within communities, and address any existing gaps or obstacles that hinder the restoration and uptake of immunisation services.
By focusing on these critical areas, Nigeria can make significant progress in bridging the immunisation gap and ensuring that children receive the necessary vaccines they need for good health and protection against vaccine-preventable diseases. This collaborative effort will be instrumental in achieving sustained progress in routine immunisation across the country.
