The Issues with Routine Immunization in Nigeria

Routine Immunization in Nigeria
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Routine Immunization in Nigeria
Routine immunization is instrumental in the prevention of illnesses and deaths. According to Olurunsaiye and Degge (2016), immunization has been linked to the prevention of approximately 2-3 million annual deaths among children below the age of five globally. Also, immunization is a cost-effective, safe strategy for preventing illnesses and deaths. As such, there has been a widespread focus on increasing vaccination coverage around the world. Yet, in Nigeria, immunization coverage is among the lowest in the world. According to Olurunsaiye and Degge (2016), only 25% of children below two years receive full immunization. Galadima et al. (2021) indicate that in Nigeria, routine immunization coverage as of 2018 was 31%, making it one of the lowest in Africa. In addition, a lack of full immunization contributes to more than 20% of all deaths among children below the age of five years (Sato, 2020). There is a need to create strategies that will improve coverage, access, and utilization of vaccines in Nigeria to preserve more lives. As Sato (2020) indicates, some of the factors that influence access and utilization of vaccines in Nigeria include high vaccine stockout rates and skepticism among communities. This paper analyzes the issues with routine immunization in Nigeria by examining access and utilization, availability, data management, and funding, among other factors that affect immunization. It also describes health promotion and education strategies that community stakeholders can utilize to improve immunization in the Ugwunani Aku community, where there was an over 40% drop-out for pentavalent vaccines.
Routine Immunization in Nigeria
Strengthening routine immunization is paramount in the reduction of vaccine-preventable illnesses among Nigerians. However, Nigeria has one of the lowest immunization coverage in the world (Olurunsaiye & Degge, 2016). This has been attributed to a number of issues that influence routine immunization in Nigeria. These issues include access and utilization, vaccine availability, storage and potency, routine immunization data management, outbreaks, health workers’ attitude, government, and funding.
Access and Utilization
Access to and utilization of routine immunization is important in increasing immunization coverage in Nigeria. However, many mothers and their children, especially below the age of five, are unable to access or utilize routine immunization, which has contributed to the low immunization in the country. According to Umoke et al. (2021), one of the most significant factors that influence access and utilization is the distance to a healthcare facility. Most mothers and caregivers are unable to fully immunize children because of the long distance from their homes to healthcare facilities. In cases where mothers can easily reach a healthcare facility that offers immunization services, children can receive full immunization. Akwataghibe et al. (2019) indicate that those in hard-to-reach communities rarely get fully immunized because of long walking distances and difficult terrains that are difficult to navigate, especially during the rainy season. As such, ensuring healthcare facilities are within walking distances, especially in hard-to-reach communities, can be instrumental in enhancing access and utilization of routine immunization.
Another issue that influences access and utilization is skepticism and hesitance about the safety and effectiveness of vaccines arising from negative beliefs and attitudes towards vaccines. Many mothers of children who have not been fully immunized believe that vaccines are harmful and can kill or paralyze their children, and as a result, they are hesitant about routine immunization (Akwataghibe et al., 2019; Umoke et al., 2021). However, parents with fully immunized children believe in the effectiveness of vaccines. Past experiences mostly inform the beliefs about vaccines. According to Akwataghibe et al. (2019), negative experiences such as adverse events after immunization discourage mothers from fully immunizing their children. In contrast, Umoke et al. (2021) indicate that mothers consider past immunizations as effective, and this encourages them to immunize their children fully. This indicates that past experiences can impact the attitude towards immunization and influence its utilization. Taiwo et al. (2017) also attribute negative perception and attitude towards immunization to lack of knowledge and awareness. Many mothers have poor attitudes towards vaccines because they lack access to information and knowledge about the benefits and safety of vaccines.
In addition, access to routine immunization is influenced by the socio-economic status of consumers. According to Sibeudu et al. (2017), Nigerians of low socio-economic status lack access to immunization services, even when the services are free due to other financial constraints associated with accessing and utilizing routine immunization at healthcare facilities. Akwataghibe et al. (2019) add that even when services are free, mothers have to pay for immunization cards, syringes, and needles, among other items needed for routine immunization. These costs often hinder access to and utilization of routine immunization. There is a need to address these indirect costs associated with access and utilization of immunization to promote routine immunization in the country.
Vaccine Availability, Storage, and Potency
The availability, storage, and potency of vaccines contribute to the issues associated with routine immunization in the country. According to Adeloye et al. (2017), one of the reasons for low vaccine coverage in Nigeria is the unavailability of vaccines. Even when community members are aware of the benefits of immunization and have accepted routine immunization, the unavailability of vaccines hinders immunization. Sato (2020) reveals that Nigeria has a high vaccine stockout prevalence, which causes routine immunization issues. The higher the stockout rate, the lower the vaccine coverage. Also, the high vaccine stockout prevalence discourages full immunization because people get tired of visiting healthcare facilities or vaccination centers only to learn that the vaccine they need is out of stock. The unavailability of vaccines in Nigeria can be attributed to a poor vaccine supply chain. As Iwu et al. (2019) indicate, an effective vaccine supply chain ensures there are no interruptions or inconsistencies in the supply of vaccines to healthcare centers. In the absence of an effective supply chain, vaccine availability becomes an issue.
In addition to vaccine availability, vaccine storage and potency also affects routine immunization. According to Dairo and Osizimete (2016), poor handling and storage of vaccines affects their potency and results in poor routine immunization. To be effective, vaccines need to be properly stored so they do not lose their strength. Some of the factors that affect vaccine storage and potency in Nigeria include an unreliable supply of electricity, a lack of fuel for generators, a lack of backup refrigerators, high vaccine transportation costs, and a lack of sufficient cold boxes, among others (Dairo & Osizimete, 2016). The more poorly handled vaccines are stored in unfavorable temperatures, the more they become less effective. The unreliability of electricity supply in Nigeria is especially demoralizing to health workers who have to move vaccines to other healthcare facilities with generator backup or store them in cold boxes every time there is a power outage (Ogboghodo et al., 2017). They may get too tired and ignore some of the cold chain management practices that help preserve the potency of vaccines. According to Ogboghodo et al. (2017), the high mortality rate for children under five years of age has been attributed to poor cold chain management, which causes vaccines to lose their potency. Even when people are immunized, immunization is ineffective because the efficacy of the vaccines has been lost.
Routine Immunization Data Management
To monitor routine immunization and make necessary changes to enhance coverage across Nigeria, there is a need for reliable routine immunization data. According to Akerele et al. (2021), one of the challenges or issues with routine immunization in Nigeria is data quality and management. Specifically, there is a disconnection between reported immunization coverage data and true immunization coverage. This disconnection has been attributed to inaccurate and incomplete data reporting in healthcare facilities, limited utilization of routine immunization data at the local level, and delays in recording immunization data (Akerele et al., 2021). This reveals a need for better reporting mechanisms as part of routine data management.
Currently, the government of Nigeria relies on the District Health Information System (DHIS2) routine immunization module for routine data reporting (Shuaib et al., 2019). This data is then routinely collected and used by the government to improve routine immunization coverage. This module has enhanced access to routine immunization data and promoted data management at the national level. To further promote data management, the government has introduced a daily short messages system as a platform for data reporting from the local to the national level (Shuaib et al., 2019; Akerele et al., 2021). This use of the short message system is meant to address the challenge posed by a lack of internet connectivity to send data from the local to national level.
Another issue that has affected routine immunization data management is the management of immunization lists from healthcare facilities. According to Shuaib et al. (2019), the vaccination lists from healthcare facilities are rarely updated, affecting the management of routine immunization data reported on the DHIS2 routine immunization module. There is a need for establishing standard operating procedures and policies to facilitate prompt updates and management of immunization data. As Etamesor et al. (2018) reveal, the use of the DHIS2 routine immunization module has, however, improved the completeness of immunization reports and made it possible to monitor routine immunization indicators. It has also enhanced the utilization of routine immunization data in decision-making at local and national levels.
Outbreaks
Effective routine immunization requires a prompt response to outbreaks. Also, according to Ibrahim et al. (2016), preventing outbreaks of vaccine-preventable illnesses requires routine immunization campaigns in communities. However, in Nigeria, there have been issues of outbreaks and poor response to outbreaks of various illnesses, indicating that there are still issues in routine immunization coverage. For instance, Baptiste et al. (2021) indicate that there have been repeated measles outbreaks in Nigeria despite measles vaccination being introduced into the routine immunization program several decades ago. These repeated outbreaks have been attributed to low immunization coverage, leaving many children unimmunized. In addition, Ibrahim et al. (2016) indicate that delays in reporting outbreaks and subsequent delays in responding to outbreaks contribute to repeated measles outbreaks. Other outbreaks, such as yellow fever, have also resurged in Nigeria, and there have also been issues with routine immunization as it applies to the specific illness. According to Nomhwange et al. (2021), there has been a poor response to yellow fever outbreaks in Nigeria due to delays in reporting as well as unpreparedness. This has contributed to repeated outbreaks of yellow fever since 2017.
One advantage of routine immunization and improved immunization coverage is that it increases herd immunity and protects the community from outbreaks and their subsequent consequences. However, disease outbreaks in Nigeria are common because there has been poor immunization coverage. For instance, Abubakar et al. (2019) indicate that there have been repeated outbreaks of whooping cough in Nigeria due to poor immunization coverage. Further, this inadequate coverage is attributed to the blatant refusal of parents to immunize their children, as well as a lack of knowledge and information about the importance of immunization, especially among parents who lack formal education. Thus, outbreaks of diseases in Nigeria indicate a larger issue in routine immunization that needs to be addressed through widespread immunization campaigns and sensitization to increase immunization coverage and create herd immunity.
Healthcare Workers’ Attitude
Healthcare workers are an important ingredient in routine immunization. They have the skills and knowledge needed to provide routine immunization services. They interact with community members, and as such, their attitude towards routine immunization and those receiving such services is an important issue in routine immunization. According to Brown et al. (2017), the attitude of healthcare workers influences the provision and utilization of immunization services. When healthcare workers are positive about immunization programs and their attitudes reflect the same, they are more likely to offer immunization services to more people in the community.
One of the reasons for poor immunization coverage in Nigeria is the poor attitude held by health workers. Brown et al. (2017) reveal that other than having a poor attitude towards immunization services which ultimately affect their commitment to offering such services, health workers also have a poor attitude towards mothers. They are unable to interact with mothers positively and inform them about the importance of immunization, resulting in incomplete immunization. According to Umoke et al. (2021), one of the reasons mothers fail to adhere to their children’s immunization schedule is the negative attitude they receive from health workers, which hinders them from fully immunizing their children.
Negative attitudes from health workers hinder mothers from going back to healthcare facilities. According to Oku et al. (2017), healthcare workers are especially rude and disrespectful to uneducated and teenage mothers. They treat them harshly when they forget to bring their immunization cards to the clinic or arrive late for immunization. There is also preferential treatment towards certain mothers at the expense of others, such that those who arrive first at the healthcare facility for immunization services are not always the first to be served (Oku et al., 2017). This has created some level of distrust and dissatisfaction among community members. However, health workers who have a positive attitude and are polite to mothers and others seeking vaccination services are more likely to promote vaccine acceptance and utilization in the community.
Government and Funding
The government plays an instrumental role in routine immunization. It creates policies, develops regulatory systems, and provides financing for the healthcare system in general. The federal, state, and local governments are responsible for developing policies supporting routine immunization and enhancing immunization coverage (Akwataghibe et al., 2019). These policies are important in strengthening the government’s efforts in increasing immunization coverage across the country. However, according to George et al. (2016), the immunization efforts in Nigeria have been hindered by poor coordination of responsibility and authority for immunization services across various governmental levels. Without proper coordination, the delivery of immunization services becomes difficult because there is a lack of clarity on who has authority and responsibility for various immunization activities.
In addition, Olutuase et al. (2022) indicate that the existing policies are not strong enough to support the vaccine supply chain in Nigeria. There is also poor implementation of existing policies which affects the distribution of vaccines to different regions in the country. Also, there is a lack of an effective system of regulation to promote accountability and oversee immunization efforts. Olutuase et al. (2022) also reveal that there have been issues with adherence to vaccine administration policies due to the lack of an effective regulatory system for vaccines. As a result, excessive administration of vaccines occurs, causing vaccine stockouts in the country.
The government is also responsible for funding the healthcare system and, more so, primary health care. However, there are issues when it comes to funding immunization activities. Erchick et al. (2017) indicate that there are always issues with late or limited funding for immunization activities, which hinders the delivery of immunization services. For instance, in government-run healthcare facilities, vaccine collection and storage are always hindered by a lack of funds to facilitate the transportation of vaccines and to buy fuel for backup generators. Lack of sufficient funds from the government also hinders outreach activities, making it impossible for healthcare workers to reach consumers. Lack of funding especially affects communities in hard-to-reach areas, yet these communities are more likely to benefit from immunization outreach activities. In addition, the federal government is responsible for providing funds for vaccine procurement. However, according to Erchick et al. (2017), delays by the federal government to release funding causes the unavailability of vaccines at the state and local levels. Vaccine procurement has to be done in advance, yet state governments have to wait until the federal government’s budgetary processes are complete to release funds. Sometimes, this makes it impossible to procure vaccines on time.
Other than delays in the release of funds, other financial challenges influence routine immunization in Nigeria. For instance, Olutuase et al. (2022) reveal that corruption at different levels of government affects the procurement and supply of vaccines in Nigeria. Some government officials divert funds meant for vaccine procurement and use them to advance their personal agenda. In the end, corruption issues limit the supply of vaccines and affect immunization coverage. This indicates that the Nigerian government needs to put in place stringent policies and measures that not only facilitate immunization activities but also promote accountability and transparency in funding immunization activities.
Indicators
Uchenna et al. (2018) applied intensification as a strategy to improve routine immunization coverage and surveillance in Ohafia and Umuahia North local government areas in Nigeria. This section will identify the indicators measured in the study by Uchenna et al. (2018). As Lankester and Grills (2019) reveal, indicators refer to the evidence of a project/intervention’s progress towards achieving an agreed-upon target. The types of indicators include input, output, outcome, process, and impact indicators. The key indicators measured in the study by Uchenna et al. (2018) are output, outcome, and process indicators. These will be discussed in detail below.
Output Indicators
According to Schumann (2016), output indicators monitor the efficiency of a project/intervention. They only measure the quantities produced rather than the progress towards achieving objectives, and as such, they measure efficiency rather than effectiveness. They measure what is produced after the completion of activities in a project (Lankester & Grills, 2019). Outputs only measure, in numbers, what a project produces towards achieving the target/objectives.
The output indicators measured by the study include the number of supportive supervisory visits. The study found that the number of supportive supervisory visits to the two areas from the government and other partners increased from 36 to 223. This indicated a 517% increase in the number of supervisory visits.
Another output indicator was the number of monthly fixed sessions. The study measured the number of monthly fixed sessions conducted compared to the number of sessions that had been planned for the month. According to Uchenna et al. (2018), the number of monthly sessions conducted in Ohafia between January and September 2017 was 1512, while the number of sessions planned in the same period was 1558. In Umuahia North, the number of conducted sessions in the same period was 1260, while the number of planned sessions was 1434. The study also measured output indicators in terms of the number of outreach sessions conducted compared to the outreach sessions planned during the one year.
Outcome Indicators
According to Schumann (2016), outcome indicators measure the effectiveness of an intervention or a project in achieving its objective. These types of indicators measure whether the intervention/project is producing intermediate results. As such, outcome indicators focus on the intervention results to ensure it is meeting its intended objectives.
One of the outcome indicators measured in the study was immunization coverage. Specifically, the study measured the status of Penta3 for children below the age of one year and found out the percentage of children receiving Penta3 immunization increased. The number of immunized children increased from 49,515 to 51,027 and 62,429 to 66,331 in Ohafia and Umuahia, respectively. The study also measured the unimmunized status of children in the two areas. Specifically, it measured the percentage of unimmunized children and found out that the percentage of unimmunized children had reduced from 34.5% to 32.5% and 20% to 15% in Ohafia and Umuahia North, respectively. This is an indication that the intervention improved routine immunization coverage.
In addition, the study measured specific outcome indicators for each vaccine. The indicators are as follows:
* Inactivated polio vaccine (IPV) immunization status
The study measured the percentage of IPV immunization in 2017 and found that in the first quarter, IPV immunization in Ohafia was 73%, and in the fourth quarter, IPV immunization was 99%. This shows that IPV immunization coverage in Ohafia improved to almost full coverage after the intervention. However, the percentage of IPV immunization in Umuahia North was 75% in the first quarter and 72% in the fourth quarter, indicating a decline in coverage.
* MSI immunization status
MSI outcome indicator was measured as the percentage of MSI immunization in the same year. In Ohafia, MSI immunization was 64% in the first quarter and 77% in the fourth quarter. In Umuahia North, MSI immunization was 66% in the first quarter and 60% in the fourth quarter. Thus, the percentage of MSI immunization coverage increased in Ohafia and reduced in Umuahia North, respectively.
* Oral polio vaccine (OPV3) immunization status
The percentage of OPV3 immunization coverage in the Ohafia area increased from 79% in the first quarter to 100% in the fourth quarter. This indicates that immunization coverage for this specific vaccine improved to full coverage. In Umuahia North, the percentage of OPV3 immunization in quarter one was 77%, while that of quarter four was 71%, indicating a reduction in immunization coverage.
* Pneumococcal conjugate vaccines (PCV3) immunization status
The percentage of PCV3 immunization coverage in Ohafia increased from 77% in the first quarter to 99% in the fourth quarter. This outcome indicator shows that the intervention improved PCV3 immunization coverage in Ohafia to almost full coverage. The percentage of immunization coverage in Umuahia North was 76% in the first quarter and 72% in the fourth quarter, revealing a reduction of PCV3 immunization coverage in 2017.
* Penta3 immunization status
The percentage of Penta3 immunization coverage in Ohafia increased from 79% in the first quarter to 99% in the fourth quarter. There was an improvement of Penta3 immunization to almost full coverage in this particular region. Contrary to this, in Umuahia North, the percentage of Penta3 immunization in quarter one was 77%, while that of quarter four was 71%, indicating a reduction in Penta3 immunization coverage.
* Yellow fever (YF) immunization status
The percentage of YF immunization coverage in Ohafia increased from 62% in the first quarter to 77% in the fourth quarter. This shows a significant improvement in YF immunization coverage in the area. However, Umuahia North YF immunization coverage reduced from 66% in the first quarter to 55% in the fourth quarter.
* Overall immunization status
Overall, the vaccine outcome indicators for the two combined regions showed a percentage increase in immunization coverage from 73.3% in the first quarter to 91.8% in the fourth quarter. This increase in percentage shows that the intervention achieved its objectives.
As revealed earlier, the study measured the number of supervisory visits from government officials and partners as the output indicators. As Schumann (2016) indicates, outcomes are achieved through the outputs that are produced by the intervention. As such, since the intervention in the study by Uchenna et al. (2018) produced an increased number of supervisory visits as the outputs, these outputs led to the achievement of another outcome. This outcome was measured by the proportion/percentage of immunization drop-out rates. According to Uchenna et al. (2018), the drop-out rate reduced from 18% to 6.4% in Ohafia and from 19% to 5.6% in Umuahia North. This indicates that the intensification improved routine immunization in the two areas and increased the number of fully immunized children. The supervisory visits also produced an outcome measured by the percentage of timeliness and completeness of immunization data reporting. Uchenna et al. (2018) indicate that the percentage of immunization data timeliness and completeness increased from 90% to 100% within the study period. This outcome indicator was also produced by the use of appropriate tools to report data promptly.
Finally, the study measured the percentage of AFP surveillance as an outcome indicator. AFP surveillance helps detect poliomyelitis cases, and Uchenna et al. (2018) applied the intensified immunization strategy to improve routine immunization and AFP surveillance outcomes. The percentage of AFP cases reporting rates increased by 26%. Also, AFP cases and stool adequacy reporting increased from 99% to 100% due to increased supportive supervision from government officials and immunization partners.
Process Indicators
Process indicators encompass the inputs, activities, and outputs of a project, and they measure how the inputs, activities, and outputs contribute towards achieving the project’s objectives (Lankester & Grills, 2019). They measure whether the required inputs, the planned activities, and the immediate results of these activities occurred. One of the process indicators measured in the study was the percentage of monthly fixed sessions conducted. The study revealed that in Ohafia, the percentage of monthly fixed sessions conducted was 91% and in Umuahia North, the percentage of monthly fixed sessions conducted was 80%. The monthly fixed sessions are activities that need to be carried out to intensify routine immunization and increase coverage. In addition, routine immunization intensification also required outreach activities. The study also measured the number of outreach interventions implemented compared to the number of outreach planned in both areas. It found that outreach implemented increased from less than 20 to 140 in both areas.
Potential Additional Indicators
While the indicators measured in the study by Uchenna et al. (2018) were sufficient, additional indicators, which will be discussed in th...