By Chikezie Omeje
Nigeria may continue to lose about 177,000 infants below age five annually due to poor administration of pneumonia vaccines.
On Tuesday, November15, 2016 Ramat Useni was getting ready to leave the General Hospital, Koton-Karfe in Kogi State after she had given birth three days earlier.
Her child was supposed to receive Hepatitis B Vaccine, HepB0, immunisation within 24 hours of birth, but Ramat left the hospital without immunising her baby.
The baby will also be due to receive Pneumococcal Conjugate Vaccine, PCV, in six weeks.
Apart from the PCV and Hepatitis B vaccine, the baby is supposed to receive Oral Polio Vaccine, OPV, within the first two weeks after birth under the revised Nigerian immunisation schedule.
But the hospital had told Ramat to go to the Primary Health Centre, PHC, in Ukwo in Konto-Karfe for her baby’s routine immunisation. The General Hospital, Koton-Karfe does not give immunisation.
A midwife at the maternal ward of the hospital, Ajara Mohammed said the hospital stopped routine immunisation more than a year ago because it had no means of storing vaccines.
Ajara said the General Hospital took an average of 20 births weekly but the mothers are all referred to the PHC, Ukwo or any other health centre that undertakes routine immunisation.
She said most mothers complied and accessed the immunisation while others went to their villages and never returned to any health centre until their babies get critically ill.
But Ramat’s husband had made an inquiry and discovered that the PHC only gives immunisation on Thursday, meaning that the Hepatitis B Vaccine, which the baby ought to have received within 24 hours of its birth would not come at least until 72 hours.
Almost two years after baby Collins, the first one to receive the free PVC in Nigeria, thousands of other children born after him in many states have not been receiving the life-saving vaccine that prevents diseases caused by pneumococcal bacteria.
Nigeria launched the introduction of PCV into its childhood routine immunisation on December 22, 2014, in Lokoja, Kogi State, about 65 kilometres away from the General hospital, Koton-Karfe where Ramat had her baby.
PCV prevents Pneumonia, which is a leading cause of death among under-five children in Nigeria, and is considered an effective means of protecting children against many strains of pneumococcal disease.
According to the World Health Organisation, WHO, pneumonia is the single largest infectious cause of death in children worldwide. Pneumonia can be caused by viruses, bacteria, or fungi but can be prevented by immunisation, adequate nutrition and by addressing environmental factors.
Pneumonia is most prevalent in South Asia and Africa and the common symptoms include cough and difficult breathing. WHO estimates that over 800,000 children under age five die from pneumococcal diseases each year with those less than two years of age most affected, especially in developing countries.
In Nigeria, Pneumonia claims the lives of approximately 177,000 under-five children annually. This accounts for 16% of all deaths within this age group.
The PCV introduction was done in December 2014 in three phases with eleven states, including Katsina, Kaduna, Plateau, Kogi, Anambra, Ebonyi, Ondo and Osun, Edo, Adamawa, and Yobe being the first benefiting states.. Almost all the states in the federation have subsequently integrated PCV into their routine immunisation schedule.
However, investigations by icirinigeria.org revealed that babies born in underserved communities in many states are still not getting the PCV as PHCs in the remote communities either lacked staff or are not functional. This is at least true with the three states of Adamawa, Kogi and Ebonyi visited by our reporters.
However, the Federal Capital Territory, FCT, which introduced the vaccine in June this year seemed to be doing well with PCV as most PHCs visited by our reporter in the six area councils in the territory were administering the vaccine..
The introduction of PCV was expected to save the lives of 35, 000 infants annually in Nigeria. According to the National Primary Health Care Development Agency, NPHCDA, the introduction of PCV could avert an estimated 173,225 deaths by 2018.
This is likely not going to be achieved because the states where PCV was first launched have not been able to reach 80% coverage as envisaged.
More than two million children in Nigeria have so far received their complete vaccinations with PCV since the introduction, but the country has an estimated annual birth cohort of 7.4 million infants.
Last year, Kogi State which was where the PCV was first officially launched had a target to reach 158,274 infants but ended up with only 85,910 infants, just about 54% success rate.
This year the state has made progress but a worrisome trend has been detected. The babies are probably not completing their dosage. Those that receive PCV 1 are far high than those that received PCV 2 and PCV3.
PCV is given three times over four weeks at the baby’s 6th, 10th and 14th weeks.
From January to October this year, 120, 039 babies have received PCV 1 in Kogi State and 101,231 received PCV 2 while 104,984 received PCV 3.
This case of dropout was also prominent in the previous year.
In 2015, 130,798 received PCV1 and 96,433 received PCV 2 while only 85,910 got PCV 3.
A more worrisome development is that those that receive pentavalent vaccine, Penta, are far higher than those that receive PCV.
Under normal circumstance, the number of those that receive PCV should be almost equal to Penta because they are supposed to be administered simultaneously.
This year, from January to October, 119,011 infants have received Penta in Kogi state while PCV uptake recorded only 104,984.
“Ordinarily the time of giving PCV, Penta and OPV are supposed to be the same, if not the same, the difference should be very little,” Theophilus Olorumaye, Kogi State Cold Chain Officer told our reporter. “But we discover that we have a gap between OPV, Penta and PCV. PCV is always lower but the reason we have not established.”
“Last year, it was lower because we did not have PCV for some parts of last year. It has been available this year but still the figures are not adding up.” he added.
The Kogi State Immunisation Officer, John Amaje said he had noticed the problem but they lacked funds to investigate the matter.
“We don’t know if it is data problem or dosage problem but PCV has had the same issue even when we did the first assessment,” John said, adding that “It is not only Kogi but I think about 9 states across the country.”
The PCV Post Introduction Evaluation in Nigeria Report discovered that there is knowledge gap in calculating immunisation indicators such as coverage, drop out and wastage rate in most of the health facilities in the 11 states where the PCV were first introduced.
The report also discovered inadequate cold chain & stores management in some local government areas – many broken down equipment, cold stores doubling as offices, congested dry stores, non-maintenance of equipment, non-use of equipment due to lack of fuel for the generators.
Vaccine storage is a big setback
PCVs are biological products that are sensitive to heat as well as freezing. The Immunisation Training Module for PCV Introduction in Nigeria explained that all vaccines, including PCV, should be stored between 20C to 80C except OPV which can be stored at negative temperatures during long storage periods.
According to the manual, If PCV is frozen, it loses its potency and provides no protection against diseases, and that previously frozen vaccines may also cause “aseptic abscesses.”
The manual noted that PCV contains two doses per vial and have no preservative and must be discarded after six hours of opening.
The challenge of effective storage of the vaccines is common in the three states, which our reporters visited, principally because of power and personnel challenges.
The Federal Capital Territory seemed to have overcome this challenge as most of the health centres visited by our reporter have solar fridges or improved power supply.
The General Hospital, Koton-Karfe where Ramat delivered her baby has two reasons why it is not giving immunisation – lack of storage facility and inadequate staff.
A midwife in the hospital, Ajara Mohammed, told our reporter that they used to get the vaccines from the cold chain on the immunisation day and return the leftover after the immunisation.
She said they stopped because there were only five staff in the maternity ward and they could not sustain the immunisation because it was tedious going to and fro for the vaccines.
“I’m the only one on the morning shift,” Ajara said. “The other two will take over for afternoon and night shift. One person is on leave and the other person is bereaved.”
She said they could start again if they could get the solar fridge to store the vaccines because they hardly have electricity.
The Cold Chain Officer in Koton-Karfe Local Government, Yunusa Isah, said the local government has 60 health centres but only four have solar fridges to store the vaccines.
All other health centres that render routine immunisation come to the cold chain manned by Yunusa to get the vaccines on their immunisation days and returned what remains. The cold chain also relies on solar fridges to store the vaccines.
Yunusa said, “Some health facilities have no staff, so we try to match those that have staff to run outreaches to those that do not have.”
Evidence gathered by www.icirnigeria.org showed that some of the health workers have not been coming regularly to get the vaccines on their immunisation days or run outreaches to other under-served health centres as they used to.
In Yolde Pate, a rural community on the outskirts of Yola in Adamawa State, a matron in the PHC in the community told our reporter that many of the mothers hardly come to the facility because of the distance and they had not been able to run outreaches to such far locations as they used to because of inadequate staff.
“For good nine months, I have not received salary,” Yunusa said. “Things are so difficult for us. Most of our staff we can’t even query them. We are just working on humanitarian ground.”
The Kogi State Immunisation Officer, John Amaje, said he spent an average of 120 litres of diesel to power the generator at the state’s central store. He said the place gets a maximum of two hours of electricity in a day.
“We run at least eight hours on generator daily,” John said. “We have been struggling to ensure availability of diesel. We are really struggling, trying to cope.”
Misuse of immunisation vehicles and absent health workers
Investigations by this website showed that immunisation vehicles are being converted to official cars by politicians and government officials while many health workers are distracted from their duty posts, partly as due to the economic recession in the country.
Some of the workers are taking advantage of the rice planting season to move to the farm, thus further compromising healthcare delivery in some states.
In Ebonyi state, it was discovered that some caretaker chairmen have converted the Hilux vans purchased to facilitate immunisation services in the local governments into personal use.
A civil servant who cannot be named for fear of victimisation said that council chairmen had taken possession of the vehicles, which they now used to run their personal businesses.
On Thursday, November 17, our reporter confirmed the allegation when he saw the caretaker chairman of Afikpo South Local Government being driven in the Toyota Hilux van for the local government immunisation support services at Osborn La Palm Royal Resort in Abakaliki.
In Kogi and Ebonyi states, the absence of health workers was observed in all the health centres visited by our reporter. The major reason for health workers staying away in Kogi State is because they are owned four months’ salary while others are owned as much as nine months’ salary.
Although in Ebonyi State, the civil servants are not being owned salary, health workers still hardly come to the office.
At Chief Joseph Nwuzor Elechi Comprehensive Hospital, Ugbodo which is supposed to offer a 24-hour service as written on its sign post, our correspondent spent more than an hour from 9.00 am to well after 10am, no single worker in the hospital was seen.
A nursing mother who lives close to the hospital, Ngozi Nwaite told our correspondent that a midwife had to be called on the phone to come to the hospital when she was in labour about a year ago.
At the Ebonyi State Ministry of Health which recently relocated to the new secretariat at Atido in the state capital, Abakaliki.
The only person at the section for immunisation and disease control told our correspondent that the building has not been linked to the power supply and most of them that still come to office came to hang around.
“I am a civil servant and my job is to sit down here until 4.00 pm,” the man who refused to give his name said while sitting close to the window unit of the corridor to receive fresh air.
Ebonyi State has the lowest immunisation uptake in the South east geo-political zone as well as the worst health indices in the zone.
PCV Stock out and cost implication
A nurse at the staff clinic of Abakaliki Local Government, Chinyere Onyejide, confirmed that the last time they had PCV stock out was in February, March and April last year.
She said some of the nursing mothers were called upon to complete their babies’ dosage when they got restocked.
Kogi State Immunisation Officer, John Amaje, also confirmed that the state had a stock out of PCV in 2015 but said that they have not recorded any such case this year.
The PCV stock out last year was nationwide but there is fear of possible vaccine stock out in 2017 and 2018 in view of dwindling funding for vaccines in the country.
Nigeria depends largely on donors to procure its vaccines and the PCV introduction has been supported by the Vaccine Alliance, GAVI, a non- profit organisation that rally funding to purchase vaccines for poor countries.
The country requires about $262 million for vaccines in 2017 and 2018, and as it transits from GAVI support, , it is expected to commit $181 million while GAVI provides the remaining fund.
To avoid vaccine stock out, Nigeria has to make adequate provision in the 2017 budget to meet its commitment. This may not be realistic as only a meagre N9.8 billion was budgeted for vaccines in 2016, although it is higher than the N2.5 billion appropriated in 2015 and N3.6 billion in 2014.
The head of Advocacy and Communications Department, NPHCDA, Eugene Ivase, observed that Nigeria faces an enormous funding gap for the immunisation programme due to the cost of additional vaccines, expanding birth cohort, loss of funding following GAVI graduation and insufficient budgetary allocation to vaccines.
He pointed out that “To fill the gap, Nigeria needs to secure more money for its vaccine programme starting from N29 billion in 2016 and rising to an estimated N63 billion by 2020.
“The government of Nigeria through the NPHCDA has made significant progress in Routine Immunization (RI). However, without adequate funding for vaccines, the RI system will experience setbacks by way of stock-outs that will lead to deaths from vaccine-preventable diseases.”
Chairman of the National Immunisation Financing Task Team, NIFT, Ben Anyene, says, “Without adequate funding for vaccines, the routine immunisation system will experience setbacks such as stockouts of vaccines that will ultimately lead to increased illness and/or deaths from vaccine-preventable diseases.”
Speaking in Abuja ahead of a peer-review workshop in April for officials from five Anglophone countries, Anyene said up to 7.5 million children in need of routine vaccination in Nigeria every year could be affected by the shortage of sustainable financing for immunisation.
Due to funding challenges, another life-saving vaccine, Rotavirus vaccine which was to be introduced into the Nigerian routine immunisation in the third quarter of 2015 has been put on hold till date.
Rotavirus vaccine prevents diarrhoea, which is the second leading disease and cause of death among under-five children.
Unlike PCV which is taken by injection, Rota is taken orally and its current market price in pharmacy stores ranges from N7, 000 to N8, 000 while hospitals charge from N9, 000 to N15,000 for each dose in Abuja. Rota is taken twice over a month interval.
PCV is given free of charge in public health facilities while private hospitals that get their stock from government charge service fee.
In Abuja, www.icirnigeria.org discovered that private hospitals charge from N1, 000 to N1500 for service fee while private hospitals in Lokoja charge between N200 and N500 for a service fee.
“We try to make them understand that the vaccine is free but they say that they want to charge for administrative cost,” Rilwanu Mohammed, the Executive Secretary of FCT Primary Health Care Development Board told our reporter.
Rilwanu said he had given the PCV to 48 private hospitals, which charge a token for service fee while the rest of public hospitals administer the vaccine absolutely free.
Certain private hospitals in Abuja charge as much as N10, 000 to N15, 000 for PCV but an investigation by www.icirnigeria.org discovered that the private hospitals did not get their vaccine from the government but purchased them from the manufacturer.
Pharmacy stores in Abuja are selling PCV between N10, 000 and N12, 000. However, it was learnt that they also buy from the manufacturer.
Two types of PCV are widely available globally – PCV10 and PCV13. Nigeria adopted PCV10, which is manufactured by GlaxoSmithKline of Belgium while Pfizer of United States of America manufactures PCV13.