1. IMMUNIZATION IN NIGERIA: CHALLENGES AND WAY FORWARD A LECTURE DELIVERED AT AGPNP ANNUAL SCIENTIFIC CONFERENCE, AIRPORT HOTEL, IKEJA, LAGOS. DR I.E. UKPONG NPHCDA July 19, 2012.

2. Presentation Outline Introduction/Background Some Global Achievements Nigerian Situation Challenges Way Forward Pentavalent Vaccine Introduction in Nigeria Conclusion July 19, 2012.

3. Introduction What is Immunization? The process whereby an ind is made immune or protected from a particular infectious or disease agent. Could be Passive or Active July 19, 2012.

4. Introduction …2 Passive Immunity: of relatively short duration – Induced by admin of antibody-containing prepn (Ig or antiserum) or by transfer of maternal antibodies Active Immunity: usu of longer duration – Acquired thru introdn of antigenic material into an ind body leading to devt of specific protective antibodies or cellular immunity. July 19, 2012.

5. Introduction …3 Immunization: a cost-effective intervention which prevents suffering, disability and death. Its benefits are universal and includes improvements in health, life expectancy and positive social and economic impact at the global, national and community levels. July 19, 2012.

6. Some Global achievements Smallpox eradication Reduction in global incidence of polio by over 99% Reduction in illness, disability and death from diphtheria, tetanus, pertusis and measles. Elimination of Poliomyelitis from the WHO regions of the Americas (1994), West Pacific (2000) and European (2002). Over 2 million deaths are currently averted through immunization each year(WHO, 2007). July 19, 2012.

7. Nigerian Situation From 2000 and 2008 National coverage for all antigens was between 10% and 50%. Consequently, – the U5 mortality rate and the IMR for year 2003 were 201 per 1,000 and 100 per 1,000 respectively (NDHS,2003) – In 2008 these were U5MR – 157/1000 and IMR – 75/1000. (NDHS,2008) July 19, 2012.

8. Immunization Coverage: 2003 NDHS July 19, 2012.

9. Immunization Coverage (2008 NDHS) July 19, 2012.

10. Immunization Trend 2003,2008 July 19, 2012.

11. What are the Challenges Weak Health and PHC System in most parts of the country. – Poor funding of the PHC system – Low political will and commitment Poor Cold Chain System Shortage of Vaccines High turn over of health workers at the LGA level July 19, 2012.

12. Challenges …..2 Weak and Passive Surveillance systems. False Contra-indications – Fear of side- effects Missed opportunities. Under-served and hard-to-reach Communities July 19, 2012.

13. Reasons for Not Receiving Immunization (NDHS, 2008) July 19, 2012.

14. Way Forward Inter-sectoral Collaboration in PHC with involvement of the Private health sector. Sustained advocacy to political leadership for support. Community mobilization and sensitization thru HE in workshops, Social clubs, markets, schools and health facilities. July 19, 2012.

15. Way Forward…..2 Increased funding for the PHC system. Cold chain system strengthening: – Provision of transport logistics – Solar Refrigerators Improvement of Health Care services through daily vaccinations of eligible women and children. Disease surveillance – Data obtained is used to improve service delivery. July 19, 2012.

16. Macro-level strategies to Improve RI Intensification of Reach Every Ward (REW) approach implementation. – Adapted in 2006 in Nigeria. – LAMPS Capacity building on Basic Guide for Immunization service providers Advocacy to political, traditional and religious leaders for ownership. Community Participation in all stages of activities. July 19, 2012.

17. Micro-level Strengthening Integration of Services at the HF level MNCH Building institutional Capacity Refurbishing / Building New HFs Improved human resources for health Improved Data and Information Management NHMIS Computers Cold chain and Logistics management Effective Social and Community Mobilization. July 19, 2012.

18. Pentavalent Vaccine Inroduction In Nigeria Resulted from the desire to red the burden of Hib infections w/o incr the burden on the cold chain system or the immunization schedule. Hib causes an estimated 100,000 to 160,000 child deaths each year in Sub- Saharan Africa. Infections caused by Hib includes:Septicaemia, Septic arthritis,Meningitis, Osteomyelitis, Cellulitis, Pericarditis and Epiglottitis(with symptoms of sore throat, fever, respiratory obstruction) Inspite of the name, haemophilus influenza type b does NOT CAUSE INFLUENZA(the ‘flu’) July 19, 2012.

19. Epidemiology of Hib in Nigeria It is estimated by WHO that every year nearly 400,000 Hib associated diseases will occur in the under five years in Nigeria The incidence of Hib in 2000 was estimated at 1,775 cases per 100,000 under five children. In 2000, Hib caused 391,724 cases in under five children Pneumonia and meningitis accounted for 96.8% (379,4080 ) and 4.3%(16,667) of these cases respectively It is estimated that Hib caused 33,912 deaths 78%(26,455) of these deaths were due to pneumonia July 19, 2012.

20. Prevention and treatment of Hib Disease Hib vaccines protects against Haemophilus influenzae type b(Hib) but do not prevent diseases caused by other types of Haemophilus influenzae, such as bronchitis, otitis, and sinusitis. They do not prevent meningitis and pneumonia caused by other agents. Antibiotics are commonly used to treat Hib meningitis and pneumonia infections Treatment with antibiotics are however not always effective because some strains of the Hib bacteria may be resistant to antibiotics July 19, 2012.

21. The Pentavalent vaccine immunizes children against five diseases The Hib + DPT + Hepatitis B vaccine is called the “Pentavalent” or five in one vaccine. The Pentavalent vaccine combines five different vaccines in one injection to protect against five diseases. These diseases are: 1. Hib diseases 2. Diptheria 3. Tetanus 4. Pertussis 5. Hepatitis B The Pentavalent vaccine will replace the DPT vaccine in Nigeria’s routine immunization schedule. July 19, 2012.

22. Who should get the Pentavalent vaccine? Pentavalent vaccine will be part of routine immunization. All children between the age of six weeks and 11 months should receive three doses of Pentavalent vaccine. There is a minimum interval between Pentavalent doses of 4 weeks. The Pentavalent vaccine is not necessary in adults or children over five years. Children under six weeks of age, children older than 5 years, adults and teenagers are at a higher risk of side effects from the DPT component of the Pentavalent vaccine. July 19, 2012.

23. The Pentavalent vaccine will be a part of routine immunization in Nigeria. It will replace DPT. The Pentavalent vaccine is replacing the currently used DPT vaccine in routine immunization. The new routine immunization schedule is: AGEANTIGENS (VACCINES) GIVEN BirthBCG, OPV0, HepB0 6 weeksOPV1, Pentavalent 1, PCV 1 10 weeksOPV2, Pentavalent 2, PCV 2 14 weeks OPV3, Pentavalent 3, PCV 3 9 monthsMeasles, Yellow Fever July 19, 2012.

24. S/n Vaccination Status At initial contactDuring subsequent contacts aDPT 1 Penta 1 and any other vaccines appropriate for age Penta 2 and any other vaccines appropriate for age. Not eligible for Penta 3 bDPT 2 Penta 1 and any other vaccines appropriate for age Other vaccines appropriate for age. Not eligible for Penta. 2 and Penta. 3 cDPT3 Not eligible for Pentavalent vaccine but will report at 9 months for measles, Yellow fever and Vitamin A Not Applicable dDPT1 +Hep.B0 Penta 1 and any other vaccines appropriate for age Penta 2 and any other vaccines appropriate for age. Not eligible for Penta 3 24

25. Pentavalent vaccine comes in two forms: Liquid and Liquid + Lyophilized. Liquid + Lyophilized will be used in Nigeria. Pentavalent vaccines come in two separate formulations: 1.Liquid 2.Liquid + Lyophilized (lyophilized means freeze dried). Nigeria will be using the Liquid + Lyophilized versi on of the vaccine (though may adopt Liquid in future) which is a 10 dose vial 25 The Liquid + Lyophilized version of Pentavalent vaccine comes in two separate vials. One vial is liquid and contains DPT - hepatitis B vaccine (used as a diluent). The other vial contains lyophilized (freeze-dried) Hib vaccine. Like the measles vaccine, the lyophilized Pentavalent vaccine has to be mixed (reconstituted) before use.

26. Conclusion Nigeria’s Routine Immunization coverage can indeed get to the desired goal of over 90% coverage and the consequent reduction in Under-5, Infant and Maternal Mortality and Morbidity through the combined efforts of all stakeholders via: – Increased political will – Improved funding of health care – Increased commitment of health workers – Intersectoral collaboration and – Integration of Health services. July 19, 2012.