COVID-19 outbreak: a potential threat to routine vaccination programme activities in Nigeria

ABSTRACT

COVID-19 is an infectious disease caused by the most recently discovered coronavirus (SARS-CoV-2). The virus and disease were unknown before the outbreak began in the city of Wuhan, China, in December 2019. Nigeria and other sub-Sahara Africa countries like the rest of the world introduced several lockdown measures as part of their public health response to mitigate the spread of the virus. This, however, was not without the likelihood of consequences considering the weak health systems. The access and supply side of vaccination was more likely to have been affected by the lockdown measures. When vaccination services are disrupted even for brief periods during emergencies, the risk of outbreak-prone vaccine-preventable diseases increases, leading to excess morbidity and mortality. This highlights the importance of maintaining essential services such as vaccination in times of emergency. There is therefore an urgent need to ensure that children are protected against those diseases for which vaccines already exist. The COVID-19 outbreak has posed a new hindrance to vaccination activities in Nigeria and across Sub-Saharan Africa with associated threat to surveillance of vaccine-preventable diseases. Achieving and sustaining high levels of vaccination coverage during this period must, therefore, be a priority for all health systems.

Introduction

COVID-19 is an infectious disease caused by the most recently discovered coronavirus (SARS-CoV-2). The virus and disease were unknown before the outbreak began in the city of Wuhan, China, in December 2019. COVID-19 has spread to essentially all countries worldwide, has infected almost 20 million people, and has killed well over half a million people.¹ In Nigeria, since the outbreak started over 41,000 confirmed cases and more than 800 deaths have been reported.² The country accounts for the second-largest number of cases in Africa behind South Africa³ The outbreak had happened, leaving many nations unprepared and with weak health systems. Nigeria and other sub-Saharan Africa countries like the rest of the world introduced several lockdown measures as part of their public health response to mitigate the spread of the virus. This, however, was not without the likelihood of consequences considering the weak health systems.

While routine vaccination programs have improved significantly across sub-Saharan Africa since the launch of the Expanded Programme on Immunization in 1974, Nigeria's, routine vaccination coverage for all recommended vaccines has remained poor although with a previously high but unsustained rate in the early 1990s. Findings from the Nigeria Demographic and Health Survey (NDHS), showed that the country had only recorded a meager 18% rise in vaccination coverage over 15 years. The vaccination coverage increased from 13% in 2003⁴ to merely 31% in 2018⁵ a decade and a half after. The documented explanations for poor childhood vaccinations coverage includes misperception, inadequate human resources, ineffective supply chains, poor service delivery, weak governance, conflicts, etc. The COVID-19 outbreak has posed a new hindrance to vaccination activities in Nigeria and across sub-Saharan Africa with associated threat to surveillance of vaccine-preventable diseases. With an already poor routine vaccination coverage pre-pandemic, there is a significant chance that more children will miss out on life-saving vaccines that can prevent debilitating diseases during this pandemic. Strong leadership, supervision, political commitment, adequate financing, and efficient coordination amid the disruption caused by the pandemic are essential to achieving and maintaining high levels of vaccination coverage.

COVID-19 and routine childhood vaccination: threats and way out

The COVID-19 pandemic is an emerging threat to childhood vaccination program in the country, especially at a time when the global vaccination agenda is about leaving no one behind. The Gavi Alliance has affirmed that border closures and travel restrictions have led to vaccine shortages in at least 21 low- and middle-income countries. It has also resulted in the postponement of Gavi supported vaccination campaigns against polio, measles, cholera, human papillomavirus, yellow fever and meningitis, which would have vaccinated 13 million or more people across these countries.⁶ Likewise, it has been reported that over 13 million children below the age of one globally did not receive any vaccines at all in 2018, many of whom live in countries with weak health systems which includes Nigeria; this number is likely to increase due to COVID-19 impact.⁷ Children who have not received any vaccine up to 12 months of age are considered as non-vaccinated and such children are at high risk of deaths from vaccine-preventable diseases. While the partially vaccinated referring to children who missed any one of the vaccines under the national vaccination program still enjoy limited benefits from the received vaccines; there is a need however to complete the vaccination at the next available opportunity because the partial immunity wanes with time. When vaccination services are disrupted even for brief periods during emergencies, the risk of outbreak-prone vaccine-preventable diseases such as polio and measles increases, leading to excess morbidity and mortality.

Before COVID-19 pandemic, there were preexisting barriers to childhood vaccination which include low coverage especially in hard to reach and insecure areas, vaccine hesitancy/noncompliance, poor attitude, and inadequate capacity of healthcare workers, poor implementation of primary health care under one roof strategy, inadequate cold chain capacity at all levels,⁸ and the generally weak health system. In Nigeria, over three million children under 1 year are either unvaccinated or under-vaccinated.⁹ This figure may rise following the disruption of essential services due to the outbreak, and resulting in a severe drop in client attendance at health facilities. This can be attributed to unawareness of continued routine vaccination program, the fear of contracting the virus, vaccine hesitancy arising from myths and misinformation about the novel virus, brief pause of vaccination services, closure of outpatient clinics, stay at home orders, and transport issues arising from lockdown measures. Many health centers were closed while some others operated skeletal services with obvious disruption in vaccination services, especially in hard to reach and conflict-prone areas. The access and supply side of vaccination was also more likely to have been affected by the lockdown measures. Suspended transport services did not exempt mothers who might want to take their children for vaccination either in the urban cities or hard to reach rural communities. Although essential service workers, including healthcare workers, were exempted, getting transportation to health facilities for work was more difficult than usual. The inadequacy or lack of personal protective equipment have been a concern for HCWs, thus encouraging the closure of vaccination clinics or in some cases absenteeism at the health post, especially in remote communities.

The complex interplay of these lockdown measures aimed at responding to the COVID-19 outbreak and the existing challenges of routine vaccination program before the pandemic will further weaken vaccination service provision resulting in further poorer uptake of routine vaccination services. The delays, refusal, and failure in the uptake of childhood vaccination results in communities not reaching the thresholds of vaccine uptake that confer herd immunity; thus raising the chances of vaccine-preventable disease outbreak in the communities amidst the COVID −19 pandemic. Last year, the Democratic Republic of the Congo, a country fighting its largest Ebola epidemic experienced a deadly measles outbreak which took more than 6000 lives,¹⁰ this highlights the importance of maintaining essential services such as vaccination in times of emergency to prevent the outbreak of vaccine-preventable diseases. While there is an ongoing effort to find a lasting solution to the pandemic, there is a need to ensure people are protected against those diseases for which vaccines already exist.¹¹

The country because of her weak health structure needs to take steps to prioritize and sustain routine vaccination programs as essential service and prevent needless loss of lives from vaccine-preventable diseases and the consequent burden it will create on the health systems.¹² While it appears clear that no single country in the world was prepared for a pandemic as lethal, overwhelming, and devastating with huge economic costs as the COVID-19 outbreak. Unsurprisingly, some countries were less prepared than the others with Nigeria, unfortunately among them. The country’s health system is confronted with rapidly increasing demand generated by the COVID-19 outbreak. When health systems are stretched, both direct mortality from an outbreak and indirect mortality from vaccine-preventable and treatable conditions increase dramatically. The 2014 Ebola outbreak revealed that an increased number of deaths secondary to measles, malaria, HIV/AIDS, and tuberculosis attributable to health system failures exceeded deaths from Ebola viral disease itself.^13,14

Vaccine-preventable diseases outbreak could be dreadful for communities and health systems already battling the impacts of COVID-19. Unlike the Ebola outbreak, the COVID-19 pandemic emergence is without doubt associated with more severe impact on the health systems, global and local economies of countries and states, and serious disruption of regular life. Any outbreak of vaccine-preventable diseases together with COVID-19 will be a double tragedy for a country like Nigeria with a poorly performing routine vaccination program. Therefore, prioritizing routine vaccination at this critical time despite the pandemic will minimize the risk of double tragedy that can occur from any vaccine-preventable disease outbreak in the middle of an ongoing COVID-19 pandemic. Dissemination of accurate information on values of vaccines and stopping the spread of misinformation about the pandemic are important to ensure that caregivers can access routine vaccination for their children despite the pandemic. Vaccination communication should complement effort at continued service provision of routine vaccination activities at all health facilities in the country, together with disease notification and surveillance.¹⁵ This can be achieved through community engagements of traditional, religious and opinion leaders, and other key gatekeepers in the community. They should play key roles in mobilizing their communities for routine vaccination more than ever before while also dispelling myths and rumors surrounding the pandemic. Successful implementation of this strategy and others will require transparency, frequent communication with the public and specific protections to ensure access for socially vulnerable populations. There is a need for active engagement of communities and other stakeholders, along with a high degree of cooperation from individuals.¹⁶

In order to ensure that no eligible child misses routine vaccination and to further improve service delivery during this pandemic; healthcare workers and parents must be assured of their safety at health facilities by the provision of adequate personal protective equipment for healthcare workers. Also, through proper training on infection prevention and control, safety practices and conducts at vaccination sessions, especially at local levels, to ensure their safety while attending to their patients. More than ever before, there is a need for vaccination education to ensure that parents are familiar with the recommended vaccination schedule and to make sure their children receive their routine vaccines while complying with national and local preventive measures.

It is essential to emphasize the need to continue to protect communities from vaccine-preventable diseases outbreaks during this uncertain period, by prioritizing and ensuring the continuation of routine vaccination services. Thus, there is a need for innovative and dynamic approaches necessary to increase demand for vaccination using demand creation strategies combined with considerable local adaptation of operational guidelines for vaccination activities during COVID-19 pandemic.

Conclusion

The country needs to prioritize routine childhood vaccination as an essential health service during this pandemic if it hopes to enhance and sustain public demand for vaccination and reduce the threat posed by COVID-19.

Disclosure of potential conflict of interest

The authors have no conflict of interest.