Dealing with National Health Emergencies in Nigeria COVID-19: Lessons from Polio Eradication

Nigeria once accounted for more than half of the polio cases around the world but today, after a successful vaccination programme, the country is polio-free. Now up against COVID-19 and aiming to vaccinate 40 per cent of the population by the end of 2021, we can look to our experience with polio for lessons.

In 2012, after a national vaccine rollout programme had suffered years of setbacks, President Goodluck Jonathan declared polio as a national health emergency in Nigeria. By 2020, increased efforts to eradicate polio had resulted in Nigeria finally being declared free of the virus. ‘Polio is no longer endemic in Nigeria,’ the World Health Organization announced. But in 2020, too, however, the Buhari administration declared another national health emergency: COVID-19.

By March 2020, a presidential task force had been set up to handle Nigeria’s COVID-19 response and plan for a vaccine roll-out. The task force had the ambitious aim of vaccinating 40 per cent of the eligible population against COVID-19 by the end of 2021, and 70 per cent before the end of 2022. With the new COVID-19 health emergency underway, a closer look at what made the polio vaccine roll-out successful can help suggest possible strategies for Nigeria’s COVID-19 vaccinations.

KEY PARTNERSHIPS

Great strides in disease eradication typically begin with effective international and local partnerships, because healthcare partnerships play a significant role in disease management and eradication around the world. In the eradication of polio in Nigeria, the Global Polio Eradication Initiative (GPEI), a global coalition of national governments and several humanitarian organizations, proved to be the most instrumental partnership.

Polio eradication efforts began in Nigeria as early as 1996. From the onset, the GPEI led the funding, procurement and supply of vaccines, strengthened by partners such as the Global Alliance for Vaccines and Immunization (GAVI) and Rotary International. In later years, the presidential task force on polio eradication led efforts to distribute vaccines by working with agencies such as the National Primary Health Care Development Agency (NPHCDA), state governments’ polio task forces and community stakeholder groups such as the Traditional Leaders Committee on Primary Health Care and the Nigerian Inter-Faith Group. During the 24-year journey to eradicate polio, this network of partners helped to create polio eradication initiatives, emergency plans, expert review committees, outbreak response assessment teams and other strategic initiatives, before finally achieving the goal of eradication in 2020.

With COVID-19, the proven efficacy of vaccines has brought the pandemic under management, but the global scramble to purchase them has left lower and middle-income countries disadvantaged. GAVI, a coalition of humanitarian organizations including the Bill and Melinda Gates Foundation, has stepped up to encourage equity in vaccine access through its COVID-19 Vaccines Global Access (COVAX) programme, in which Nigeria is a participant. As part of its plan to vaccinate 108 million eligible Nigerians, the presidential task force on COVID-19 has leveraged several partnerships to ensure that Nigeria can access vaccine doses. Initially, Nigeria received a pledge of 56 million vaccine doses to kick off its vaccination drive with 16 million doses expected from COVAX and 40 million from the African Union. Nigeria is also expecting over 6 million additional doses from other entities including the private sector coalition against COVID-19 (CACOVID), the MTN telecommunications group and national governments such as India and the United States, bringing its total pledge to about 85 million doses.

As with Nigeria’s polio eradication efforts, the presidential task force on COVID-19 has formed local partnerships to ensure that its vaccine roll-out plan will be successful. The task force is working in collaboration with the NPHCDA, the National Agency for Food and Drug Administration and Control, the Nigeria Centre for Disease Control as well as various other professional bodies to achieve its vaccine roll-out plan.

The use of a centralized presidential task force in managing Nigeria’s local and international partnerships is one of the major lessons Nigeria has gained from polio eradication efforts. Before forming a presidential task force on polio eradication between 1996-2012, Nigeria experienced 16 years of slow vaccination efforts in the drive to eradicate polio, and by 2012 Nigeria accounted for more than half of polio cases globally. However, forming a presidential task force to establish and coordinate partnerships in polio eradication helped Nigeria meet its eradication goal in eight years, moving the country from being the epicentre of the disease to being polio-free. The similar deployment of a centralized team at the presidency to establish and manage key partnerships against COVID-19 has made commendable efforts in just over a year. Regardless of the slow ‘snail pace start’ to the COVID-19 vaccine rollouts, analysts such as SBM Intelligence’s Ikemesit Effiong have highlighted, international partners have continued to deliver pledged vaccines and local vaccination efforts are ongoing.

THE VACCINE ADMINISTRATION PLAN

Although there are marked similarities in the partnership structures of the polio and COVID-19 vaccine rollouts, when it comes to the fieldwork involved in the administration of vaccines, several differences exist. This is understandable because different disease outbreaks require different approaches to data collection, monitoring and other public health aspects. Polio mainly affected children in identified high-risk areas in northern Nigeria such as Borno and Yobe, so Nigeria employed several strategic vaccination tactics to reach the relevant populations for vaccination. The tactics included micro-planning, a well-known public health strategy that involves detailed planning at community level for smaller healthcare populations. Micro-planning also ensures that vaccination programmes reach priority populations and that health officials can identify and deal with barriers to vaccinations. House-to-house campaigns, hospital immunizations, and vaccinations at transit points (such as nomadic cattle routes, markets, and even motor parks) were involved in the drive to eradicate polio. In areas with high-security challenges such as the North East, there were vaccination drives at internally displaced persons (IDP) camps, as well as programmes for training military personnel to administer vaccines at such locations. Lessons from the many years of setbacks the efforts of GPEI and several state primary healthcare development agencies (including those of Yobe and Borno) faced helped Nigeria transition from using hand-drawn maps to locate settlements, to using geographical information system (GIS) maps in hard-to-reach areas of northern Nigeria. These improvements and eventual disease eradication have led to the creation of a well-developed rural vaccination system; one that is able to vaccinate populations more effectively in hard-to-reach areas and handle the difficulties of navigating such terrains.

Unlike polio, which was most prevalent among the young, with COVID-19, older people and those with underlying medical conditions are more at risk of developing severe complications. Coupled with this, not rural areas but cities are currently the disease’s significant entry points. These nuances have influenced Nigeria’s approach to disbursing COVID-19 vaccines, especially its priority demographics and its use of digital technology. Although micro-planning is still involved in the process, the presidential task force on COVID-19 set up an electronic pre-registration and call-up system through optimized mobile and web pages. The government also used text messages for appointment reminders and to organize follow-ups with citizens after vaccinations.

Nigeria’s COVID-19 vaccine rollout began with healthcare and frontline workers as the top priority, with the elderly as next in line, and then the rest of the population. As part of a micro-planning strategy, local governments in urban areas with high disease burdens were identified and prioritized for vaccinations.

The digital approach to vaccine registrations means, however, that the government may not prioritize the use of its well-developed rural vaccination system in getting to populations in hard-to-reach areas. This means that rural populations without internet access may not receive COVID-19 vaccinations even if the country meets its 40 per cent vaccination target by the end of 2021. Jerry Oche, a public health financing expert, has called the digital registration process, ‘elitist because many Nigerians especially in the rural areas are not internet savvy and therefore could find this process cumbersome.’ Martin Egbanubi, the general secretary of the Nigerian Union of Allied Health Professionals (NUAHP), has also highlighted ‘inequities in the distribution and administration of vaccines in Nigeria as well as poor awareness in rural areas.’ Ultimately, differences between the vaccination rollout approaches against polio and COVID-19 are additionally driving states like Kaduna and Cross River to find novel ways like drone technology to administer vaccines in hard-to-reach locations within their territories.

VACCINE DISTRIBUTION AND LOGISTICS

One major concern raised by healthcare experts has been whether the government can effectively handle vaccine storage, transport, and delivery; especially because COVID-19 vaccines require cold chain transport and storage. According to virologist, Ibrahim Abdulfatai, ‘Nigeria can receive the vaccines but the problem that awaits us is that of logistics and storage. One thing about vaccine administration is that the cold chain is very important. You must maintain the standard of the cold chain from the manufacturer to the end dealer, to the patient it is administered to. If we can get this vaccine to places like Abuja, Lagos what about remote communities? How will they store these vaccines?’

COVAX originally pledged to supply Nigeria Pfizer-BioNTech vaccines. These require ultra-cold storage and transport temperatures of about -80°C. This vaccine brand, therefore, requires a more technical and expensive storage and handling system. However, in February 2021, Nigeria switched to the Oxford-AstraZeneca and Johnson & Johnson vaccines once these were proven effective. Both vaccines have higher storage temperatures of between 2°C and 8°C, and while they still require cold storage and transport, they are more in line with Nigeria’s refrigeration and logistical capacity, avoiding any potential loss of potency and wastage.

The distribution of polio vaccines also made use of cold chain storage, transport and distribution systems, providing Nigeria with some experience for handling the expected COVID-19 vaccines. As part of a vaccine accountability management system, the NPHCDA established cold chain monitoring systems in 2019, and this initiative included the training of key personnel for temperature monitoring. The NPHCDA management system involves the tracking of vaccine vials before field officers receive them, the monitoring of vials during vaccination, and accounting for empty vials after vaccine administration. For COVID-19 vaccine rollouts, the NPHCDA prioritized the use of its vaccine accountability management system and the leadership of its previously trained vaccine accountability officers to head the different levels of vaccine administration, including temperature monitoring of vaccine storage facilities.

Nigeria has maintained similar transport and distribution systems for polio vaccination rollouts with its COVID-19 vaccine rollouts. Distribution follows a top-down approach, with vaccines moving from the federal level to zonal or state levels, and finally to local governments where vaccine administration happens. At the zonal level, there are walk-in cold rooms for vaccine storage, while local governments make use of refrigerators to store vaccines. Vaccines are transported to the zonal or local government level by third-party logistics firms that provide cold chain transportation equipment.

Regardless of the similarities between polio and COVID-19 vaccine storage systems, and despite the concerns experts have raised, Nigeria appears determined to expand storage efforts to meet COVID-19 vaccine pledges for vaccines like Moderna and Pfizer- BioNTech, which have temperature requirements beyond the country’s storage capacity. Dr Faisal Shaibu, the executive director of the NPHCDA, notes that the Nigerian government purchased 60 additional ultra-cold storage freezers in addition to the three it had at the beginning of the year, allowing the successful receipt of Moderna vaccines donated by the United States in August 2021. This represents a new frontier in Nigeria’s cold storage and logistics capacity.

COMMUNITY ENGAGEMENT

Irrespective of the development of effective partnerships or well-planned distribution and administration systems, the success of any vaccination drive rests with the people who receive immunization. Thus, community engagement with vaccine recipients is crucial for a vaccination campaign to succeed. This includes assuring recipients and communities of vaccine safety, disbursing timely information to communities about the need for vaccinations, and dealing with perceived rumours about vaccinations.

Nigerians are not new to vaccination campaigns, but Nigerians are also not entirely receptive to vaccination campaigns. This reluctance lay behind some of the challenges to the eradication of polio. In 2003, ethno-religious sentiments in northern Nigeria cost the GPEI, Nigeria’s international partner for the eradication of polio, approximately US$500 million in additional spending. At the time, Western powers were rumoured to have contaminated polio vaccines with anti-fertility agents in a bid to reduce Muslim populations. These sentiments were fuelled by religious and political leaders, and vaccine purchase agreements had to be changed to continue the vaccination drive. Other anti-vaccination sentiments on record include communities using vaccine rejection as a means to protest government actions or policies, which happened in Jigawa and Katsina in 2018, where local communities rejected polio vaccines in protest for not receiving insecticide-treated nets for the control of malaria. Faced with such challenges, engaging with influential community leaders in hard-to-reach communities has been the only way to ensure successful vaccination drives.

Anti-vaccination sentiments are not unique to Nigeria. The 2020 coronavirus pandemic has seen a rise of conspiracy theories around the world. People have accused Bill Gates of funding vaccines for population control, and some religious leaders have outrightly proclaimed vaccinations to be ungodly. Armed with previous lessons in dealing with anti-vaccination campaigns, Nigeria’s presidential task force on COVID-19 deployed massive media campaigns even before receiving the first batch of vaccinations. To boost public confidence, leaders and people of influence, including the presidency and some state governors, have opted to receive vaccination shots publicly. States like Lagos have engaged influential district community leaders to drive local awareness of the need for vaccinations. The community engagement strategy includes a rumour response framework, which identifies and classifies rumours according to their impact, and disseminates proper information through the use of infographics on social media, text messaging, and media campaigns.

THE IMPACT OF NIGERIA’S CORONAVIRUS STRATEGY

Partial vaccinations began only six months ago, so it may be too early to create a scorecard, especially as key partners successively redeem their vaccine pledges. After receiving the first batch of COVID-19 vaccines in March 2021, Nigeria has administered 2.11 million doses, accounting for just two per cent of its eligible population. 38 per cent of the population will need to be vaccinated in the second half of 2021 for Nigeria to meet its 40 per cent target. Despite this low vaccination rate, Nigeria leads West Africa in terms of vaccination numbers. The newly deployed electronic system for vaccinations is a step in the right direction. But digitization has, so far, done little to help with the long queues at vaccination centres, with some locations reporting waiting times as long as five hours. These long queues may be the result of how the vaccine administration centres operate, and further digitization may help improve this. The distribution of vaccines to endpoints through the use of third-party logistics firms is a strategy that seems to be working effectively and has led to very few complaints about vaccine availability at centres. As conspiracy theories surrounding vaccinations continue to run wild, scepticism still exists among Nigerians and the government can only continue engaging citizens, to abate it.

As Nigeria gears towards its year-end COVID-19 vaccination target, health officials need to pay more attention to a constantly overlooked strategy—how Nigeria can deal with setbacks and adapt solutions to its failures. This strategy has been vital in successfully combating other national health emergencies, including the Ebola virus. Nigeria was the last country in Africa to eliminate the wild poliovirus, and it took several years of adapting and responding to failure before the goal of virus eradication was achieved. The creation of an emergency operations centre to improve preparedness for polio eradication became very critical to the success of eradicating Ebola, as the centre facilitated quick responses and contact tracing. As COVID-19 vaccination numbers in Nigeria grow daily, indicating societal acceptance of vaccinations, there are opportunities to also identify how responses to the challenges COVID-19 has brought could be deployed when combatting other national health emergencies

This essay was published with the support of the Nigeria Health Watch and the Solutions Journalism Network.

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