The Expanded Programme on Immunization (EPI), launched in 1978 to provide routine immunization for children under two, initially saw sporadic success. By the early 1990s, the country reached its peak with a universal childhood immunization rate of 81.5%.
However, Nigeria has since experienced a gradual and steady decline in immunization coverage. By 1996, national data indicated coverage of less than 30% for all vaccines, dropping to 12.9% by 2003. This low figure, consistent with the 2003 national immunization coverage survey, ranks among the world’s lowest and contributes to the poor health of Nigerian children. Within the West African subregion, Nigeria’s immunization rates are the worst, second only to Sierra Leone. Notably, Nigeria’s polio epidemic is the most severe in Africa, posing a threat to neighboring nations.
The goal of the Expanded Programme on Immunization (EPI) in Nigeria is to enhance the health of Nigerian children by eradicating six major diseases: polio, measles, diphtheria, whooping cough, tuberculosis, and yellow fever. Between 1985 and 1990, as outlined in the national health plan of that period, the EPI aimed to reinforce immunization efforts, expedite disease control, and introduce new vaccines and relevant technologies. In 1995, aligning with global initiatives, Nigeria committed to World Health Assembly Resolutions (WHAR) and United Nations General Assembly Special Session (UNGASS) goals to achieve polio eradication, reduce measles mortality, and eliminate maternal and neonatal tetanus by 2005.
Nigeria also embraced the Millennium Development Goals (MDGs), aiming for a two-thirds reduction in child mortality by 2005 compared to 1990 levels. Furthermore, Nigeria ratified UNGASS goals in 1998, aiming to achieve full immunization coverage for children under one year of age at 90% nationally with at least 80% coverage in every administrative unit by 2010, alongside eliminating vitamin A deficiency.
In 1998, Nigeria outlined core EPI policies, including monitoring system performance, assessing disease burdens, evaluating vaccination strategies, and ensuring immunization coverage nationwide. Following the African Regional Summit on EPI in 1999, Nigeria established specific policies to strengthen the EPI, aiming for 80% DPT3 coverage in all states by 2004, eliminating wild poliovirus-associated acute flaccid paralysis cases, reducing measles morbidity and mortality, and increasing yellow fever coverage to at least 80% by 2004. Additionally, Nigeria planned to include vitamin A and hepatitis B in its national immunization programs by 2004, ensuring coverage not less than 80% for all antigens, and adopting new technologies such as multi-dose vial policy and vaccine vial monitors.
Acceptance rates of COVID-19 vaccination in Nigeria ranged from 20.0% to 58.2% as observed by a study covering Nigeria’s six geopolitical zones. The highest rates of acceptance were observed at 58.2% 55.5% in Ondo, Edo, and Delta, 51.1% in Kano, and 50.2% across Nigeria’s six geopolitical zones. Conversely, the lowest acceptance rates were recorded at 20.0% across the six geopolitical zones, 24.6% in Bayelsa State, and 32.52% across Nigeria’s six geopolitical zones. Additionally, acceptance rates were 34.7% in Anambra, 45.6% in Abia, and 47.1% in Abuja.
Vaccination against childhood illnesses like diphtheria, pertussis, tetanus, polio, and measles stands as an important method in preventing childhood sickness and death. It is imperative for all healthcare systems to prioritize attaining and sustaining high rates of immunization coverage. Monitoring progress toward this goal can be effectively done by assessing immunization coverage data, which serves as a gauge of a health system’s capability to provide vital services to the most susceptible part of the population.
Factors Affecting Routine Immunization in Nigeria
Immunization rates in northern Nigeria rank among the lowest globally. According to the 2003 National Immunization Schedule, the percentage of fully immunized infants in targeted states was alarmingly low: less than 1% in Jigawa, 1.5% in Yobe, 1.6% in Zamfara, and 8.3% in Katsina. Consequently, thousands of children suffer from preventable diseases due to lack of vaccination.
Several factors contribute to these dismal rates. Firstly, primary healthcare services are severely inadequate and have deteriorated due to insufficient investment in personnel, facilities, drugs, and poor resource management. Additionally, public confidence and trust in healthcare services are low, largely stemming from substandard facilities and delivery standards. External “vertical” interventions by outside agencies have further weakened the capacity of local service providers to implement sustainable programs. At the family and community level, there is minimal demand for immunization due to a lack of understanding of its importance. The factors that were reported for non-acceptance of the COVID-19 vaccination were disbelief, lack of trust in the government, conspiracy theories, vaccine side effects COVID-19 fear of the unknown.
1. Misconceptions Regarding Routine Immunization
Misunderstandings about the preventive benefits of routine immunization are prevalent in Nigeria. Research conducted in six states indicates that in rural Enugu, various illnesses such as diarrhea, fever, convulsions, vomiting, and malaria are believed to be preventable by vaccines. Similarly, in rural and urban Kano, malaria, teething issues, vomiting, convulsions, and pneumonia are among the listed vaccine-preventable diseases.
During community research in Katsina state, some immunization decision-makers and caregivers asserted that only polio immunization is necessary, mistakenly believing that once a child receives polio drops, they are protected against all childhood illnesses, including those without vaccines available, such as acute respiratory infections. Those least likely to possess accurate knowledge often include individuals who do not utilize public health facilities for treating common illnesses, those with limited access to such facilities, and individuals with low levels of literacy.
2. Influence of Religion
Religion poses a significant challenge to immunization acceptance in Nigeria, particularly among the Muslim population in northern regions. Generally, areas with higher Muslim populations in the north exhibit lower immunization coverage, ranging from as low as 6% in the northwest to a high of 44.6% in the southeast. For instance, in Ekiti state, the northeastern and western areas, influenced more by Islam, demonstrate lower immunization coverage and poorer educational attainment. Christians, on the other hand, exhibit higher immunization coverage, with a rate of 24.2% compared to only 8.8% for Muslims.
3. Political Challenges
The decline in immunization appears to be linked to political issues. In Nigeria, the boycott of polio vaccinations in three northern states in 2003 created a global health crisis rooted in politics. Political challenges include low government commitment to fulfilling EPI policy and excessive centralization of EPI administration at the federal level. Poor measles coverage between 1998 and 2005 was attributed to vaccine shortages and administrative issues. Political interference has also led to patronage-based appointments and frequent personnel changes, even at the state government level, resulting in inappropriate staffing and administrative disruptions.
4. Resistance to Routine Immunization
Another significant challenge facing immunization programs in Nigeria is the refusal of certain vaccines or vaccination by parents or religious groups, particularly prevalent in the northern regions. The reasons for such refusal are delineated below:
a) Fear and Misinformation
Many decision-makers and caregivers reject routine immunization due to rumors, misinformation, and fear. Efforts to improve coverage must include addressing people’s attitudes and the influence of these on behavior. Concerns regarding routine immunization are widespread across Nigeria. In Muslim rural communities in Lagos State, fathers of partially immunized children suspect hidden agendas linked to attempts by unknown NGOs sponsored by foreign entities to decrease the local population and raise mortality rates among Nigerians. Similarly, in Jigawa, Kano, and Yobe States, there is a belief that activities are driven by Western nations seeking to enforce population control on local Muslim communities.
b) Low Confidence and Trust
There is a prevalent lack of confidence and trust in routine immunization as effective health interventions in many parts of Nigeria. A study in Kano State in 2003 found that 9.2% of respondents (mothers aged 15–49) lacked faith in immunization, while 6.7% expressed fear of side effects. Many perceive immunization to offer only partial immunity at best, leading to skepticism, as seen in Kano and Enugu. The widespread misconception that immunization can prevent all childhood illnesses diminishes trust because when it fails to provide such protection, faith in immunization as an intervention diminishes.
5. Vaccine and Immunization Supply Shortages
Under the EPI’s mandate, the primary task is to support states and local governments in their immunization programs by providing vaccines, needles, syringes, cold chain equipment, and other necessary logistics. However, vaccine supply has consistently been problematic for Nigeria, primarily due to insufficient and untimely funds release. For instance, in 2001, although the full amount was approved, only 61% was released, and late disbursement in April 2001 forced the purchase of vaccines at inflated prices. In 2002, no funds were released, and by March 2003, the funding cycle had only reached the stage of budget approval.
EPI failed to supply syringes for Rubella infection in 2005, and the limited safety boxes supplied were donated for SIAs. Following an assessment in 2003, UNICEF was tasked with future vaccine supply. Despite this, vaccine shortages persist, as exemplified by delays in cerebrospinal meningitis (CSM) vaccine supply, leading some states to purchase their stocks. Additionally, late arrival and insufficient quantities of measles vaccine exacerbated a measles outbreak in the north, with Abia receiving inadequate supplies.
Perceived Benefits of Routine Immunization
Primary advantages include promoting children’s health and ensuring their survival. Another significant benefit is the cost-saving aspect derived from reduced disease incidence and fewer hospital visits. In 2004, caregivers in Lagos and Enugu highlighted that immunization lowers both mortality and morbidity rates, alleviates parental anxiety related to child rearing, and optimizes the utilization of time and financial resources.
