Adequate supply of cold chain facilities is essential in the delivery of life-saving routine vaccines to the last mile. However, Nigeria is still struggling to cover the storage deficit which was accentuated during COVID-19 pandemic. ADETOLA BADEMOSI, in this piece, looks at the factors hindering the delivery of quality vaccines to remote areas in the country.
Kasimu Zakariya and Abass Haske are community health extension volunteers in Kabin Mangoro Primary Healthcare Centre (PHC), situated in Kabin Mangoro community in the Federal Capital Territory (FCT). The community has Gade indigenes and also accommodates the Hausas and Fulanis.
However, Kabin Mangoro is situated deep in a bushland, a distance of over 67 kilometres from Abuja’s Central Business District.
A first time journey to the community leaves one bewildered. There is a long stretch of untarred road that is lonely, dusty and seems as though it leads nowhere. After riding on a motorcycle for about one hour, the village appears from a distance.
In the community exists a primary healthcare centre (PHC) that has nothing to depict a typical health centre. Apart from the roofing sheets blown away by the wind, the wards look unkempt, adorned with worn-out beds and dust, while cobwebs have taken over parts of the interior.
With no basic amenities like water, good roads, electricity and telecommunications network, Kasimu, in a bid to make routine vaccines available for children in the village, has to embark on a two-hour treacherous journey on his motorcycle every two weeks.
He receives routine vaccines like the polio, diphtheria, BCG, Rota, Penta vaccines, among others, from Kuje Local Government Area (LGA) secretariat. The LGA is one of the six LGAs of Abuja.
“We usually get routine vaccines from the Kuje Local Government secretariat whenever we have immunisation. It is about two hours to and from our village,” said Kasimu who also doubles as the Routine Immunisation focal person at the PHC.
In an environment where electricity is unavailable and the nearest cold-chain facility is two hours away, one could not help but wonder how the facility’s vaccine freezer is being managed.
Across Africa, governments and donors have made progress in making life-saving vaccines available in African countries but getting them in good conditions to the “last mile” has been a major challenge.
Vaccine cold chain is a network of cold rooms, freezers, refrigerators, cold boxes and carriers that keep vaccines at the right temperature at every link on the long journey from the manufacturing line to the syringe.
However, findings have shown that electricity is a major challenge with cold-chain management. In some cases, other factors are insufficient backup refrigerators and cold boxes, poor temperature monitoring tools, among others
For Kasimu and Abass, maintaining these vaccines’ efficacy through every means possible is their topmost priority, a reason they adopt the twice-a-month vaccination schedule.
According to Kasimu, “We only collect for the number of children we are expecting. We have our monthly target population and we immunise twice a month due to the nature of the road and other factors.
“We do immunisation every two weeks so we have to economise it.”
Despite owning a motorcycle, providing logistics to convey the vaccines from the secretariat dispensing point to the community is a Herculean task for Kasimu.
“We find it difficult to supply vaccines because of the difficulty in getting motorbikes to town. Although I have one, it is in bad shape. Sometimes, they have to send the vaccine through a bike man directly from town,” he lamented.
Vaccines are kept in cold boxes and administered to children within 48 hours. However, the leftovers are stored in the freezers donated to the Kabin Mangoro health facility in 2021.
The freezers were funded by Gavi, the Vaccine Alliance, as part of its Cold Chain Equipment Optimisation Platform (CCEOP) and procured through UNICEF.
Prior to the donation, what was used in the facility for vaccine storage was a small-sized refrigerator powered by a generating set.
Being the only health workers manning the community PHC, Kasimu and Abass after all efforts to make these vaccines available to the PHC, are also faced with parents’ biases against immunisation.
They say some parents would usually not bring their children to the health centre for routine immunisation, citing cultural and religious beliefs.
“We have issues with people’s attitude towards taking vaccines. Some will say due to their family background they don’t take injections. Even oral polio vaccines they don’t allow. We called the village head to explain to him and when he called the concerned persons, they gave him their reasons,” he explained.
An unmanned health centre
The community’s village head, Yinusa Kabir, lamented the dearth of social amenities in the community, especially in the aspect of quality healthcare.
Kabir, while interacting with Nigerian Tribune in his sparsely furnished palace, said neither doctors nor nurses are available in the health centre except for the two volunteers, Kasimu and Abass.
“Getting quality healthcare here is challenging because currently the primary healthcare centre doesn’t have permanent staff. It is our children that finished from health institutions that are managing the place and they are only volunteering to help the community and nobody is paying them,” said Kabir.
He said the medical personnel who were initially deployed to the community could not stay due to the community’s peculiarities such as distance, lack of good road, absence of electricity and telecommunications network and spate of insecurity.
Importance of vaccine cold chain
One of the major targets of the Sustainable Development Goals (SDGs) is Goal 3. Target 3.8 is ‘Access to safe, effective, quality and affordable essential medicines and vaccines for all.’
From the manufacturing stage to actual vaccination, maintaining a degree of temperature is critical to retaining the potency of vaccines. As a result, cold chain management is essential for transportation and storage.
According to the Pan American Health Organisation (PAHO), the cold chain is a set of rules and procedures that ensure the proper storage and distribution of vaccines to health services from the national to the local level.
“The cold chain is interconnected with refrigeration equipment that allows vaccines to be stored at recommended temperatures to maintain their potency,” it said.
Vaccines help prevent diseases and each dose administered is expected to be potent enough to provide immunity against the targeted disease. Going by this, to think that a vaccine is likely to provide very low efficacy when it is not properly stored bolsters the need to raise conversations around this.
UNICEF states that a high-quality cold chain allows health workers to deliver life-saving vaccines to every last child, stressing that they must be stored within a specified temperature range from the time they are manufactured until the moment of vaccination.
“This is because temperatures that are too high or too low can cause the vaccine to lose its potency (its ability to protect against disease). Once a vaccine loses its potency, it cannot be regained or restored,” it said.
Nigeria’s immunisation supply chain architecture comprises the national, zonal, states and local government areas (LGAs) and health facilities. The National Strategic Cold Store (NSCS) is located in Abuja while the zonal cold stores in the six geopolitical zones are in Bauchi, Minna, Kano, Lagos, Enugu and Warri.
Each state and LGA houses their cold stores in the capital city of the state and 774 LGAs while the health facilities are located across the wards in the LGAs.
How COVID-19 accentuated Nigeria’s cold chain inadequacy
Nigeria, after India, according to UNICEF’s 2023 State of the World’s Children report, has the second highest number of zero-dose children in the world. Its vaccination rate was also affected in the peak of the COVID-19 pandemic in 2020 where children missed out important life-saving routine vaccines.
Also, the WHO attributed the decline to “COVID-19 related issues such as service and supply chain disruptions, resource diversion to response efforts, and containment measures that limited immunisation service access and availability.”
Similarly, in the peak of the COVID-19 pandemic, the storage peculiarities further accentuated the cold-chain inadequacy of some countries including Nigeria.
According to the storage and handling summary for Pfizer and Moderna COVID-19 provided by the Centre for Disease Control (CDC), the vaccine may be stored in the freezer between -50°C and -15°C (-58°F and 5°F) until the expiration date.
For refrigerators, it said the vaccine may be stored between 2°C and 8°C (36°F and 46°F) for up to 30 days.
This underscores the importance of reliable cold-chain to vaccine supply to the last-mile. This may have spurred the United Nations Children Emergency Funds’ (UNICEF) intervention in terms of provision of solar powered vaccine cold-chain in Nigeria and 33 other countries.
Meanwhile, the Executive Director, National Primary Health Care Development Agency (NPHCDA), Dr Faisal Shuaibu, in a written response to enquiries from the Nigerian Tribune, said the country requires an annual 125,450 litres (L) and 150,000L of negative and positive storage at the national level.
Currently, he said there is a deficit of 44,217L and 63,915L respectively, a situation that necessitated the receipt of multiple shipments “at a time and rental of warehouses to cope with the deficit.”
Further in his response, Dr Shuaibu said the national, zonal and state stores are equipped with Ultra Cold Chain (UCC) equipment, Walk-In-Cold-Rooms (WICRs) and Walk-in-Freezer-Rooms (WIFRs) while the LGAs cold stores and health facilities are provided with chest freezers and Solar Direct Drive (SDD).
Similarly, in 2021, UNICEF delivered 800 ultra-cold chain freezers to nearly 70 countries, with a storage capacity of 200 million mRNA vaccines.
According to UNICEF, the Japanese government had provided approximately $39 million in emergency funds for “the development of vaccine cold chains in Nigeria as well as 31 other African countries affected by COVID-19.
“The supply chain challenges highlighted by COVID-19 vaccination effort also underlines the need for massive expansion of storage space, which will confer a measure of resilience in the system,” said Nigeria’s former Minister of Health, Dr Osagie Ehanire, while also confirming the inadequacy.
N2.4bn to scale up vaccine cold chain, supply in five years
Data shows that between 2018 and 2022, government’s budgetary allocation to upscale vaccine cold-chain and supply is an approximated N2.4 billion ($5.2 million).
A careful study of the document showed that compared to 2018 and 2019, the allocations increased in 2020, 2021 and 2022.
Government’s efforts at improving storage capacity gap
In the face of increasing population as well as the introduction of new vaccines in the country, the Nigerian government, as part of its efforts to improve the storage capacity gap in the country, embarked on a national storage expansion project called the ‘Three-Hub Project.’
The project involved the expansion of the Abuja store, the Kano and the Lagos cold stores to address the cold chain capacity needs of the country till 2035.
Meanwhile, NPHCDA Executive Director, Dr Shuaibu, has disclosed the deployment of over 9,000 Cold Chain Equipment (CCE) across LGAs and health facilities in the country under the Cold Chain Equipment Optimitisation Platform (CCEOP) initiated by Gavi Alliance, with the Federal Government financing the project.
“Upon completion of the ongoing installations, Nigeria will have a ward saturation of 96 percent health facilities with functional solar equipment. The remaining four percent without functional solar CCEs are wards with insecurity or without built health facilities,” said Shuaibu.
Getting quality vaccines to the last mile: Experts react
A public health expert, Professor Chimezie Anyakora, amplified the need for political will and massive investment to reinforce Nigeria’s cold-chain facilities as this is crucial to public health. He stressed the need for authorities to deploy the use of drones in delivering vaccines to hard-to-reach communities.
On his part, Dr Kolawole Oladipo, a specialist in Medical Virology, Immunology and Bioinformatics, stressed the need to appropriate adequate funds for this purpose.
“Nigeria must ensure that sufficient funds reach the operational level of the programme regularly. Invest in modernising vaccine supply chains and management to ensure that the correct amounts of the right potent vaccines are available at each vaccination session. Investments in innovations that can overcome access barriers to vaccinations are needed,” he said.
This report was supported by the International Women’s Media Foundation’s Global Health Reporting Initiative: Vaccines and Immunization in Africa
While also speaking on Nigeria’s likelihood to produce its own vaccines, he said the government will have to commit adequate funding to research and development.
Oladipo said, “Yes, Nigeria has all what it takes; we have done it in the past. What is needed is more commitment from government and private organisations in terms of funding the aspect of research and development.”
This report was supported by the International Women’s Media Foundation’s Global Health Reporting Initiative: Vaccines and Immunization in Africa.
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