Oyadiran OT, Usman SA, Osoba ME, Olukorode SO, Lucero-Prisno III DE. Towards effective and efficient COVID-19 in Nigeria. Journal of Global Health Reports. 2021;5:e2021023. doi:10.29392/001c.21404

Reports Towards effective and efficient OC VID-19 vaccination in Nigeria Oluwafemi T Oyadiran 1, Shamsudeen A Usman 2, Moyosoore E Osoba 2, Sarah O Olukorode 3, Don E Lucero-Prisno III 4 1 Medical Research Council Unit, The Gambia, London School of Hygiene and Tropical Medicine, Fajara, The Gambia, 2 St. Nicholas Hospital, Lagos, Nigeria, 3 Lagos State University College of Medicine, Lagos, Nigeria, 4 University of Ilorin Teaching Hospital, Ilorin, Nigeria Keywords: covid-19, cold-chain, nigeria, vaccination https://doi.org/10.29392/001c.21404

Journal of Global Health Reports Vol. 5, 2021

Vaccines are prospective subverts in battling the COVID-19 virus ravaging the globe and the Nigerian cold-chain system needs a thorough overhaul in order to optimize distribution. This paper presents a situational analysis of the Nigerian cold chain system, the challenges and opportunities that exist. The problems plaguing the aforementioned system are diverse, ranging from lack of infrastructure, inadequate capacity and limited integration of recent technology to poor training of workers in the cold chain system and these problems are accentuated by the storage peculiarities of the Pfizer and Moderna COVID-19 . It also compares the capabilities of cold chain workers in the various geopolitical zones in Nigeria and gives a succinct insight into the situation of the cold chain system in neighbouring African countries. Additionally, measures to mitigate the devastating effects of the defective cold-chain system and facilitate effective and efficient distribution of the vaccines are also proffered and these measures include reorganization of the supply chain, training of vaccinators and technicians, accurate estimation of future needs and procurement of infrastructure to increase storage capacity and preserve the cold chain. Finally, it offers recommendations on COVID-19 vaccine procurement in consistence with our economic realities and distribution.

Although little is known about vaccination in West Africa transportation and storage in a potent state from the man- before the colonial era, research showed the involvement of ufacturer to the point of use. This requires suitable cold colonial doctors in introducing vaccines to Africa. With the chain infrastructure, compliance with standards, and effec- help of their European counterparts, they built laboratories tive management. In most countries, the vaccine cold-chain called Pasteur Institutes for vaccine production.1 system consists of cold rooms, freezers and ice-lined re- Inasmuch as vaccination began in Nigeria during the frigerators, cold boxes, vaccine carriers, ice packs and per- colonial era, the World Health Organization (WHO) for- sonnel. Distribution of vaccines in Nigeria would follow the mally created the Expanded Program on political divisions of the country. Nigeria consists of six (EPI) in Africa in 1974 with the aim of eradicating six dis- geopolitical zones further divided into a Federal Capital eases: , measles, , pertussis, tuberculosis, Territory and thirty-six states which are further divided into and . In 1978, Nigeria’s EPI was created by the World 774 local government areas (LGA). The cold-chain system of Health Organization (WHO) with the aim of providing vac- the country is made up of five strata; the National Strate- cines against the six aforementioned diseases for children gic Cold Store (NSCS) which is the primary storage site for aged 0-2 years. This intervention’s coverage peaked in the all vaccines in the country, six zonal stores located in each early 1990s reaching 81.5% of Nigeria’s children popula- geopolitical zone in the country receive supplies from the tion.2 NSCS, state stores receive supplies from zonal stores, LGA The Nigerian government changed the EPI to the Na- stores receive vaccines from their state store and the PHC tional Programme on Immunization (NPI) in 1996 to show centers get supplies from LGA store.3 its dedication to the programme. Eventually, the NPI was merged with the National Primary Health Care Develop- CHALLENGES OF THE COLD-CHAIN SYSTEM ment Agency (NPHCDA) in 2007, the agency in charge of primary health care (PHC). Nigerians are vaccinated accord- POOR INFRASTRUCTURE ing to the NPI schedule and are expected to have completed the schedule by the age of one. Additionally, house-house With the persistent increase in population, onset of new polio campaigns are held in order to maintain a polio-free diseases, advent of novel vaccines and breakdown of cold status. chain equipment (CCE), the current cold chain capacity is bound to be insufficient. Findings suggest that Nigeria cur- rently has a cold chain capacity of 201m2 and needs a total COLD CHAIN SYSTEM IN NIGERIA - capacity of 672m2 to meet up with demands. Hence, there is a 70% deficit of the routine maximum demand.3 With Vaccine cold-chain management is essential for vaccine reference to the ultra cold chain capacity of Nigeria, Dr Towards effective and efficient OC VID-19 vaccination in Nigeria

Faisal Shuaib, the Executive Director of the National Pri- about half (51.3%) had appropriate practice.9 mary Healthcare Development Agency, disclosed during a Another study conducted in 35 immunization clinics in tour of the National Strategic Cold Store (NSCS) in Abuja Ile-Ife, Southwest Nigeria, showed that only 54% of vacci- that the NSCS has three ultra-cold chain equipment which nators were aware of the shake test, only 19% could inter- have a combined capacity of 2100 litres; operate at a tem- pret colour changes on a vaccine vial monitor and just 29% perature of -85°C and can store up to 400,000 doses of the of respondents kept record of vaccine stock-on-hand.5 Pfizer vaccine.4 Additionally, with the current design of the Nigerian cold DIFFICULTY TRANSPORTING VACCINES TO ENDPOINTS chain system and possession of 6340 CCE as against the 9565 CCE needed to achieve coverage in every ward in the Availability of potent vaccines in sufficient quantity to the country, there is a CCE gap of 3225; an overt deficit that end users is crucial to the success of the cold chain. How- negatively impacts vaccination coverage.3 Also, it was re- ever, there are areas that are difficult to reach due to un- ported that in some facilities in Ile-Ife, equipment needed navigable terrain, poor access roads and distance to storage to maintain the cold chain were lacking as only 37.1% had sites.10 Individuals in hard-to-reach areas consequently thermometers, 31.4% had refrigerators for storing vaccines, have low vaccination coverage. A study revealed that over 45.7% had cold boxes and only 20% had emergency trays. one-third of polio in 2013 were from under-immunized and Furthermore, electricity and water supply were available in hard-to-reach areas and vaccine coverage in some of these only 31.4% and 45.7% of the facilities respectively.5 Find- areas was as low as 23% for Oral 3 and 22% ings from a study done in Oyo revealed that epileptic power for Pentavalent vaccine 3.11 Although transportation from supply and absence of generator fuel were the major chal- national to state stores is quite reliable, there are numerous lenges faced in storage facilities while others were insuffi- breakdowns in the supply chain from local cold stores to cient backup refrigerators and cold boxes, poor temperature endpoints. monitoring tools among others.6 These unacceptable indices aren’t peculiar to Nigeria. The efficiency of the oldc chain system has also been de- Drawing comparisons with Ghana, a study carried out in a terred by the use of dated equipment, limited integration of rural district in Ghana revealed an average score of 60%, technology as many facilities still make use of stem ther- 32%, 27%, 53% and 16% in the areas of temperature control, mometers while continuous temperature trackers and log- stock management, distribution, vaccine management and gers as well as temperature-sensitive alarms are generally information system respectively.12 Similarly, exposure of lacking at storage sites. Hence, out-of-range temperature vaccines to out-of-range temperature is a widespread prob- may often go undetected when the monitors are not on site lem in Cameroon as studies conducted in forty health facil- and this culminates in poor temperature monitoring and ities located in 8 districts in Cameroon revealed that only control and reduced potency of vaccines.6 52.5% (21 of 40 facilities), 20.6% (7 of 34 facilities) had at least one freezer and constant power supply respectively SUBPAR TRAINING OF COLD CHAIN WORKERS while almost 27.5% of the health facilities were conducting EPI activities without any cold chain equipment.13 Simi- Human resource is integral to the proper functioning of the larly, a study conducted in 94 health centres in the Central cold chain and the capabilities of the workers in this system Region in Togo revealed that approximately 30% of these will invariably have an impact on its efficiency and effec- facilities lacked refrigerators for storing vaccines while 19% tiveness. There is an important association between regular had refrigerators were out damaged or out of commission.14 training and awareness of by health work- Overall, there is limited progress in achieving universal ac- ers. A study carried out among vaccinators in Benin, South- cess to immunization in sub-Saharan Africa as only 13% of ern Nigeria revealed that 29.2% had received no training countries in the region achieved 80% coverage in each dis- in cold chain management, 22.1% of respondents did not trict in 2015 and in 2016, only 19% of the countries sup- store vaccines under appropriate conditions, 64.9% had bad ported by the Global Alliance for Vaccines and Immuniza- cold chain monitoring practices, and 64.2% had bad prac- tion met the WHO’s 80% benchmark for effective vaccine tice of storing heat-sensitive vaccines.7 These findings are management.15 similar to those found in a study conducted among 457 Pri- mary Health Care Workers in Kwara, North Central Nige- STORAGE PECULIARITIES OF COVID-19 ria, where about half (52.1%) of the respondents knew the optimal vaccine storage temperature, most (67.8%) of the VACCINES participants were aware of the shake test but only 48.8% of them knew how to conduct it. Though 58.4% knew the VVM The advent of the COVID-19 vaccines have ushered in a stages, only 45.3% could interpret it correctly.8 A similar ray of hope in dealing with this deadly pandemic. However, study conducted in Giwa, Kaduna, a state in Northwestern low- and middle-income countries (LMIC) such as Nigeria Nigeria to evaluate the knowledge, attitude and practice of need to figure out w ho to protect its teeming population cold chain management among primary health care work- and meet up with the storage requirements of the vaccines. ers found that majority (71.8%) of the respondents knew The Pfizer and Moderna vaccines were designed with the right temperature range for which vaccines should be mRNA technology that requires intensely cold storage to stored. However, only 3.8% had good knowledge of cold elongate shelf-life. The Pfizer variant requires storage at chain management. While most respondents (78.5%) -70°C ± 10°C for up to ten days unopened and on getting to showed a positive attitude towards cold chain management, its point of use, it can either be stored in ultra-low temper-

Journal of Global Health Reports 2 Towards effective and efficient OC VID-19 vaccination in Nigeria ature freezers for up to six months, in thermal shippers for preserve the potency of vaccines and prevent wastage. up to 30 days whilst refilling with dry ice every five days and Train vaccinators and technicians. In other to meet regular hospital refrigeration units at 2-8°C for up to five up with the need to rapidly vaccinate as many Nigerians as days. Once thawed or refrigerated under 2-8°C, the vaccine possible, vaccinators who can be mobilized swiftly will be cannot be refrozen.16 On the other hand, the Moderna vari- required. As such, the number of vaccinators required may ant can be stored at -20°C for up to six months, 2-8°c for up exceed the number of currently trained and experienced to 30days within the six-month shelf life after thawing and vaccinators, particularly because the existent immunization at room temperature for up to 12hours.17 workforce will be required to maintain the NPI. It is unar- The Oxford-AstraZeneca vaccine uses double-stranded guably a necessity that the vaccinators for COVID-19 re- DNA technology unlike the single-stranded mRNA technol- ceive comprehensive training and competency assessment ogy employed by Pfizer and Moderna. Hence, it has lower to ensure that those who receive the vaccine are safe and chances of degrading at lower temperatures and can there- more so, public confidence in the process is established. A fore be stored at regular refrigerator temperature. Conse- complete online course on COVID-19 vaccination training quently, it has a shelf-life of 6months when refrigerated at has been drafted by the WHO in conjunction with the 2-8°C. Furthermore, the Oxford-AstraZeneca vaccine costs United Nations Children’s Fund (UNICEF) for use by coun- US$3-4 (N1,143-1,524) as opposed to US$37 (N14,098) for tries in the training of frontline health workers. This re- Moderna and US$20 (N7621) for Pfizer.18 source can be adapted by Nigeria’s Ministry of Health, translated to major ethnic dialects, and used in the training SOLUTIONS ON STORAGE AND DISTRIBUTION of the nation’s COVID-19 vaccination workforce. Additionally, maintenance and repair of CCE requires ex- tensive technical know-how. The average time taken to re- History has demonstrated that a vaccine in itself is not a pair a fridge at the LGA level of the cold chain in Nigeria is panacea; it is pertinent that logistical and cold-chain sys- two months to two years. Hence, it is important for Nige- tems are efficient in the storage and distribution of vaccines ria to adopt hands-on training approach of technicians at to ensure potency upon administration. Owing to the high local technical colleges and tertiary institutions and spare cost and storage requirements of the Moderna and Pfizer parts for CCEs should also be made readily available. This vaccines respectively, the Oxford-Astrazeneca vaccine ap- will create an extensive workforce that can promptly detect pears a feasible alternative for LMICs like Nigeria. While and tackle problem with CCEs and this will ultimately challenges with the Nigerian cold chain system abound, the strengthen storage and distribution capacity. This method following can be employed to ensure success in vaccinating which was adopted in Ethiopia led to the training of 516 majority of Nigerians against the novel coronavirus: technicians and restoration of 100m2 CCE capacity. CCE Reorganize supply chain. The Federal Government of maintenance and repair is currently in the module of some Nigeria is in control of two levels of the chain including technical colleges in Ethiopia and Tanzania.19 the NSCS. A 3-hub system was designed to reduce the bur- den on the NSCS after an analysis of the NPHCDA storage ADEQUATE NEEDS FORECASTING challenges. The 3-hub system involves Kano, Abuja (NSCS) and Lagos zonal storage sites receiving vaccines directly Estimation of capacity and vaccine needs is pivotal to the from suppliers and delivering them directly to States Stud- efficiency of theold c chain given that it takes approxi- ies show that moving from the two tier federal system to a mately two years to procure and install cold chain equip- single 3-hub federal system would reduce storage needs by ment.19 Needs estimation can be done using previous con- 30%3 lower cost of operations leaving zonal stores available sumption (assessed at the national level), target population for a sudden increase in capacity requirement. Additionally, (assessed at the national level) and size of immunization the implementation of the 3-hub federal system will foster sessions (assessed at the primary health centres and other prompt availability of vaccines to states by eliminating the facilities where the vaccines are given)20 Veritable data also zonal level. needs to be taken particularly at the local level where visi- Increase storage capacity and integration of recent bility into vaccine inventory levels is generally lower as the technology. Effective storage of vaccines is an integral accuracy of forecasting and needs estimation depends on component of the supply chain management as it ensures the source data used.3 The WHO EPI forecasting tool is very that vaccines do not lose their potency. Recent study useful for this process as it analyses different scenarios and showed that for current vaccine programs e.g. Polio, Bacil- also provides a multiyear forecast (three to five year pe- lus Calmette-Guerin, Tetanus etc., there is a need for in- riod) of vaccines, safe injection supplies, storage capacity crease in storage capacity at all zonal levels within the fed- and cold chain equipment.20 eration to reach 100% reliability. Therefore, an expansion of the current storage facilities is a prerequisite prior to ac- DEVELOPMENT OF MOBILE SESSIONS FOR HARD-TO- quiring the coronavirus vaccines. Due to the unreliability REACH AREAS of Nigeria’s power sector, funding should be channeled to- wards procuring clean and efficient ooling c technologies In order to ensure adequate coverage in hard-to-reach ar- such as solar-powered refrigerators. Additionally tempera- eas, immunization outreaches and adoption of non-generic ture monitoring and control devices should be introduced transportation methods to circumvent transportation bar- into the cold chain system. These devices give real-time riers should be considered. Mobile teams should be created temperature, alert workers when out-of-range tempera- and equipped with boats for coastland and other vehicles tures are detected causing them to intervene and ultimately

Journal of Global Health Reports 3 Towards effective and efficient OC VID-19 vaccination in Nigeria capable of navigating various terrains. in order to design and implement the aforementioned so- lutions. With a teeming population of over 200million peo- DISTRIBUTION OF COVID-19 VACCINES ple, extreme poverty levels, limited primary health centres, cold chain equipment and storage capacity, procurement of the OxfordAstraZeneca variant is more in consistence with Salient ethical considerations should guide the distribution our realities if we are going to achieve a nationwide cover- of the COVID-19 vaccines. In light of the limitation in vac- age. Finally, outsourcing a carefully calculated percentage cine supply, the WHO Strategic Advisory Group of Experts of storage and distribution to accredited private facilities on Immunization (SAGE) proposed a 3-stage prioritization under the purview of the local government may reduce the roadmap for vaccine administration where (1-10 % of a burden of vaccine storage on the government and facilitate country’s total population is vaccinated in Stage 1, effective and efficient vaccination against covid-19 in the (11-20)% in Stage 2, and (21-50)% in Stage 3.21 The public country culminating in eradication of COVID-19 in Nigeria. health strategy employed in the administration of vaccines should depend on the burden of disease and the local epi- demiology. The current epidemiological setting in Nigeria is that of community transmission.22 Hence, health workers FUNDING and older adults within the country-defined specific age cut-off should be prioritized for vaccination in Stage 1. In None stage 2, older adults not covered in stage 1 including per- sons with comorbidities, disadvantaged or persecuted AUTHORSHIP CONTRIBUTIONS groups, sexual minorities, people living with disabilities, refugees, internally displaced persons, health workers in- All authors contributed equally to the draft and final ersionv volved in immunization delivery, high priority teachers and of the manuscript school staff should be vaccinated. In stage 3, other teachers and school staff, other essential workers outside health and COMPETING INTERESTS education sectors, pregnant women etc. should receive the vaccine.21 All authors have completed the Unified ompetingC Interest form available at http://www.icmje.org/conflicts-of-inter- CONCLUSIONS est/ in line with the Journal of Global Health editorial policy and declare no conflicts of interest. Despite the numerous challenges plaguing the system, op- portunities are equally numerous. A sturdy roadmap, strong CORRESPONDENCE TO: political will and intense collaborations will increase the Shamsudeen Ayomide Usman feasibility of the proposed solutions. Accurate data collec- St. Nicholas Hospital, Lagos, Nigeria tion and appropriation of funds should also be prioritized [email protected]

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Journal of Global Health Reports 4 Towards effective and efficient OC VID-19 vaccination in Nigeria

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21. WHO SAGE Roadmap For Prioritizing Uses Of 22. Garba B, Zakaria Z, Salihu MD, Bande F, Saidu B, COVID-19 Vaccines In The Context Of Limited Bala JA. Breaking the cycle of the COVID-19 Supply. https://www.who.int/publications/m/item/wh transmission: A challenge for Nigeria. J Glob Health. o-sage-roadmap-for-prioritizing-uses-of-covid-19-va 2020;10(2). doi:10.7189/jogh.10.020309 ccines-in-the-context-of-limited-supply. Accessed January 1, 2021.

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