You should all please read this...
Nigeria launched the
introduction of the pneumococcal conjugate vaccine (PCV)into its childhood
immunization schedule in Lokoja, on December 22nd 2014. PCV prevents one of the
deadliest bacterial causes of pneumonia, meningitis, blood infections and
middle ear infections in children. Before now, only parents with the means
could afford to vaccinate their children for thousands of naira in private
clinics. But now, government is offering it for free to all kids. This is a big
deal, so get excited!
PCV_launch_Nigeria
A journey that began 6 years ago has finally
come to a successful end. But it was not an easy ride. As I think about the
road to this introduction, I remember all the twists and turns along the way
and marvel at the tenacity and perseverance of the chief actors in this story.
In 2008, I was working
for a Johns Hopkins project called Pneumo Adip, which was set up to accelerate
the introduction of PCV into African and Asian countries. You may wonder why
anyone needs a project to do that, right? Well, it turns out that having a
vaccine that works is not enough to get countries to use it, unless the vaccine
is for Ebola. I bet countries will scramble for an Ebola vaccine, if it comes.
But then most diseases are not like Ebola. For more silent diseases like
pneumonia, it takes concerted effort to make the decision makers recognize the
burden of the disease, the value of the vaccine and the actions to take on it.
For example, it took Nigeria 21 years to adopt the Haemophilus Influenza b
(Hib) vaccine into our routine system. The first country to use Hib vaccine in
their national program started in 1991, we started 2012.
I remember sitting in
the Premier Hotel Ibadan during the 39th Annual General and Scientific
Conference of the Paediatric Association of Nigeria (PANCONF) in January 2008.
The halls were packed, the place was buzzing, the energy was infectious,
pediatricians were milling around discussing how to save babies. I had come
from Baltimore to field test a pneumonia diagnostic tool and discuss the
prospect of Nigeria introducing PCV into the national immunization program.
At one of the session
breaks, I cornered Dr. Abanida, then Director of Immunization at NPHCDA and
asked him, “Doc, when are we going to introduce penta and PCV?” “Very soon” he
replied, “We will apply for both vaccines this year”. This was an unexpected
and pleasant surprise. I had predicted he would commit to only penta, but PCV
as well? That was great. You see, it was no coincidence that we were coming
late to the penta party when countries like Kenya had introduced the vaccine 8
year before. As a country, we had been preoccupied with battling polio,
especially after the major polio vaccine rejection of 2004. In addition, our
systems were weak. Indeed, before 2005, we would not have been able to apply
for Gavi support for new vaccines even our immunization coverage was less than
50%, less than the required threshold. To get Gavi’s help, countries have to
meet certain eligibility criteria and they have to formally apply and be
approved for support.
Just as Dr. Abanida had
declared, in April 2008, Nigeria tendered their first Gavi application for
penta and PCV introduction support. In June 2008, the reviewers granted the
application a conditional approval.
Disappointed but not
deterred, in September 2008, the new vaccine application team led by Dr. Oteri,
then Gavi desk officer at NPHCDA, responded to the conditions and queries from
Gavi. But the second submission was rejected and the country was asked to
re-apply.
Three things then
happened that delayed the process for the next two and half years. First, Gavi
suspended all new vaccine applications due to internal processes and funding
constraints. No country could apply for new vaccine support in 2009. Second,
Gavi revised their new vaccine application policy, now requiring an
immunization coverage rate of at least 70% instead of 50%. Third, Nigeria’s
vaccine coverage dropped below 50% to 42% according to WHO-UNICEF estimate
released in June 2010. This new drop caused Dr. Dorothy Esangbedo, then the
President of the Pediatric Association of Nigeria, to lament bitterly and call for
stronger action to shore up routine immunization.
Under the new policy
and with the lower coverage, Nigeria could not re-apply in 2010. In fact, a
workshop in August 2010 convened by NPHCDA to develop the third submission was
truncated by the twin news that our coverage rate had dropped and Gavi coverage
requirement had increased.
When Gavi began
revising their policy, there had been talk and expectation in some quarters
that countries such as Nigeria, who were already in the application process
before the policy change, would be “grandfathered in”. That did not pan out. To
help matters, Gavi delayed the implementation of the new coverage requirement
by one year, which left Nigeria with one window of opportunity to apply in May
2011.
But there was one more
hurdle to scale. Coverage estimates for 2010 had to be 50% or better. The National
Immunization Coverage Survey (NICS), showed coverage to be 71% for 2010, but
Gavi only recognizes the WHO/UNICEF estimates, which was still 42% and would
only be updated in July. Nigeria needed the updated estimates to apply in May.
The update would be two months late. What to do?
The emails and phone
calls started going back and forth advocating for a solution. At IVAC we pushed
for different options: allow Nigeria use the NICS to apply, allow a phased
introduction, so that states that meet the coverage criteria can be supported
to introduce the vaccine, while effort be made to raise coverage in the other
states. Dr. Mohammad Ali Pate, then Minister of State for Health, was very
vocal in his advocacy to find a solution. Eventually and exceptionally, Gavi
allowed Nigeria to apply for penta and PCV in May 2011. Then in July 2011,
penta was approved and PCV was conditionally approved. All decisions were
subject to the 2010 WHO/UNICEF DTP3 coverage estimates being >50%.
After the July 2011
conditional approval for PCV, Nigeria worked on responding to the conditions
attached to the approval by strengthening the cold chain system. Then, 15
months later, in October 2012, Gavi gave the final approval for a phased roll
out of PCV to begin in 2013. However, due to global supply constraints and
other operational issues such as strikes in the Nigerian health sector, the
first child could not be vaccinated till December 2014.
I didn’t go for the
launch, but my colleagues went, and it was gratifying to see the culmination of
everyone’s effort. Big thanks should go to the NPHCDA, Gavi, UNICEF, WHO,
Pediatric Association of Nigeria, CHAI and all other groups who have pushed
hard to see this happen.
1stChild_PCV_in_Nigeria
First Nigerian Child to
receive the Free Pneumococcal Conjugate Vaccine
As I look at the grainy
picture of baby Collins, who is the first child to be vaccinated, cry out in
pain from the shots of the first PCV vaccination, I wish I could tell him,
“Baby, don’t cry, laugh
instead, even though that injection is painful. You are getting a shot a life.
Something that babies before you did not get, but thankfully those after you
will receive. If we are able to immunize 87% of your fellow babies every year
with this vaccine, we can save about 200,000 lives by 2020. Isn’t that
something to laugh or even rejoice about? Yes indeed, it is cause for
celebration. I only wish it didn’t take six long years for this to happen.
Think of all the babies we could have saved in that time. Anyway, you are too
young to understand all this. After all, what do you know? You are just a baby.
You probably just want to suck you mother’s breast right now, forget all this
noise and go to sleep. So I’ll let you be.”
Dr. Chizoba Wonodi (MBBS, MPH,
DrPH),
Nigeria Country Programs Lead,
Johns Hopkins International Vaccine Access Centre,
Advisor, Saving One Million Lives
Initiative,
Advisor, Gavi’s Strategic Demand
Forecast for vaccines.
Avon Healthcare