EFFECT OF COLD CHAIN FACILITY STATUS ON VACCINE DISTRIBUTION AND INFANT IMMUNIZATION COVERAGE IN GADA LOCAL GOVERNMENT OF SOKOTO STATE NIGERIA. A.A. ADEIGA1, S. AHMAD2 1 NIGERIAN INSTITUTE OF MEDICAL RESEARCH,YABA, LAGOS, NIGERIA. 2 SOKOTO STATE MINISTRY OF HEALTH, SOKOTO, NIGERIA. THIRD ANNUAL CONFERENCE ON ‘VACCINES ALL THINGS CONSIDERED ‘ AT SHERATON PENTAGON SOUTH , ALEXANDRA VIRGINIA. USA 3RD -4TH NOV. 2005.

BACKGROUND History of Immunization in Nigeria Immunization activities started in 1956 prior to eradication of small pox. Expanded Programme on Immunization (EPI) was introduced in 1978 and implemented in 1979. Objective was to protect children against Tuberculosis, whooping cough, poliomyelitis, tetanus, diphtheria and measles. Evaluation after 1st five years in 1983 showed: low immunization coverage of 10% high infant mortality rate from vaccine preventable diseases.

a. lack of political will Background contd. The programme was revised and relaunched in 1984. There is still no progress. In 1988, National Immunization Days (NID) was introduced and conducted. In 1990, Nigeria attained Universal Childhood Immunization with coverage of 81.5% for all vaccine antigens. Thereafter, routine immunization suffered a setback due to a. lack of political will b. creation of more LGAs c. low demand for immunization Consequently The Federal Government relaunched EPI as National Programme on Immunization (NPI) in July 1996 to reflect national committment. It became an agency in 1998 to take charge of all immunization activities. Background contd

SPECIFIC OBJECTIVES OF IMMUNIZATION promoting child health reducing vaccine preventable childhood diseases reducing mortality of children from deadly diseases preventing and controlling epidemics STATE OF THE PROGRAMME SO FAR Low immunization coverage is frequently reported. Reasons poor knowledge of immunization long distance to site of immunization centers long waiting for health care providers poor medical facilities poor motivation bad terrains of communities

EXPERIENCE OF GADA LOCAL GOVERNMENT: Gada LGA is in Sokoto state with the capital in Gada town. - LGA Population = 226,525 - Population children < 5yrs = 62,000 It has 4 health districts: Gada A Gada B Kaffe Wauru Terrain of the Health Districts is shown in Table 1.

TYPE OF TRANSPORTATION TABLE 1: TERRAIN OF DISTRICTS DISTRICTS TERRAIN TYPE OF TRANSPORTATION Gada “A” PLAIN, EASY TO REACH MOTORABLE WITH ANY VEHICLE Gada “B” HILLY AND DIFFICULT TO REACH LAND ROVER, MOTOR CYCLE, DONKEYS Kaffe SANDY TERRAIN AND DIFFICULT TO REACH DONKEYS AND MOTOR CYCLE Wauru PLAIN AND EASY TO REACH MOTORABLE WITH ANY VEHICLE

Report on state of health in the LGA Uneven distribution of health and cold chain facilities Health districts with bad terrains suffer neglect in distribution of facilities High morbidity and mortality rates are frequently reported in disease outbreaks especially measles This history informed the need to conduct a survey of Cold chain facilities and capacity to contain vaccines in the health districts Aim of the study to establish status of cold –chain facilities in each health districts to assess quantity and type of vaccines available in the facilities of each district to determine how this and other factors affect infant immunization coverage for BCG, DPT, OPV, and measles vaccinations. Report on state of health in the LGA

METHOD The survey conducted addressed, the following:- Existence and number of cold chain facilities such as freezers, fridges, cold boxes in each health district; Power source to each health district Types and number of doses of vaccines contained in the facilities Infant Immunization coverage of children under 2 years of age using EPI cluster method. Questionnaires were administered with WHO cluster form for infant Immunization. Recall history and Immunization Cards were used as tools .

RESULT AND DISCUSSION SITUATION OF FACILITIES AT GADA TOWN LGA HQS 1. Cold Chain facilities Freezer Fridge Cold boxes with Ice packs Working condition 6 4 26 All working well 2. Power Source Electric Power from National Grid Alternative Power Supply Connected 2 big generators plus Solar Power Plant 3. Vaccine Holdings Vaccine in the facilities Vaccine Preservation 20,000 doses of BCG 15,000 doses of DPT 40,000 doses of OPV 10,000 doses of Measles vaccine All preserved at – 20 ◦C

RESULT AND DISCUSSION(CONTD) STATUS OF COLD CHAIN FACILITIES AT DISTRICTS 3 health districts are inadequate Gada A ( partially) Gada B ( no working facility) Kaffe ( no working facility) Wauru has adequate facilities (Table 2) POWER SOURCE TO THE DISTRICTS (Table 3) VACCINE HOLDING FACILITIES IN THE DISTRICTS (Table 4)

TABLE 2: STATUS OF COLD-CHAIN FACILITIES IN THE HEALTH DISTRICTS . WORKING CONDITION FREEZER FRIDGE COLD BOXES Gada “A” 1 3 Fridge partially working. Cold boxes functional when ice packs are available. Gada”B” 4 Cold boxes functional when ice packs are available. Kaffe Fridge not functioning. Cold boxes functional when ice packs are available. Wauru 2 5 All facilities are functioning.

TABLE 3: POWER SOURCE TO THE HEALTH DISTRICTS ELECTRIC POWER FROM NATIONAL GRID. A LTERNATIVE POWER SUPPLY Gada “A” NOT CONNECTED SMALL SIZE GENERATOR Gada “B” NO GENERATOR Kaffe BROKEN DOWN GENERATOR Wauru CONNECTED MEDIUM SIZE GENERATOR

TABLE 4: VACCINE DISTRIBUTION IN HEALTH DISTRICTS VACCINES IN THE FACILITY AT TIME OF VISIT VACCINE PRESERVATION Gada”A” 500 doses of DPT 300 doses of tetanus toxoid Preserved at 150C in the fridge Gada “B” No vaccine storage - Kaffe Wauru 500 doses of BCG, 1,200 of DPT, 600 of oral polio vaccine 800 measles Preserved at -200C in freezer and 40C in the fridge

RESULT AND DISCUSSION (Contd.) IMMUNIZATION COVERAGE low Immunization coverage many missed opportunities due to: a low availability of vaccine at health districts vaccines badly stored where power is epileptic no vaccine storage at districts with bad terrains d. seldom presence of health care providers (Tables 5& 6)

TABLE 5: IMMUNIZATION COVERAGE OF CHILDREN UNDER 2 YEARS OF AGE DISTRICTS PERCENTAGE OF CHILDREN NOT IMMUNIZED PERCENTAGE OF CHILDREN PARTIALLY IMMUNIZED PERCENTAGE OF CHILDREN FULLY IMMUNIZED COMPLETION OF IMMUNIZATION AT ONE YEAR OF AGE. Gada”A” 65.2% 28.1% 6.3% 2.4% Gada”B” 74.2% 19.7% 5.3% 0.8% Kaffe 72.6% 21.5% 5.4% 0.5% Wauru 47.4% 23.6% 24.3% 4.7%

TABLE 6: IMMUNIZATION COVERAGE BY ANTIGEN RECEIVED IN THE TABLE 6: IMMUNIZATION COVERAGE BY ANTIGEN RECEIVED IN THE HEALTH DISTRICTS DISTRICTS BCG (%) DPT OPV MEASLES Gada “A” 21.7 32.3 95 29.4 Gada “B” 3.4 11.7 87 13.3 Kaffe 4.1 9.3 88.3 12.5 Wauru 39.4 52 94 48.1

RESULT AND DISCUSSION (Contd.) REASONS FOR FAILURE TO IMMUNIZE Lack of transportation Mothers not informed Poor advocacy and community mobilization Lack of motivation Inadequate vaccine at health districts due to poor vaccine distribution (Table 7)

LACK OF VACCINE AT FACILITY TABLE 7: REASONS FOR FAILURE TO IMMUNIZE OR COMPLETE IMMUNIZATION DISTRICTS LACK OF TRANSPORTATION ( %) LACK OF INFORMATION LACK OF MOTIVATION LACK OF VACCINE AT FACILITY Gada “A” 13.4 35.2 26.8 24.6 Gada “B” 28.5 40.7 9.5 37.7 Kaffe 25.5 24.8 10.2 38.5 Wauru 15.6 48.2 25.8 11.4

CONCLUSION Gada B and Kaffe districts with bad terrains suffered poor vaccine distribution. Reasons: Inadequate Cold Chain facilities No source of power supply Vaccines provided only on Immunization days. Low Immunization coverage is generally reported. 3. Missed opportunities (defined as any visit by any eligible child to a health facility, which did not result in his/her vaccination) Factors attributed are: Low staff strength in the health districts Low literacy level of the community Irregular presence of health care providers causing missed opportunities Poor advocacy and community mobilization

RECOMMENDATIONS 1. Provision of: sustainable cold chain facilities such as kerosene or gas fridges, solar power plant as alternative power source. 4-wheel drive vehicles for bad terrains. 2. Increase advocacy and community mobilization 3. Formation of NGO involving the community (including religious leaders) to promote advocacy. 4. Establish community involvement to : provide people to be trained as health workers contribute to the provision of facilities 5. Subsidize cost of transportation to Immunization centers

REFERENCES: 1.Salamaso et. al., Infant Immunization coverage in Italy, estimated by simultaneous EPI cluster survey regions Bull. WHO 1999 77(10): 843-851 2.Bosu et. al., Factors attendance to Immunization sessions for children in rural districts of Ghana. Acta tropica 1997; 68(3):259-267 3.Amin. R. Immunization coverage and child mortality in two rural districts of Sierra leone. Soc. Sci. Med. 1996. 42(11): 1599-1604. 4.Gedlu E; Tesema T. Immunization coverage and identification of problems associated with vaccination delivery in Gondar North west of Ethiopia. East Afr. Med. J 1997. 74(4): 239-241 5.Sokley J; Jain DC; Harit: A.K. Dhariwal A.C. Moderate Immunization coverage levels in East Delhi: Implications for disease control programmes and introduction of new vaccines J. Trop. Paediatr 2001; 47(4): 199-203. 6.National Immunization Days reports of National Programme on Immunization for Sokoto State Nigeria 2002.