Constraints of primary health care workers in the implementation of immunization in Enugu state

At the end of 2011, Nigeria was estimated to have a population of 167 million . The Expanded Programme on Immunization (EPI), introduced in 1978 with the aim of providing routine immunization to children less than the age of two years, recorded initial but intermittent successes. The optimum level was recorded by the early 1990s with the country achieving a universal childhood immunization coverage of 81.5%. But since that period of success, Nigeria has witnessed gradual but consistent reduction in immunization coverage. By 1996, the national data showed less than 30% coverage for all antigens, and this decreased to 12.9% 2003 . This figure which is consistent with the 2003 national immunization coverage survey figures is among the lowest in the world and explains the poor health status of children in the country. It is the worst in the west African subregion, only better than Sierra Leone. For instance, the polio epidemic in Nigeria is the worst in the African region and constitutes threat to other nations [3].

The vision of EPI in Nigeria is to improve the health of Nigerian children by eradicating all the six killer diseases, which are polio, measles, diphtheria, whooping cough, tuberculosis, and yellow fever. Between 1985 and 1990, as outlined in the national health plan for that period, the objectives of EPI were to strengthen immunization, accelerate disease control and introduce new vaccines, relevant technologies and tools. In1995 in line with the above, Nigeria became a signatory to the World Health Assembly, adopted the World Health Assembly Resolution (WHAR) and United Nations General Assembly Special Session (UNGASS) goals for all countries to achieve by 2005 (i) polio eradication, (ii) measles mortality reduction and (iii) maternal and neonatal tetanus elimination (MNTE). Nigeria also adopted the millennium development goals (MDGs) calling for a two-third reduction in child mortality, as compared to 1990, the year 2005. In addition to the above, the country ratified the United Nations General Assembly Special Session (UNGASS) goals urging Nigeria to achieve by 2010 (i) ensure full immunization of children under one year of age at 90% coverage nationally with at least 80% coverage in every district or equivalent administrative unit, and (ii) vitamin A deficiency elimination. In 1998 following from the above, Nigeria laid out the core activities of EPI policies which included the following: (i) monitoring of the performance, quality and safety of the immunization system through indicators; (ii) assessment of the current burden of vaccine-preventable diseases as well as the “future” burden of vaccine preventable diseases in terms of sickness, death and disability, as well as the economic burden; (iii) assessment of the impact of vaccination strategies, through on-going epidemiological surveillance and reliable laboratory confirmation, as well as impact assessments in Nigeria; (iv) monitoring of the national immunization policies, particularly the vaccines used in the country and the target population for these vaccines (immunization schedules); and (v) monitoring of the overall proportion of children and women who are vaccinated (immunization coverage) and ensuring that all districts of the country are well covered with vaccination. In 2000, following the African Regional Summit on EPI held in Harare in November 1999, the Federal Ministry of Health specifically stated its policies on the country’s initial visions for EPI as follows:
(i) Immunization System Strengthening: By the year 2004, Nigeria should achieve the EPI district-focused plan and attain 80% DPT3 coverage in all the states of the federation. The specific policy also stated that the government should ensure increased funding for EPI.
(ii) Accelerated Disease Control: By the year 2004, there should be no cases of acute flaccid paralysis associated with wild poliovirus in Nigeria. As for measles, by the year 2004 the country should have reduced measles morbidity by 90% and measles mortality by 95%; while the coverage for yellow fever is expected to increase to at least 80%.
(iii) Innovations: By the year 2004, Nigeria should include vitamin A and hepatitis B (HB) in its national immunization programmes; and the vaccination coverage should not be less than 80% as with other antigens. Under the new technology drive, the country should adopt the multi-dose vial policy (MDVP) and vaccine vial monitor (VVM) and also introduce new methods for monitoring its use.

Immunization against childhood diseases such as diphtheria, pertussis, tetanus, polio and measles is one of the most important means of preventing childhood morbidity and mortality. Achieving and maintaining high levels of immunization coverage must therefore be a priority for all health systems. In order to monitor progress in achieving this objective, immunization coverage data can serve as an indicator of a health system’s capacity to deliver essential services to the most vulnerable segment of a population .

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