Optimising childhood immunisation in Nigeria

In 2016, about 2 million child deaths globally were prevented through routine vaccination; if all children had been immunised fully, a further 1.5 million child deaths could have been prevented. Globally, in 2016, Nigeria had the largest number of eligible infants who did not complete routine Diphtheria, Pertussis and Tetanus vaccinations. Optimal child immunisation coverage has been associated with variables acting at the child, household, community, country, health system and policy levels. This study aims to inform improvement of childhood immunisation programmes in Nigeria through examination of nationally representative survey data on child vaccination in Nigeria by child, household, community and health system factors, with a particular focus on the place of residence. Multilevel logistic regression models were applied for quantitative analyses of Nigeria’s 2003, 2008 and 2013 Demographic and Health Surveys (DHS), singly, pooled overall and stratified by rural/urban; these were augmented by qualitative thematic analysis of data collected from two slums in Abuja, Nigeria. Interview with parents, health workers and community leaders in the slums around Abuja solicited their views of the enablers and barriers to child immunisation.Fully Immunised Child Coverage (FIC, the percentage of children aged 12-23 months who had received all doses of routine infant vaccines) rose from 12.9% in 2003 to 25.3% in 2013, and varied across sociodemographic characteristics including place of residence. In pooled DHS data analysis, overall and stratified, FIC adjusted odds (aOR) were: 1. Total population- antenatal care (attendance versus non-attendance, aOR=4.42, 95% CI=2.00-9.76), place of delivery (health facility vs home, aOR=3.86, 95% CI=1.94-7.67), maternal education level (higher vs no education, aOR=6.57, 95% CI=2.32-18.59), Religion (Christian vs Muslim, aOR=2.37, 95% CI=1.82-3.10) and place of residence (urban vs rural, aOR=1.60, 95% CI=0.60-4.24). 2. Rural and urban stratified: A.Rural – antenatal care (aOR=8.37, 95% CI=5.34-13.12), place of delivery (aOR=1.47, 95% CI=1.12-1.94), maternal education (aOR=4.99, 95% CI=2.48-10.06), Religion (aOR=2.63, 95% CI=1.79-3.86). B.Urban- antenatal care (aOR=5.65, 95% CI=2.73-11.71), place of delivery (aOR=2.79, 95% CI=1.83-4.25), maternal education (aOR=6.04, 95% CI=2.99-12.20), Religion (aOR=2.39, 95% CI=1.53-3.73). 3. Intra-urban stratified: A.Urban formal- antenatal care (aOR=6.82, 95% CI=2.29-20.34), place of delivery (aOR=2.62, 95% CI=1.43-4.79), maternal education level (aOR=9.18, 95% CI=3.05-27.64), Religion (aOR=1.59, 95% CI=0.89-2.86). B.Urban slums - antenatal care (aOR=8.07, 95% CI=2.15-30.25), place of delivery (aOR=5.39, 95% CI=2.18-13.33), maternal education (aOR=5.03, 95% CI=1.52-16.65), Religion (aOR=5.69, 95% CI=2.02-15.45).The overall stubbornly low FIC rates in Nigeria are of serious global public health concern. Qualitative research suggests that improving vaccine availability and instituting parent-health workers communication channels, would improve FIC in the slums, where 30-40% of Nigerians now reside. Longer term measures to improve FIC for the total population are increasing antenatal attendance and health facility delivery, improved immunisation education and higher education levels among mothers, while in rural areas more health facilities are required, and in urban areas additional targeted development of immunisation education messages specifically aimed at Muslims living in urban slums could be advised. Suggestions to improve childhood immunisation include nationally representative qualitative study on stakeholders views on enablers and barriers of childhood immunisation, strengthening the implementation of relevant government policies and place of residence directed interventions like regular availability of vaccines, session reminder system, active community participation in health facility management, regular supportive supervision, inter personal communication skills development and introduction of date and time appointment for immunisation