Six of the ten countries that are home to 60% of unvaccinated children in the world are in Africa. There have been fresh steps to narrow this gap: African ministers have committed to increase resources to improve coverage as well as to target missed opportunities for vaccinations. The Conversation Africa health and medicine editor Candice Bailey spoke to Professor Charles Shey Wiysonge about gaps in vaccination coverage on the continent and efforts to narrow them.
Where has Africa done well, where has it done badly in vaccines?
Vaccination is one of the most successful and cost-effective ways to save children’s lives and help them grow into healthy adults.
Africa has done particularly well with polio eradication and introducing new and underutilised vaccines. Nigeria, the last polio endemic country in Africa, has been polio free since July 2014, which is an enormous achievement.
The original target was to stop global polio transmission by 2000. This target and several others were missed because of lack of progress in Nigeria, Afghanistan and Pakistan. The Nigerian government and its technical partners established and enforced clear accountability systems that helped them achieve their goals.
But Africa is still lagging behind with vaccinations. The countries with the largest numbers of unvaccinated children are Nigeria, Ethiopia, the Democratic Republic of Congo, Uganda and South Africa. And many other countries have large geographic areas with thousands of unvaccinated children. This is measured by the number of children who have not yet received the required three doses of the diphtheria, tetanus and pertussis vaccines.
Overall immunisation coverage in Africa is only 77%.
Measles and rubella have not yet been eliminated on the continent. And 14 African countries have not been able to eliminate maternal and neonatal tetanus.
Tetanus is a stark reminder of the shocking inequality in health-care provision in Africa. Of the 14 countries, Angola, the Democratic Republic of Congo, Equatorial Guinea, Ethiopia and Guinea are close to elimination. Chad, Kenya, Niger, Nigeria and Sudan are drastically behind. The Central African Republic, Mali, Somali and South Sudan are held back by conflict.
In these countries, thousands of pregnant women still become infected with tetanus during delivery and too many babies become sick with tetanus and die because their mothers were not vaccinated. It is of utmost importance to reach all girls and women with tetanus vaccination.
African ministers are committing more resources to improve vaccination coverage. Where will this get us?
The commitment is landmark and could allow for equal access to existing vaccines for all Africans. For many years immunisation programmes in Africa were plagued by insufficient national leadership.
The ministerial commitment is a positive sign of that leadership. National leadership can make a big difference. For example, national leadership led to the polio success story in Nigeria. In the same way, a lack of national leadership in Somalia affected immunisation service financing, staffing and delivery. Even if vaccines are provided and delivered by external aid agencies and nongovernmental organisations, underlying health-care system challenges imply that positive change will not be sustained.
To maintain current accomplishments and make further progress on immunisation in Africa, it is essential that African governments make the needed investments and efforts to achieve immunisation goals. The joint ministerial commitment is a step in the right direction, as there is power in joint action.
Aside from money, what else is needed?
Accountability is also needed. The ministerial commitment can only bring about sustainable positive change if the ministers walk the talk. They need to live up to that commitment by ensuring accountability and that there is implementation at country level.
As part of this accountability system, every country should have a national vaccine action plan. These systems should be able to review sub-national (district) progress towards national goals. The country plans should give proper attention to the quality of data, community ownership and uninterrupted availability of vaccines in all vaccinating facilities.
Without knowing who has been vaccinated for which diseases at local and country level, it is impossible to allocate resources where they will provide the most return or to understand how to improve programme efficiency. Data need to be useful and inform immunisation strategy at every level.
But to increase vaccination coverage, vaccines must be available and the community must be engaged. Vaccine stock-outs are commonly reported in many African countries and these interrupt immunisation services.
You identify missing gaps as being a big deal. Why?
Missed opportunities occur when children or adults (who are eligible for vaccination) come in contact with health-care services but for some reason they don’t receive the vaccinations they need.
At least one in every four children in Africa is still not receiving the vaccinations they need. As a consequence, a substantial proportion of over 1.5 million children who die from vaccine-preventable diseases globally live on the African continent.
Many of the children who have not yet received the vaccinations they need have access to and actually visit health facilities.
Studies have shown that the problem of missed opportunities is huge in many developing countries. About 32% of children who visit health facilities need vaccines, but do not receive them.
The problem is even bigger in Africa, where studies show that up to 96% of children in some areas visit clinics but do not get vaccines.
How do countries fix this?
Missed opportunities have to do with policies, training, organisation and management of health-care services. These are things that can be corrected quickly and with relatively little investment, and can have an impact on increasing immunisation coverage. They can also help Africa to achieve the goals of the Global Vaccine Action Plan.
African countries should regularly conduct field assessments to understand how opportunities to vaccinate people are being missed by health-care workers and their systems, and act to reduce their occurrence.
In countries where child vaccination was missed, there are now adolescent and adult unvaccinated populations. In addition, a new phenomenon is emerging in some African countries known as “vaccine hesitancy”. Vaccine-hesitant people may accept all vaccines but with concerns. Some may accept only some vaccines, or delay in taking up vaccines. Others may totally reject all vaccines.
It is very important to get the right information about vaccinations to both the people who need vaccinations and those who provide the vaccinations.
Parents, guardians, adolescents, adults and health workers need to understand the vital importance of keeping immunisations up to date.