Improving cold-chain capacity for vaccine distribution in Nigeria

After Margaret Keenan received the first shot of the COVID-19 vaccine, the global immunization program has administered 4.54 doses globally, reaching over 1.23billion people, which is 15.8% of the world’s population. Out of these, only 1.2 % from low-income countries have received at least one dose, and less than 2% of the global reach has been in Africa.

These statistics are perturbing with the new Delta-variant detected in 21 Africa countries and sporadically spreading over the past few months.

More so in July, the continent recorded a 43% week on week rise in COVID-19 deaths as fatalities increased from 4382 from the first week in July to 6273 on July 11, 2021. Over the months the continent also recorded 1 million new cases.

Dr Marshidison Morty, World Health Organisation (WHO) Regional Director for Africa, during a Covid-19 Press conference said that “Under-resourced health systems are facing dire shortages of the health workers, supplies, equipment and infrastructure needed to provide care to severely ill COVID-19 patients”. This is further worsened by the problem of Vaccine scarcity to complement existing treatment. The vaccine has proven to be most cogent when compared to earlier measures such as isolation, social distancing, hand washing and sanitizing.

The rate of the COVID-19 vaccine roll-out is indubitably slow with around 3 million doses per week in the continent which is a far cry from the reality of other continents like  Europe where the UK alone has risen from a daily dose of 31,718 to 158,760.

It is, however, commendable to mention the effort of distributing to lower-income countries through the COVID-19 Vaccines Global Access  (COVAX) facility.

Informed by a survey conducted by the WHO, Dr Matshidiso Moeti has revealed that there is still a wide gap in cold chain and refrigerating capacity in most African countries.

In the survey submitted to the Africa Report by the WHO Africa regional office, of the 34 countries, 31% have over 50% districts with gaps in cold chain capacity.

The Cold Chain is defined by the WHO as the system used for storing vaccines in good condition.

It spans from the point of manufacturing to the point of administration.

 It is otherwise referred to as the vaccine supply chain, or the immunization supply chain. 

A deficit in the cold chain vaccine system could have several devastating effects such as loss of vaccines potency, wastage of purchasing funds.

For vaccines to be adequately stored, equitably distributed, and most importantly, efficient it is important that a viable cold chain system is put in place and maintained from the point of manufacturing, to supply, distribution chain and eventually administration.

The vaccine cold-chain system typically consists of cold rooms, freezers and ice-lined refrigerators, cold boxes, vaccine carriers, ice packs and personnel.

In Nigeria, the vaccine cold-chain system is constituted of five strata; a national strategic cold store, six zonal stores, individual states stores, 776 Local government areas, and ultimately the Primary Health Care Centre.

Cold Chain Flowchart

Source: CDC Vaccine Storage and Handling Toolkit

An effective vaccine cold-chain system thus will include effective storage, distribution and handling at all the strata and their points of administration.

Before the pandemic, the country had a deficit in vaccine coverage.

The WUENIC (WHO/UNICEF) estimates of national immunization coverage show that Nigeria has a national DPT (Diphtheria-Pertussis-Tetanus vaccine) coverage rate of  41% compared to 61% for Ethiopia and over 90% for countries like Rwanda, Ghana, Malawi and Angola.

One of the factors responsible for this is the gap in the cold chain system that existed in the country from zonal to the primary health care facilities.

In 2017, an investigation by the Guardian newspaper indicated that just 23 of the 48 cold chain equipment in two  LGAs (Billiri and Funakaye) of Gombe states were operational, resulting in significant delays in immunization coverage in the two LGAs. 

A study by the Clinton Health Initiative in 2018 revealed that the country needs 10,000 functional cold chain systems to cover all the country health facilities but 

41% of clinics have no vaccine refrigerators and 35% of existing vaccine refrigerators are non-functional.

In the Ile-Ife community of Osun State, Nigeria, some of the equipment needed to maintain the cold chain was lacking.

In response to this challenge, the Nigerian government through its agency, the National Primary Health Care Development Agency has made a giant stride towards improving the cold chain system before the pandemic and especially during the pandemic.

Some of these efforts include establishing long term contracts with third party logistics to enhance seamless direct transport of vaccines from the national level to facilities, alternating electricity-powered refrigerators with solar cold chain equipment amongst others.

Even though there is evidence to show improvement in vaccine management in the country, there is still a gross challenge with storage and transportation of vaccines at facilities owing to the incessant power outages, absence of generators, and poor road network in some areas.

On March 2, Nigeria received its first batch of 3.94 million of the AstraZeneca/Oxford vaccine, through the COVAX Facility, a partnership between CEPI, Gavi, UNICEF and WHO.

Dr Adeleye Solomon Bakarey, a Senior Lecturer/Research Fellow (Virology) at the 

Institute For Advanced Medical Research & Training (IAMRAT) says this choice of the AstraZeneca/Oxford vaccine was a better option for the countries considering the temperature requirements for the other options and the erratic power supply in Nigeria.

Several pieces of research have also confirmed that the AstraZeneca/Oxford vaccine is relatively easy to handle and maintain potency with a temperature requirement of 2-8°c compared to Pfizer and Moderna with a recommended storage temperature of -70oC and -20oC respectively.

Evaluating the Present Chain System

Though the director-general of the National Primary Health Care Development (NPHCDA) announced the purchase of three units of ultracold chain units to accommodate other brands such as the Prizer and Moderna vaccines, this may only take about 450,000 doses of the vaccine.

This is a shortfall from the Federal Government’s ambition to immunize 40% of its citizens by the end of 2021 considering that there are only four months left till the end of the year.

In the last distribution of the AstraZeneca Oxford vaccines donated by the COVAX, vaccinators at the primary health centres were required to collect vaccines from their zonal centres daily.

In Kaduna state, one of the vaccinators, Mr Abdullahi said that the zonal office in Zaria was responsible for storing the COVID-19 vaccine for 7 local government areas of the state which includes his health centre.

 In Sokoto state, a Routine Immunization (RI) Officer at one of the hospitals who pleaded anonymity said the government has done well to provide a solar-powered refrigerator in all the primary health centres in the state. “Some of these have not been used”.

We didn’t have any issue with our cold chain system during the last COVID-19 distribution exercise.

She however went on to say that she feels different about the new modena vaccine and other brands that may follow.

” Not all our facilities can store vaccines that require such temperature, I am not sure we can even transport them without spoiling them”

She stated that the present refrigerators in use have a temperature capacity of 2-8°C.

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 Despite the government noticeable efforts to improve storage equipment in the country, Doctor Henry Okafor, the registrar of the internal medicine department at the Usman Dan Fodio Teaching Hospital also reiterated the observation of some other health professionals that some primary health centres in the country do not only lack refrigerators but lack consistent electricity supply to power the refrigerators as required.

He also raised the concern that improper storage or handling of the vaccine may lead to a loss of potency of the vaccine.

When this happens, it offset the relevance of the whole exercise. 

Despite the fact that the country has been able to manage quite well with AstraZeneca, the new supply of Moderna vaccines, as well as the impending supply of larger quantities of it and other brands will necessitate a greater conscious effort to adequately store and safely distribute vaccines to ensure their potency from point of manufacture to end-users.

Improving the Cold Chain System

In 2017, UNICEF solved a major challenge of vaccine distribution in Nigeria (Gombe state) and thereby increased access to vaccines in the state. This was done through the donation of solar-powered refrigerators for preserving vaccines.

The Vaccine Alliance, GAVI has also recognised the need to include solar-powered vaccine refrigerators in addressing issues of cold chain inadequacies.

The Nigeria government through its relevant ministries, departments and agencies is to increase the purchase of more solar-powered vaccine refrigerators to complement existing ones, and address the challenge of incessant power supply, while maintaining existing ones.

“Partnership with private organisations” according to Dr Okocha will help to improve the cold chain system in Nigeria through donations of cold chain equipment just as the donations of vaccines.

To improve vaccination coverage, the responsible agency for vaccination coverage should consider utilizing technology to boost its existing direct delivery systems, such as ‘PushPlus’ to particularly cover for the new donations and their peculiar requirements. 

 In 2019,  through the direct delivery programs in Zamfara state, vaccines were delivered directly to all the government health facilities and 14 local government cold stores in the state.

Early this year, the Ekiti state government acquired 187 solar-powered cold chain refrigerators for vaccine storage for its primary healthcare centres in the 177 wards of the state.

Replicating such efforts by other state’s leaders would go a long way in complementing the ongoing efforts of the federal governments.

Presently, the country still falls short of the 15% Abuja declaration standard which it committed to in 2001.

The current budget of N547 billion for healthcare constituted only seven per cent of the budget’s total of N13.08 trillion as against the set standard of 15% of the declaration.

 It is critical that the government goes above and beyond its current financial commitment to increase and encourage decentralised financing for the health sector to improve the country’s cold chain system, particularly given the need for about 10,000 primary health centres to be covered across the country’s 776 local government areas.

Increased financing would also aid in the maintenance and repair of Cold Chain equipment, which would entail training and enlisting the services of local professionals to maintain, detect, and quickly resolve technical difficulties with cold chain equipment.

“This OUTBREAK story was supported by Code for Africa’s WanaData program as part of the Data4COVID19 Africa Challenge hosted by l’Agence française de développement (AFD), Expertise France, and The GovLab”