PERSPECTIVE

Niger J Paed 2012; 39 (4):152 - 158

PAN Advisory

Committee on

Immunisation

Paediatric Association of Nigeria

(PAN) recommended routine

immunization schedule for Nigerian

children

DOI:http://dx.doi.org/10.4314/njp.v39i4.1

Accepted: 9th May 2012

Abstract Vaccine preventable dis-

eases are a major contributor to

child morbidity and mortality espe-

cially in the Sub-Saharan Africa

and Nigeria in particular. It ac-

counts for 17% of global total under

In this paper, the Paediatric Asso-

ciation of Nigeria recommends a

comprehensive routine immuniza-

tion schedule for children of all

ages striking a delicate balance be-

tween optimal immune response

generation and avoidance of undue

exposure to high risk environment;

while avoiding neutralization by

maternal antibodies.

(

)

Paediatric Association of Nigeria

Email: pan.nigeria@googlemail.com

Www.pan-ng.org

-

five mortality per year and 22% of

child mortality in Nigeria. This im-

plies that appropriate deployment of

relevant vaccines would signifi-

cantly reduce mortality and speed

up the achievement of Millennium

Development Goal 4 (MDG 4).

Introduction

reduce mortality and speed up the achievement of Mil-

lennium Development Goal 4 (MDG 4). Although the

Expanded Programme on Immunization (EPI) has been

in place in Nigeria for more than 30 years (since 1979),

Vaccine preventable diseases are a major contributor to

child morbidity and mortality especially in the Sub-

Saharan Africa and Nigeria in particular. It accou₁nts for

the under five mortality has only decreased from 192 in

1

7% of global total under-five mortality per year.

3

1

990 to 157 in 2008. Figure 1 shows the slow trend of

In Nigeria, vaccine preventable diseases were responsi-

progress in mortality rates in Nigeria across three suc-

cessive five year periods preceding the 2008 survey.

ble for 22% of child mortality amounting to over

2

00,000 deaths per year. This implies that appropriate

deployment of relevant vaccines would significantly

Fig 1. Trends in early childhood mortality rates (Deaths per 1,000)

Neonatal mortality: the probability of dying within the first month of life. Post-neonatal mortality: the difference between infant

and neonatal mortality. Infant mortality: the probability of dying before the first birthday. Child mortality: the probability of

dying between the first and fifth birthdays. Under-five mortality: the probability of dying between birth and the fifth birthday.

3

Source: National Demographic and Health Survey 2008

1

53

4

5,6

This is further corroborated by a study covering 1970-

003 which showed that the EPI programme had little

routine immunization schedule in 2004 , 22 years after

the vaccine became available in the global market in

1

2

effect on under five mortality rate in Nigeria

982. Haemophilus influenza b vaccine which became

available in 1987 is only being introduced in Nigeria in

2

tries in the WHO African region to introduce the Hib

vaccine (only before Guinea Bissau). Obviously, this

trend does not augur well for the Nigerian child.

The World Health Organization (WHO) initiated the EPI

in 1974 with the goal of making vaccines available to all

children throughout the world. Since the commencement

of the EPI in Nigeria in 1979, very limited number of

th

012 - 25 years later. Nigeria is the 45 out of 46 coun-

‘new’ vaccines has been added to the initial basic rec-

ommended number. Over a period of about 30 years,

only Hepatitis B and yellow fever vaccines have been

added. Although there are plans to include Haemophilus

influenza b (Hib) vaccine this year (2012) and later

Apart from the narrow range of antigens available to the

average Nigerian child, routine immunization coverage

has remained poor over the years. The Diphtheria-

Pertussis-Tetanus 3 (DPT 3) coverage has only in-

(

2013), Pneumococcal vaccine; the pace of expansion is

7

rather too slow in comparison to child morbidity and

mortality rates.

creased from 33 in 2004 to 69 in 2010. This persistent

low coverage (Fig 2) together with frequent vaccine

stock outs has greatly compromised the future of Nige-

rian children and requires urgent and focused attention

from all concerned.

Hepatitis B vaccine was introduced into the country’s

8

Fig. 2: DPT3 coverage for Nigeria. Source: WHO vaccine-preventable diseases: monitoring system 2011 global summary

a

b

Regular data not available from 1997-2004. Regular data not available from 1997-2003

Additionally, the children who get to be immunized ac-

cording to our compromised schedule do not receive

booster doses. This again increases their susceptibility to

the same diseases in late childhood as acquired immu-

nity wanes. Booster antibody responses are not only

faster and stronger than the primary series, but are also

ules in which more time elapses between doses (2, 4, 6

months), or between the priming and boosting doses.

However, vaccine antibodies elicited by primary immu-

9

nization with non-live vaccines eventually wane. Also,

longer interval (> 4 months) between priming and boost-

ing doses allows time for affinity maturation of memory

B cells leading to enhanced capacity to re₉s_,₁p₁ond to anti-

gens and thus higher secondary responses.

9

more prolonged and of higher neutralizing capacity.

Most Nigerian children do not benefit from booster vac-

cine doses due to its total absence in the National routine

immunization schedule.

Our primary doses are however, scheduled with shorter

intervals. This is done for two major reasons; to ensure

compliance and to induce early enough but moderate

levels of protection before children are exposed to our

high risk environment. There is therefore an even greater

need for booster doses for Nigerian children so as to

achieve optimum protective antibody levels and for

longer duration. Studies have shown that the lower re-

sponse to early primary DPT vac₁c₀ine series becomes

insignificant after the booster dose.

It is generally agreed that antibody titres are generally

higher with increasing age of immunisation. As infants

grow older, the immune system matures and transmitted

maternal antibodies disappear. This explains the usual

postponing of the commencement of primary series to at

least 6–8 weeks o₁f₀age or even up to three months of age

in some countries

Accelerated infant vaccine schedules in which three

vaccine doses are given at a one month interval (2, 3, 4

or 3, 4, 5 months) result in lower responses than sched-

1

2

According to WHO , “several countries are appropri-

ately providing additional vaccine antigens, but they lag

1

54

behind in providing the adequate number of doses or

booster doses for traditional vaccines and give little con-

sideration to older age groups.”There has not been ap-

preciable number of immunogenicity studies in respect

of response to routine vaccines in our population so as to

establish the adequacy of immune response and the

length of protection. Data from disease surveillance and

immunogenicity studies would enhance the periodic

review of routine immunization schedule for the coun-

try.

The National Health Bill has been carefully articulated

and it is at an advanced stage of being signed into law. It

has provisions for proper funding of health programmes

and services. It is however regrettable that it took so

long to get to the current stage, while children are dying.

1

3,14

have shown that routine immunization is more

Data

acceptable to mothers in Nigeria and other countries

than campaigns. The well known wave of OPV rejection

in Northern Nigeria in 2003 was not to the routine OPV

but to the house to house campaigns.

Vaccines should be administered to children at ages

when optimal immune response would be obtained but

also, before children are exposed to the risk of contract-

ing the target disease. Developing a routine immuniza-

tion schedule requires maintaining a delicate balance

between these two factors and also ensuring that admin-

istered antigens are not neutralized by maternal antibod-

ies.

Challenges

The challenges which are not insurmountable include

wrong attitude and mal-orientation of health workers,

poor political commitment, beaurocratic bottle-necks

and low level of awareness. Others are poor global do-

nor interest in routine immunization and the overshad-

owing influence of supplemental immunization activi-

ties (SIAs) over routine immunization activities. Paedi-

atric Association of Nigeria is willing to partner with

Governments to overcome these challenges.

In view of all the foregoing, it has become imperative to

develop a more comprehensive National routine Immu-

nization Schedule for the country so as to significantly

enhance the health of the Nigerian child. The general

objective of this paper by the Paediatric Association of

Nigeria (PAN) is to recommend an optimum National

Routine Immunization Schedule that will help achieve

an early comprehensive protection of the Nigerian child

from major infectious causes of morbidity and mortality

in the Nigerian environment. The specific objectives

include;

PAN Recommendations

This is a follow up to the PAN position paper on immu-

nization which was submitted to Government in 2008.

We here recommend an optimal routine immunization

schedule that considers early exposure of Nigerian chil-

dren to infections, low response to too early and short

interval primary series vaccination and therefore greater

need for boosting. There should be enough resources to

invest in the health of Nigerian children. The recom-

mended optimum schedule is presented in Tables 1 - 3

below.

•

To increase the number of antigens covered in the

routine immunization schedule

To extend the schedule beyond infancy to include

the older child and adolescents

To institutionalize and provide adequate number of

booster doses

To maintain traditional antigens and improve on

them

To advocate for the protection of the rights of our

children to good health.

To provide guidelines for catch-up immunization

for older children who are not previously immu-

nized.

*The other type of typhoid vaccine, Ty21a, has liquid

and capsule forms. The liquid form is no longer avail-

able. The capsule form for individuals > 5 years requires

3-4 orally administered doses, taken every other day. If

the schedule is interrupted by an interval > 21 days, re-

start the series from beginning. If the delay is less than

2

1 days, resume series without repeating the previous

dose. Booster doses are given after 3-7 years.

*DTaP contains the normal infant doses of diphtheria

tetanus and acellular pertussis vaccines.

**Tdap contains lower doses of diphtheria and pertus-

*

Opportunities and Strengths

*

Currently, there is a level of Federal Government com-

mitment to immunization of children at the presidential,

ministerial and agency levels (though more commitment

needs to shift from polio only, to routine immunization).

sis, but same infant dose of tetanus; the size of the letter

indicates the size of the dose.

+

*

The other type of Cholera vaccine, Dukoral, is not

licensed for children < 2 years. Children aged 2-5 years

should receive 3 doses > 7 days apart (but not more than

The basic health system structure that will drive routine

immunization programme is already in place. These are

structures from the Federal to State and Local Govern-

ments and even to wards and settlements. These have

been well articulated in a micro plan by the National

Primary Health Care Development Agency. It however

requires revitalization and strengthening especially at

the state and local government levels for effective func-

tioning.

six weeks). Intake of food and drink should be avoided

for one hour before and after vaccination. If the interval

between doses is delayed for more than six weeks, pri-

mary vaccination should be restarted. One booster dose

is recommended every six months, and if the interval

between primary immunization, and the booster is more

than 6 months, primary immunization must be restarted.

1

55

Table 1: Proposed Routine Immunization Schedule from infancy to childhood and adolescents

Age

Vaccines

Notes

0.05ml for infants < 12 months, 0.1ml for children >

1

Birth

BCG

1

If > 2 weeks, skip birth dose)

2 months

2

OPV 0

3

Hep B-1(Birth dose)

If > 2 weeks, skip birth dose)

6

weeks

OPV-1

Penta-1 (Hib+DTP+Hep B)

4

5

1

2

Rota 1

PCV13-1

Do not give if child is > 15 weeks (3 / months)

6

1

0 weeks

4 weeks

OPV-2

Rota 2

OPV-3

Do not give if child is > 32 weeks (8 months)

Penta-2

PCV13-2

6

months

Penta-3

Last dose of Hep B not given earlier than 24 weeks

st

of age and 16 weeks from 1 dose

rd

nd

PCV 13-3

3 dose given at a minimum of 2 months after 2

dose

7

Vit A-1

100,000 IU for 6-11 month old, 200,000 IU for > 12

month old

9

1

months

Measles-1

Yellow fever

OPV

Booster every 10 years

2-15 months

8

DTaP- booster

Vit A-2

Hepatitis A

Repeat every 6 months until 5 years of age

2 doses at 6 months interval

1

8 months

1

0

11

MMRV (or MMR + Var or Mea-

9

sles-2 + Var)

2

5

years

Typhoid (Vi Polysaccharide) vac-

cine*

OPV

Re-vaccinate every 4 years

DTaP**

MMR

1

3

1

0 - 14 years

Tdap***

Every 10 years

Yellow fever

Every 10 years

Three doses at 0, 2 and 6 months interval

1

4

HPV quadrivalent (males and fe-

males) ₁₅

+

>

15 years

5 dose TT schedule (females

only)

See below for the schedule

Table 2: Vaccines for special groups

Age

Vaccines

Notes

1

2

1

2-15 months

Men ACYW135 (conjugated)

For children in the meningitis belt only. Polysaccha-

ride vaccine is given after 2 years.

During epidemics and at refugee camps. 2 doses 14

days apart and a booster 2 years later

+

>

1 year

Cholera vaccine* (Sanchol and

mORCVAX)

than two years, primary immunization must be repeated.

Adults and children less than six years should receive

two doses of Dukoral > 7 days apart (but not more than

six weeks). Intake of food and drink should be avoided

for one hour before and after vaccination. If the interval

between doses is delayed for more than six weeks, pri-

mary vaccination should be restarted. A booster dose

every two years is recommended. If the interval between

the primary series and booster immunization is more

+Tt immunization schedule for females of child bearing

age (15 – 45 years)

•

TT 1 - First contact: No protection

TT 2 - 4 weeks after first dose: offers protection for

3

years

•

TT 3 - 6 months after 2nd dose: protects for 5 years

1

56

5

•

TT 4 - 1 year after 3rd dose: offers protection for 10

years

TT 5 - 1 year after 4th dose: protects throughout

child bearing years

Rota – Rotavirus vaccine given orally with minimum

of four weeks interval between doses. Rotarix requires

two doses only while RotaTeq requires three doses. The

first dose of either vaccine is to be given at age not later

than 15 weeks, and last dose not later than 32 weeks of

age. Catch-up immunization not recommended. The use

of rotavirus vaccines should be part of a comprehensive

strategy to control diarrhoeal diseases which should in-

clude, among other interventions, improvements in hy-

giene and sanitation, zinc supplementation, community-

based administration of oral rehydration₁s₂olution and

overall improvements in case management.

General Notes

The manufacturer's instructions should be followed

strictly.

When multiple injectable vaccines are required during

the same visit, they should be given at different sites.

OPV should be given to children less than five years of

age at the time of each supplementary immunization

activity.

6

PCV13 – 13-valent Pneumococcal conjugate vaccine.

Second dose should be given at a minimum of 4 weeks

When a dose in the primary series is delayed, resume

without repeating the previous dose.

st

after 1 dose._nT_dhird dose is given at a minimum of two

months after 2 dose.

Table 3: Typical recommended routine Immunization

Card

7

Vit A – Vitamin A. Although this is not a vaccine but a

micronutrient, it is integrated into routine immunization

as an effective means of raising supplementation cover-

age. It is administered orally at six monthly intervals

until five years of age. First dose is given at age not less

than six months. Dose is 100,000 IU for 6-11 months

and 200,000 IU for 12 months or less ..

Age

Vaccines

Birth

BCG, OPV 0, Hep B- Birth dose

OPV-1, Penta-1, Rota 1, PCV-1

OPV-2, Rota 2

OPV-3, Penta-2, PCV-2

Penta-3, PCV 3, Vit A-1

Measles-1, Yellow fever

OPV, DTaP, Vit A-2

Hepatitis A, MMRV

Typhoid

OPV, DTaP, MMR

Tdap, Yellow fever, HPV (males

and females)

6

1

6

9

1

2

5

1

weeks

0 weeks

4 weeks

months

8

DTaP – Diptheria, Tetanus and acellular Pertussis vac-

cine.

months

9

Var - Varicella vaccine can be given singly or in com-

2-15 months

8 months

years

0 - 14 years

b₁₀ination.

MMRV - Measles, Mumps, Rubella and Varicella

v₁₁accine.

MMR – Measles, Mumps and Rubella vaccine.

2

Men A & C – Meningococcal ACYW135 conjugate

1

vaccine. The polysaccharide vaccine is not given to chil-

dren less than 2 years.

>

15 years

5 dose TT schedule (females only)

1

3

Tdap – Infant dose of Tetanus and smaller doses of

Diphtheria and acellular Pertussis vaccine is used for

boosters to avoid unwanted reactions.

Notes to the schedule

1

4

HPV – Human papiloma virus vaccine is for both

1

BCG – Bacillus Calmette-Guerin. It is given intrader-

males and females. There are 2 types; quadrivalent and

bivalent.

mally on the upper left arm.

For children of six months of age and less, mantoux test

should first be carried out to exclude active infection or

previous immunity before BCG is given (children less

than six months do not mount sufficient reaction to tu-

1

5

TT – Tetanus toxoid.

Catch-up immunization schedule for children < 5

years who are not previously immunized.

1

5

berculin test) .

2

OPV – Oral polio vaccine; two drops given orally.

•

BCG - for children of six months or less, mantoux

test should first be carried out to exclude active in-

fection or previous immunity before BCG is given

Minimum interval between doses is four weeks.

3

Hep B - Hepatitis B vaccine is given intramuscularly at

(

reaction to tuberculin test) .

children less than 6 months do not mount sufficient

the outer thigh at birth or soon after-not later than two

weeks of age. Four doses of Hepatitis B vaccine coul_rd_d

be given (including the birth dose), but the last dose (3

15

•

Rotavirus vaccine – last dose must be given not

later than 32 weeks. Do not initiate rotavirus vacci-

nation if child is 15 weeks or older.

Pertussis vaccine – give acellular vaccine in place

of whole cell if child is above three years.

Beside above exceptions, children less than five

years who are not previously immunized should

follow the normal recommended schedule maintain-

ing the minimum intervals between doses.

th

or 4 ) must not be given earlier than 24 weeks₁(₆six

months) and 16 weeks (4 months) from the fist dose.

•

4

Penta-1 (Hib+DTP+Hep B) – Pentavalent vaccine con-

tains Haemophilus influenza, Diphtheria, Tetanus, Per-

tussis, and Hepatitis B vaccines. It is given intramuscu-

larly on the outer thigh. The third dose is scheduled at

six months due to the Hep B component as explained above.

1

57

Catch-up immunization schedule for children 5-18 years who are not previously immunized

Vaccine

BCG

Notes

Mantoux test should first be carried out to exclude active infection be-

fore BCG is given.

Tdap

Given once, then every 10 years unless a booster is required

Yellow fever

Repeat every 10 years

5

-dose TT

All females > 15 years

HPV quadrivalent (males and females > Three doses at 0, 2 and 6 months after dose 0. Not recommended after

1

0 years)

26 years

Typhoid (Vi Polysaccharide) vaccine

Re-vaccinate every 3-7 years

Varicella

1 dose for < 7 years and 2 doses for > 7 years with 2 months interval

Booster doses of other vaccines should be administered as applicable.

Additional recommendations

in vaccine issues as well as non-voting representatives

from relevant medical and health professional associa-

tions.

•

Disease surveillance should be institutionalized as

part of routine services in the health sector.

Periodic immunogenicity studies should accompany

disease surveillance and Routine Immunization as

part of monitoring and evaluation of vaccine im-

pact.

•

Institutionalize routine monitoring and reporting of

adverse events following immunization and inte-

grate it into the pharmaco-vigilance system.

Review routine immunization schedule periodically

to adapt to changing disease and vaccine trends.

Integration of routine immunization with other high

impact child survival interventions such as nutrients

supplementation.

•

Routine Immunization coverage to be raised ur-

gently to 85-90% for all vaccines.

Eradicate vaccine stock-outs by establishing a ro-

bust vaccine forecasting and a special express fund

release mechanism specifically for vaccines.

Maximal exploitation of solar energy for optimum

vaccine cold chain maintenance.

Protect Routine Immunization by ensuring that sup-

plemental immunization activities are not done at

the expense of Routine Immunization and by allo-

cating more funds for Routine Immunization than

for SIAs.

•

Conflict of interest : None

Funding : None

PAN Advisory Committee on Immunization

(

2010-2012)

Dr. DO Esangbedo- Chairperson

Dr. Beckie Tagbo- Secretary

Prof. AO Olowu

Dr. E. N. Ekure

Dr. M Mukhtar-Yola

Dr. O. Ojo

Dr. I. Emodi

Prof. A. Omoigberale

Dr. N. Ibeziako

Prof. C. Ezechukwu

Prof. WN Ogala

•

Development partners must be guided to put the

global agenda in the context of peculiar country

situations while Nigeria insists on owning her pro-

grammes and policies.

Establish a Nigerian Vaccines and Immunization

Advisory Committee comprising Paediatricians who

are immunization experts as chair and majority of

membership; then Epidemiologists, Immunologists,

ex-officio members from federal agencies involved

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