Esha Homenauth - A Student Perspective: Immunization Delay in Nigerian Infants

The advent of immunization is arguable the most significant public health intervention of the last century. However, in third world countries like Nigeria, there is a delay in the receipt of vaccines that evidently put children at heightened risk for acquiring vaccine-preventable diseases, as well as pose a health threat at the population level. Acquiring vaccines at predetermined ages ensures that children are protected as early as possible against specific diseases (Luman et al., 2002). Delay in the commencement of immunization creates a spiraling host of concerns such as: delay in completion of immunization, resulting in a pool of susceptible unimmunized children that may contribute to epidemics (NVAC, 1991). In Nigeria, poor compliance of vaccines at birth, like the first dose of hepatitis B, Oral Polio and BCG vaccines are reported; therefore, identifying the factors that contribute to such delays are imperative, such that immunization programs can be tailored to limit the incidence of untimely vaccine initiation.

In a study conducted by Sadoh et al.,(2013) published in the Tanzania Journal of Health Research Vol 15, No.3, the factors associated with the delay in commencement of immunization in Nigerian infants were assessed. In this study, a cross-sectional, descriptive approach was undertaken, involving 153 consecutive mothers of infants present for their first immunization at the Institute of Child Health Child Welfare Clinic of the University of Benin, Benin City. 

Findings of this study highlighted that only children born in healthcare facilities were likely to commence vaccination on time; whereas, children born outside of facilities were more likely to receive late or missed vaccines. Additionally, some vaccines were only available on specific days of the week, thereby creating an additional barrier to timely immunization. Mother's lack of knowledge about the role of vaccines is also a factor owing to delay in coverage. This factor alludes to the role that health care professionals must take in order to communicate the importance of timely vaccine coverage. Women with high socioeconomic status, maternal education above secondary school and delivery in a health facility were significantly associated with receiving immunization in the first week of life.

Health education that emphasizes the need for timely vaccine coverage is a suggested solution to deal with the incidence of immunization delays. In this study, it is observed that antenatal care and immunisation session health education activities as well as health care workers are important sources of health care information, since the majority of mothers get their information from health care-related sources. Therefore, improvements in these resources are likely to result in improvements in immunization coverage.

In Western societies, there is a growing trend of vaccine-hesitant parents who are concerned about the safety and efficacy of vaccines, resulting in a decline in vaccine coverage. However, in Nigeria, this situation is quite different. Individuals are vaccinating their children later or not at all as a result of poor resources and insufficient knowledge about the importance of vaccines. With Bioline International providing open access to this article, and other articles in this journal, this concern can be addressed at a wider forum so that relevant policy implications can be made to deal with this issue. The tremendous role of vaccines have been documented over the last century; therefore, mechanisms in place to improve the current immunization efforts in Nigeria are imperative, such that children can be vaccinated on time in order to prevent the unwanted resurgence of vaccine preventable diseases.

Sadoh, A.E., Wilson, E.S., Uduebor, J., Ekpebe, P., Iguodala,O.(2013)Factors contributing to delay in commencement of immunisation in Nigerian infants. Tanzania Journal of Health Research, 15(3):1-8

Esha Homenauth - A Student Perspective: Determinants of Under-five Mortality in Nigeria

Infant mortality has declined globally by 2.2% between 1990 and 2010,(Rajaratnam et al. 2010), but still falls short of the estimated 4.4% needed to achieve the 4th Millennium Development Goal (MDG 4). Nigeria, the largest country in West Africa, accounted for 12% of the global under-five mortality (U5M) in 2008 (UNICEF, 2010). An unusual trend in U5M decline exists in Nigeria as a result of inconsistencies in the data available for analyses. Currently, the rate of U5M in Nigeria is far behind the decline rate of 11.0% per year needed to acquire the MGD4 in West and Central Africa.

Interventions that target child health need to be efficient in prioritizing scarce resources. A study conducted by Akinyemi et al., published in the African Population Studies Vol 27, No.1, addressed the trends in U5M determinants in Nigeria and determined how the independent contribution of these determinants influenced changes in under-five mortality risks. In this study, a re-analysis of representative sample data collected during the Nigerian Demographic and Health Surveys (NDHS) of 1990, 1999, 2003 and 2008 was done. Eligible women between the ages of 15-49 years in selected households were interviewed. They were asked questions about their summary (number of children born and survived)and detailed reproductive history (sex and date of every live birth, survival status at time of interview, current age of surviving children and age at death).

Results from this study indicated that there was an increase in U5M deaths between 1990 - 2003, but later reduced in 2003-2008. Greater reductions however, were observed in mortality during age 1-4 years than during infancy (0-11 months). A number of variables were observed to have varying degrees of influence on U5M risk. Improvements in the level of maternal and paternal education (through the introduction of universal basic education) was observed to be a significant indicator in the decline of infant mortality. Improvements in antenatal care, skilled delivery, contraceptive use and tetanus toxoid injection during pregnancy were observed to improve U5M mortality risk, however, little change has been observed in these areas of maternal health between 1990 - 2008; largely as a result of population expansion while the number of health facilities and personnel remain unchanged. Improvements in childhood vaccination and oral rehydration therapy has also resulted in a decline in infant mortality. Reduced access to potable drinking water and toilet facilities were observed to increase the risks of under-five deaths.

This study was successful in demonstrating that the effect of changes on mortality risk is proportional to the magnitude of the changes in the determinants. Reduction in U5M risk requires a combination of factors such as maternal education, antenatal care, childhood vaccinations, improvements in household environmental health and birth spacing.

From the perspective of a Health Studies student, this study provides important policy implications for Public Health. Improvements in female education, behavioural/health-related, household environmental health factors and birth practices will result in a reduction in under-five mortality. Promoting birth space is imperative country-wide, as well as improvements in the quality of maternal and child health services. With Bioline International providing open access to articles from this journal, important discussions about the issue of under-five mortality can be stimulated, and relevant interventions can be implicated. As mentioned, disparities in under-five mortality trends in Nigeria exists as a result of insufficient data. Interventions that target improvements in collection of data and analysis is important such that policy implications can be made and resources can be efficiently targeted.

Akinyemi, J.O., Bamgboye, E.A., Ayeni, O.(2013)New trends in under-five mortality determinants and their effects on child survival in Nigeria: A review of childhood mortality data from 1990-2008. African Population Studies, 27(1): 25-42

Esha Homenauth -- A Student Perspective: Role of Nutrition in Anti-Retroviral Therapy

In Africa, approximately 25 million people are victim to HIV/AIDS (UNAIDS, 2006). In Malawi 46% of young adults between the ages of 15-24 are affected, with 60% of the infections occurring mostly among girls. Gender, demographic and geographical discrepancies in HIV/AIDS prevalence exists within the country, reinforcing the need for government interventions. Through improved education on modes of HIV transmission, risk reduction, blood screening and efficient barrier methods, antibody testing, disclosure and notification of partners, prevention of mother-to-child transmission (PMTCT) services, medical treatment and management of infected individuals including the use of anti-retroviral therapy (ART), the risk of transmission of HIV/AIDS will be greatly reduced.

Wasting and weight loss are the main problems among HIV-infected individuals. Adequate nutrition is important for successful ART. Research shows that malnutrition prior to ART is significantly associated with increased mortality (Ni et al, 2006). As such, nutritional intervention plays an integral role in the HIV treatment program, reinforcing the need for an improved diet to enhance ART acceptability, adherence and effectiveness.

A study by Bisika and Mandere published in vol. 20 no 3 of the Malawi Medical Journal focuses on identifying an intervention that would complement the the use of ART in Malawi. Qualitative data was collected through consultative workshops and in-depth interviews with health professionals and representatives from community-based organizations. 85% of the ART beneficiaries reported inability to afford a balanced diet due to illness, while 17% reported missed treatment due to lack of food. Bisika and Madere argue that the institutional capacity to implement nutritional support is limited due to already strained human resources, food storage facilities and size of health facilities. They also highlight the cost associated with nutritional support for ART beneficiaries as well as differential food assistance for individuals at different stages of infection.

Most patients on ART battling HIV indicate the need for nutritional support when ill.Health officials suggested the need for therapeutic and supplementary feeding and food rationing for individuals experiencing weight loss due to malnutrition. Therapeutic and supplementary feeding was provided based on information about adult BMI, pregnant or lactating mothers and children weight for height ratio. Due to unfamiliarity of therapeutic nutrition, the need for nutritional education is imperative. Food rationing was provided to individuals who lacked food security. Researchers suggest that advances in nutrition for HIV infected individuals on ART will require increasing the number of facilities that provide nutritional support as well as addressing limitations such as irregular food supplies and human resources.

In summary, this paper highlights the importance of adequate nutrition for individuals affected with HIV/AIDS. An appropriate diet is important for all individuals utilizing anti-retroviral therapy, not just those affected in developing countries. However, the role of nutrition is fundamental in developing countries due to unpredictable availability and unequal distribution of food supply. Information regarding the measures in place in developing countries like Malawi is important as it highlights the short comings in dealing with the HIV/AID epidemic. In Malawi, as the number of individuals affected by HIV/AIDS increases, the pressure on these already strained resources also increases. Providing open access to this article as well as others in this issue allow relevant information regarding the importance of improved nutrition on the health status of HIV/AIDS-affected individuals. It allows provides a forum for discourse among public health officials in these developing countries to seek out interventions in order to improve the livelihood of these infected individuals.

Bisika, T., & Mandere, G.(2008)Integration of nutrition in the antiretroviral therapy scale up plan for Malawi. Malawi Medical Journal; 20(3):93 - 98