What the Major COVID-19 Vaccine Announcements Mean for Nigeria

“Access is only the first challenge that will need to be addressed for widespread vaccination against COVID-19 in Nigeria. There are also concerns about the state of cold chain infrastructure and perceptions of the safety and effectiveness of the vaccine among the population.”

Note: This article was originally published on November 19, prior to the Oxford/AstraZeneca vaccine news on November 23. An update on the Oxford/AstraZeneca vaccine’s potential for Nigeria is included at the end of the piece.

Two major pharmaceutical firms have announced COVID-19 vaccine breakthroughs in the last week. Updated analysis of the data for the Pfizer/BioNTech and the interim analysis for Moderna vaccine candidates show both give about 95% protection against the deadly COVID-19 disease. Pfizer, which in an earlier interim analysis reported a 90% protection, will submit for regulatory approval “within days.” These developments have raised hopes that the COVID-19 pandemic, which has caused over one million deaths and has had a devastating effect on the global economy, may soon be over.

Among those who welcomed the news of the Pfizer vaccine candidate was Nigeria’s President Muhammadu Buhari, who said, “The world must now make a great effort to facilitate equitable access and distribution of these vaccines, to protect people in ALL countries.” The Nigerian Federal Government later said that Nigerians will have early access to any vaccine that has been established to be effective for COVID-19. These assurances come despite well-founded concerns that Africans may not get equal access to these vaccines. But access is only the first challenge that will need to be addressed for widespread vaccination against COVID-19 in Nigeria. There are also concerns about the state of cold chain infrastructure and perceptions of the safety and effectiveness of the vaccine among the population.

Access to vaccine supply likely to be insufficient for the need

Nigeria, which has recorded over 65,000 confirmed cases of COVID-19 and around 1,200 deaths, is the most populous country in Africa and will need the largest number of vaccines doses on the continent. According to projections from the Africa Centres for Disease Control and Prevention (Africa CDC), Nigeria will need to vaccinate about 60% of its population –  or about 120 million people – to stave off the possibility of future widespread outbreaks.

Because both the Pfizer and Moderna vaccine candidates require two doses to be fully effective, Nigeria may need 240 million doses. There are reports that the Pfizer Country Manager in Nigeria, who is also the representative of the company in Africa, said Nigeria would be a priority for their vaccine supply to Africa. However, Nigeria is not known to be among the countries that have directly secured prospective COVID-19 vaccines for its citizens from any pharmaceutical company. In fact, the pharmaceutical companies leading in the race to deliver a COVID-19 vaccine, especially Pfizer, have already made deals that suggest people in countries like Nigeria may not have early access to their vaccines.

To protect against a monopoly of access by wealthy countries, GAVI, the Vaccine Alliance, has been securing vaccine candidates for low-income countries through their COVAX co-financing facility. According to the Africa CDC, though, COVAX has promised the whole of Africa just 220 million doses. This number of doses is less than what is needed in Nigeria alone, and while Nigeria has shown interest in using the COVAX facility, GAVI said it will be supporting only 3% of any one country’s population in the early months after COVID-19 vaccine approvals. In Nigeria, this means that only about six million people will be able to receive vaccines.

Current infrastructure not ready for “ultra-cold chain” vaccine delivery

There are currently 40 vaccine candidates undergoing human trials, with results expected in the coming months. The progress made by Pfizer and Moderna, which developed their vaccines using mRNA technology, means they will likely receive the earliest approval to be deployed in most countries. The Pfizer vaccine needs to be stored at -80°C and the Moderna vaccine at -20°C for long-term storage. These are extremely cold temperatures, and in Nigeria, there is no precedent for an “ultra-cold chain” for vaccine delivery.

Nigeria has been working to optimize and expand its cold chain infrastructure across the country in a cold chain expansion plan with support from GAVI, but the storage equipment in this plan only cool to temperatures of 2°C to 8°C. “For the new COVID-19 vaccines that require extremely low temperatures, it is unclear at this time how the cold chain will be obtained,” says Shola Molemodile Dele-Olowu, a physician with almost a decade of experience in the immunization sector in Nigeria. “The current cold chain expansion that is happening in the country cannot handle the temperature that is required for the Pfizer vaccine in particular.”

The Moderna vaccine candidate is viewed as a better candidate than Pfizer’s because it can be stored at the standard refrigeration temperatures of 2°C to 8°C for up to 30 days. Still, the logistical requirements for both vaccines may make it difficult to access in most parts of Nigeria. Dele-Olowu explains there are challenges with cold chain sufficiency, particularly at lower levels of immunization service delivery: “Even though new cold chain equipment uses solar power, many Primary Health Clinics offering immunization in the country don’t have them.” Despite these deficiencies, she believes Nigeria has a vaccine distribution system that has been proven to work for vaccines that are stored at temperatures of 2°C to 8°C.

Dr. Richard Mihigo, the Deputy Incident Manager for Emergency Response at WHO Africa region, says, “There is a robust network that was established by the polio program to vaccinate children even in the most remote and unsecured area.” Dr. Mihigo explains that Nigeria has a strong network of cold chain facilities for vaccine deployment but will need to improve on its vaccination strategy to deploy a vaccine that requires ultra-cold storage.

Three months ago the WHO announced that wild poliovirus has been successfully eradicated from Nigeria. Over 200,000 volunteers were mobilized across the country to immunize over 45 million children. This was described as a historic achievement because 8 years ago Nigeria, which was the last country in Africa with polio, accounted for over half of the cases worldwide. “These are the kinds of experiences that will be critical for Nigeria when it will come to COVID-19 vaccine deployment,” says Dr. Mihigo.

Possible hesitancy due to perceptions of vaccine safety and effectiveness

Even assuming access to a sufficient supply of vaccine doses and the infrastructure to deliver them, the last barrier to overcome may be a particularly acute form of vaccine hesitancy in Nigeria, especially when it comes to Pfizer.

In 1996, Pfizer ran a controversial drug trial in the northern state of Kano during its meningitis epidemic, which resulted in the death of 11 children. This incident has not been entirely forgotten.

There have been surveys where Nigerians were asked if they would take a COVID-19 vaccine when it becomes available, and they show that the perceptions of the safety and effectiveness of the vaccine are in question among the population.  “If you go to Nigeria, about only 65% say they would take it. If you go to South Africa, about 85% say they will take it,” says Dr. Nicaise Ndembi, Senior Science Advisor of the Africa CDC, based on their own vaccine perception survey.

In another survey, while 65% of South Africans in a survey of 19 countries said they would take a “proven safe and effective” COVID-19 vaccine, only 46% of Nigerians in the survey say they would. Dr. Ndembi says, “It means we have a long way to go to mobilize,” emphasizing the need “to have a very good community engagement strategy for delivery, a very good engagement of the community in terms of acceptability of those vaccines.”

November 24, 2020, update: This week Oxford University and  AstraZeneca announced their COVID-19 vaccine candidate is 90% effective when an initial half dose followed by a full dose is administered. Unlike the Pfizer and Moderna candidates, the Oxford candidate can be stored and transport at 2°C to 8°C temperature at all times using the cold chain facilities already available in Nigeria. The vaccine also costs US$3-4 per dose – far cheaper than Pfizer and Moderna candidates –  making it the most viable candidate so far for African countries. The Oxford candidate will likely be one of the first COVID-19 vaccines to be deployed in Nigeria as it is part of the vaccines Gavi, the Vaccine Alliance, has secured through their COVAX Facility.