Barriers to Optimal AEFI Surveillance and Documentation in Nigeria: Findings from a Qualitative Survey

"The attitude of some health workers towards caregivers is not good, and the information given to the illiterate caregivers in the rural areas is not sufficient to encourage immunisation and AEFI reporting. And usually, there is no feedback, even when few cases are reported and investigated..." - focus group discussion participant

Although serious adverse events following immunisation (AEFI) caused by vaccines are rare, perceived vaccine safety concerns are one of the causes of vaccine hesitancy in the form of outright rejection or drop-out in many countries, including Nigeria. Effective spontaneous AEFI reporting is the first step to ensuring vaccine safety. However, half the global population lives in countries with weak vaccine safety monitoring systems. This study employs a qualitative approach to understand of the barriers to optimal AEFI surveillance and documentation in Kebbi State, Nigeria.

The paper begins by outlining the basic structure of AEFI surveillance system in Nigeria. As one part of this system, parents, caregivers, vaccinators, or healthcare workers within the communities can notify a health facility about AEFI cases, especially in a mass vaccination campaign setting, which can be documented at the health facility for proper management.

The researchers used a qualitative research design (a grounded theory approach) that involved 2 focus group discussion (FGD) sessions with a total of 18 people, as well as10 key informant interviews. Participants were key officers whose responsibilities have a strong bearing on immunisation service delivery, AEFI monitoring, reporting, and documentation and communication strategies. Only two women participated in this study, reflecting the gender imbalance in the health workforce in the study setting.

This study found that the AEFI surveillance system is in place in Nigeria. However, its functionality is sub-optimal, and the potential capacity is yet to be fully harnessed due to health systems and socio-ecological impediments such as:

• Ineffective communication and information management: Poor communication and information management by the operators (local and national) impact caregivers' knowledge and capacity to report AEFI. In this vein, the quality of sensitisation (health education sessions) and engagement with the parents was poor, bringing dissatisfaction and loss of confidence in the immunisation services. No evidence suggests community engagement and media publicity to raise awareness and stimulate AEFI reports at the population level. The consistent lack of feedback from the national level on the reported cases was a disincentive to continued AEFI reporting.
• Caregivers' and parental factors: There appears to be a low level of awareness about reporting AEFI cases, which is linked to the poor sensitisation or information deficits about AEFI during health education prior to immunisation session (bearing in mind the education profile of women in the study, especially in the rural communities).
• Human-resource-related issues, including: poor knowledge of health workers on what needs to be reported and what channels to use to do so; limited training; lack of designated officers for AEFI; excessive workload; poor supportive supervision; and attitudinal issues (e.g., poor motivation/lack of commitment). Fear of reprimand, i.e., feeling that the cause of the AEFI is a result of inadequacies in their professional practices, hinders reporting and documentation of AEFI cases.
• Governance and leadership weaknesses, such as: moribund AEFI committees; lack of quality supervisory visits; and oversight and poor implementation of AEFI policy guidance.
• Insecurity: Fear of being killed by armed bandits and kidnapping impedes AEFI surveillance activities by limiting access of both the health workers and recipients of health services (clients, caregivers, and parents). Health workers have been victims of such attacks.
• Socio-economic factors and infrastructural deficits: For example, poverty at the individual and population level affects the ability of parents and the community to access health services, including reporting and managing AEFI cases.
• Funding and logistics issues: The AEFI surveillance system in Nigeria lacks funding, and data tools for reporting and documentation are not routinely available.

In drawing implications from the findings, the researchers argue that:

• Communication between routine immunisation (RI) providers and clients (caregivers/mothers) needs to be strengthened. Adequate health education services should be provided before vaccine administration, such that caregivers/mothers will be able to make well-informed decisions regarding AEFI detection, reporting, and follow-up actions.
• There should be a systematic engagement of community informants supported with the necessary tools to intensify AEFI detection and reporting from the community level. Media publicity and the strengthening of existing community resources, such as traditional and religious institutions that have proven useful in other public health programmes (e.g., the Polio Eradication Initiative), can be leveraged to improve the sensitivity of AEFI surveillance in Nigeria.
• Some relevant measures or strategies could be employed to ensure AEFI surveillance is uninterrupted in the context of insecurity. Such strategies could emanate from the lessons learned as the polio programme evolved in Northeastern Nigeria, where Boko Haram Insurgency turned the region into the last wild poliovirus (WPV) sanctuary in Nigeria and Africa. Some strategies used were: deployment of community informants to detect and notify acute flaccid paralysis (AFP) cases from inaccessible or partially accessible areas, civilian-military security partnership and health service delivery, and the use of mobile phone applications for auto-visual AFP detection and reporting (AVADAR) by health workers and informants in challenging terrains and insecure areas. (The Med Safety App on the android phone being piloted to promote self-reporting of AEFI is akin to the AVADAR innovation. Per the researchers, there is a need to fast-track the consolidation and finalisation of this app.)
• The empirical evidence provided by this study's participants could serve as an advocacy tool for vaccine pharmacovigilance strengthening in Nigeria. The government needs to prioritise AEFI surveillance and documentation as a core component of RI service delivery.
• This work also adds to the growing international call for introducing courses on AEFI - causes, management, surveillance, and reporting, to medical and nursing educational curricula. Pre-career and on-the-job-training of health workers may reduce the fear of reporting and mitigate the feeling of professional incompetence that deter reporting and documentation of AEFI among health workers. Further, supportive supervision during their professional life provides an on-the-job training opportunity and a means of instituting accountability for the health workers at the PHC level.

In conclusion, addressing the impediments to AEFI reporting in Nigeria requires health system strengthening and a whole-of-the-society approach to improve vaccine safety surveillance, restore public confidence, and promote vaccine demand.