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Diphtheria is an acute bacterial infection caused mainly by the gram-positive, toxin-producing strains of Corynebacterium diphtheriae (C. diphtheria). Although the epidemiology and control of diphtheria have been known for a long time with an effective vaccine to prevent it. However, the disease continues to infect and kill many children, adolescents and even adults. If we slightly discuss about the situation of diphtheria outbreak in Nigeria, according to WHO report Nigeria has recorded an uncommon upsurge in cases of diphtheria across numerous states. A total of 5898 cases of diphtheria were informed from 59LGAs in 11 states across the country from 30 June to 31 August (WHO, 2023).

Diphtheria immunization coverage rates

Immunization is one of the public health interferences for preventing disease. In 1974 WHO has recognized the Expanded Program on Immunization (EPI) to ensure that all child are routinely vaccinated by 1990 (WHO, 2023). Nigeria adopted the EP policy in 1978 policy in 1978 and started vaccinating their children by PENTA vaccine including diphtheria, pertussis, tetanus, hepatitis B, and Haemophilus influenza type b. Currently Nigeria includes two vaccines for the prevention of diphtheria these are pentavalent and tetanus-diphtheria toxoid (Td) vaccines (Azees et al., 2023). However, the outline of PENTA vaccines may disturb the vaccination system both positive and negative way. The immunization program of Nigeria gets disturbed with the outline of pentavalent vaccine (MacDonald, 2015). The potential issues were replacing the older vaccine stock with new vaccine, which affected the attention of either or both vaccines (the newly introduced and the previously identified vaccine) (Sadah et al., 2016). Another significant challenge was it affects the accessibility of vaccine including the cold chain supplies, resulting in stock out and lack of space for larger supplies. Sadah et al (2016) overall stated that the addition of pentavalent vaccine is frequently anticipated with barriers and can disturb the exposure of both old and new vaccine. The introduction of the pentavalent vaccine resulted in lessening the number of vaccinations directed per visit from 2 to 1 at ages, 6, 10 and 14 weeks (Sadah et al. 2016)

The study by Ophori et al (2014) reported that vaccination rates in northern Nigeria are lowermost in the world. According to the data presented by NIS, the proportion of fully immunized infants in the beleaguered states was less than 1% in Jigawa. 1/5% in Yobe, 1.6% in Zamfara, and 8.3% in Katsima. As a outcome, due to poor immunization program vast number of children in Nigeria are victims of diphtheria. According to the data presented by UNICEF, between the year 1995 and 2005 showed DPT coverage decline from 56% to 45% (Ophori et al., 2014). EPI policy in Nigeria stated that by 2004, no municipal in the country should have or report cases of diphtheria. However, the statistical data presented by the UNICEF report showed that his vision is not yet comprehended. In 1990, DPT had a exposure of 56%, which fell to 31% in 1995, and to 26% in 1996, and fluctuated between 25% and 45% between 1997 and 2005 (Ophori et al., 2014). Although the national DPT3 exposure stands at 67.73%, there was an approximate 95% upsurge in handling in 2010 as in contradiction of the 36.3% coverage recorded in 2006. The southeast zone with a reporting of 91.18% offers the highest figure, while the northeast zone with 46.16% represents the lowest. The DPT3 handling by States shows that Enugu state has the maximum DPT3 coverage of 98.21%, while Taraba State presented the lowermost DPT3 reporting with 15.63% (Ophori et al., 2014).

The most recent study by Agarwal et al (2023) identified the matters in monitoring diphtheria in Nigeria. They identify two major issues including less immunization coverage and inadequate availability to healthcare services. NIS reported that about 3.1 million (14%) children have zero or missed doses of vaccines. Almost 40% of children did not obtain any vaccine from the health organization, while 49% got only the main PENTA vaccine, and only 33% were given all three doses of the PENTA valent vaccine (Agarwal et al., 2023). However, the global coverage of the third dose of DPT3 gradually increased in 2000 from 72% to 76% in 2001. Meanwhile, it declined in 2002 with fluctuations observed in the preceding years. It dropped 86% in 2019 to 81% in 2021, its lowest level since 2008. Azees et al (2023) highlighted the stagnant or falling DPT3 coverage since 2019, stating that around 25 million children were unvaccinated or under-vaccinated are living in 10 countries including Nigeria (Azees et al., 2023).

Furthermore, if we only discuss the immunization coverage of Nigeria, then according to National Immunization Coverage Surveys (NICS) Nigeria had a sharp rise from 25% in 2005 to 75% but dropped form 74% in 2010 to 52% in 2012. This progress falls far short of Sustainable Development Goal (SDG) 3, which aims to achieve at least 90% of all primary immunization for children aged 12 to 23 months. The percentage of children aged 12-13 months who gets basis vaccination augmented from 23% in 2018 to 31% in 2018%. The proportion of children who gets none of the basic immunizations deteriorated from 29% to 195 during the same period (Azees et al., 2023). However, Adegboye et al (2023) stated that DTP3 immunization rate fell from 86% in 2019 to 81% in 2021. Instead of the hard work of the diphtheria herd immunity threshold (75-80%), complete immunization reporting of 56% in Nigeria stays suboptimal, with noteworthy differences in DPT3 vaccination coverages across Nigerian states (<20% to 80%).

Vaccine hesitancy (VH)

VH related to the diphtheria vaccine is a concern in some regions including Nigeria. It refers to the unwillingness or denial to vaccinate despite the accessibility of vaccines. Sato et al. (2021) reported that in emerging countries worldwide, almost 20 million children are expected to have unreachable by routine vaccination in 2016, of which 60% are concentrated in 10 countries, one of which is Nigeria. It has been identified that VH is found to be a significant matter in African countries as well. In Nigeria, some famous incidents clearly indicated the prevalence of VH, like the Nigerian vaccination boycott in 2003. This incident was hastened by political leaders and that donated to formation of determined VH in region. The study by Sato et al (2021) found that the prevalence of VH was 13%, however, they distinguished vaccine hesitaters in two types one who absolute deny vaccination and other are floating refusers. The current immunization program of Nigeria offers the Bacillus Calmette-Guerein (BCG), polio 3, PENTA3/DPT3, measles, and yellow fever vaccines (Ogboghodo et al., 2016). However, the current rates of vaccine coverage are suboptimal with rates 51/3% for the BCG vaccine, 34% for the polio vaccine, 48.1% for the measles vaccine and 39% for the yellow fever vaccine. VH was identified as the contributing factor in such suboptimal rates of vaccination coverage (Sato et al., 2021).

Factors leading to VH

Some of the leading factors to VH in relation to the diphtheria vaccine are lack of awareness, misinformation, religious or cultural beliefs, and fear of side effects. In some Nigerian communities, there may be a lack of awareness about the importance of vaccination and the risks of diphtheria. Adegboye et al (2023) provided evidence that suggested that motherly schooling, common delusions or principles, household decision producing dynamics (impact of male partner and family), mistrust in vaccines and severe effects related to the immunization are related with low vaccine acceptance. People may not fully understand the disease and the benefits of vaccines. Misinformation false information, or false beliefs about vaccines can lead to hesitancy. This misinformation can spread through social media, community rumours, or mistrust of healthcare providers. Religious and cultural beliefs can also result in conflict with vaccination (Ophori et al., 2014).

Addressing these concerns requires sensitivity and cultural competence in healthcare delivery. In Nigeria, the biggest issue to the receipt of vaccination is a spiritual one specially among the northern Nigerian Muslims. Majorly, the Muslims of north has the low vaccination exposure, the minimum being 6% (northeast) and the maximum being 44.6% (southeast) (Ophori et al., 2014). Fears concerning repetitive immunization are articulated in several parts in Nigeria. Ophori et al (2014) in their study mentioned that Kano state that 9.2% of defendants (mother aged 15-49) evinced “no faith in immunization’, while 6.7% articulated fear of negative impact of vaccines. Multiple Indicators Cluster Survey (MICS) reported also specified that 64% of children aged 12 to 23 months did not take all routine immunizations and that 11% of women declined to vaccinate their children due to their anxiety about side effects, while 26% did not vaccinate their children due to suspicion and terror (Ogundele et al., 2023).

Strategies that can be applied for the prevention and mitigation of diphtheria

VH should be addressed with the simple, consistent, sustained, and robust measures necessary to build trust in vaccines and immunization programs. Addressing VH related to the diphtheria vaccine in Nigeria, or any other region, requires a multifaceted approach involving healthcare providers, public health authorities, community leaders, and other stakeholders. Promoting education and awareness about vaccine can be help (Sato et al., 2021). This can be developing public health campaigns that provide accurate and easily understandable information about the diphtheria vaccine, its importance, and safety. Acknowledge and respect cultural beliefs and practices related to health and vaccination. Engage with local leaders and influencers who can help bridge cultural gaps. Engage community leaders, religious leaders, and traditional healers in discussions about vaccination. Their support can be influential in dispelling myths and encouraging vaccination (Ophori et al., 2014). Make vaccines readily available and easily accessible to all communities, including remote or underserved areas. Offer vaccination services at convenient times and locations to accommodate people's schedules. NCDC recommended that Nigeria should follow the childhood immunization schedule and guarantee that their children are fully vaccinated. To fastening up the immunization the carers for diphtheria-infected should practice strict sanitation, particularly while managing food and cooking ( Adegboye et al., 2023).


Adegboye, O. A., Alele, F. O., Pak, A., Castellanos, M. E., Abdullahi, M. A., Okeke, M. I., ... & McBryde, E. S. (2023). A resurgence and re-emergence of diphtheria in Nigeria, 2023. Therapeutic Advances in Infectious Disease 10 , 20499361231161936.

Agrawal, R., Murmu, J., Kanungo, S., & Pati, S. (2023). “Nigeria on alert: Diphtheria outbreaks require urgent action”-A critical look at the current situation and potential solutions. New Microbes and New Infections 52

Azees, A. S., Soyannwo, T., Adeniyi, M. A., Osinubi, M. O., & Imhonopi, G. B. (2023). Diphtheria Outbreak in Nigeria: An Epidemiological Evidence Review. Cross River Journal of Medicine (2), 3-3. .

MacDonald, N. E. (2015). Vaccine hesitancy: Definition, scope and determinants. Vaccine 33 (34), 4161-4164.

Ogboghodo, E., Esene, H., & Okojie, O. H. (2016). Determinants of uptake of pentavalent vaccine in Benin City, Southern Nigeria. Int J Community Med Public Health , 3195-201.

Ogundele, O. A., Fehintola, F. O., Salami, M., Usidebhofoh, R., & Abaekere, M. A. (2023). Prevalence and patterns of adverse events following childhood immunization and the responses of mothers in Ile-Ife, South West Nigeria: a facility-based cross-sectional survey. Osong Public Health and Research Perspectives 14 (4), 291.

Sadoh, A. E., Nwaneri, D. U., Ogboghodo, B. C., & Sadoh, W. E. (2016). Effect of introduction of pentavalent vaccine as replacement for Diphtheria–Tetanus–Pertussis and Hepatitis B vaccines on vaccination uptake in a health facility in Nigeria. Vaccine 34 (24), 2722-2728.

Sato, R., & Takasaki, Y. (2021). Vaccine Hesitancy and refusal: behavioral evidence from rural Northern Nigeria. Vaccines (9), 1023.

WHO. (2023). Diphtheria-Nigeria.

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