LAGOS, Nigeria — In the departure hall of Nigeria’s busiest airport, Murtala Muhammed International in Lagos, passengers get their travel documents ready for check-in. In addition to a passport, ticket, and visa, travelers to many destinations need a yellow fever vaccination card, as Nigeria struggles with an ongoing outbreak. The cards are automatically issued following immunization at a government hospital and are validated with a signature and stamp from the port health authority.
WHO has identified vaccine hesitancy as one of the greatest threats to global health. As the World Health Assembly meets in May, Devex is exploring the rise of vaccine hesitancy and what it means for global health efforts.
But although 1 in 5 people who contract yellow fever in Nigeria die from it, not everyone gets immunized — and some are finding ways to bypass the travel requirements, increasing the risk of the epidemic-prone disease spreading to other countries.
One way to do it is to buy a falsified vaccination card, readily available at the airport for those who either don’t want to be immunized or don’t have enough time before they travel.
The Nigerian government told Devex the cards are fake, while evidence at the airport suggests they are authentic but fraudulently obtained. Airport staff and travelers said the cards had been bought at the port health authority’s store, duly stamped and signed as a way of generating underhand revenue for staff. Devex was able to buy one for 3,000 Nigerian naira ($8.50) and no evidence of immunization.
“There is no excuse for not receiving necessary immunization and we need a sense of patriotism — doing the right thing and not putting others at risk.”— Dr. Lawal Bakare, founder, EpidAlert
The port health authority denied the involvement of their staff and said that banners at the airport warn travelers of the dangers of fake cards.
“I don’t think we are doing a bad thing,” an airport worker told Devex. “Without the card, you might miss your flight and that will be [a] waste of money over an ordinary card.”
Desperate travelers continue to request them. “Some will even call you to get one for them on their way to the airport. We also have friends and relatives that want to travel and know that we have access to the cards,” she said.
One traveler who has used such a card on trips to South Africa, Kenya, and Ethiopia said none of the embassies had flagged the card as falsified, nor denied him a visa. He suggested the lengthy process of obtaining the card legally — which means scheduling a hospital appointment and then waiting 10 days after immunization for the card to become valid — means many travelers are not able to get it on time.
“I see it as an outcome of a systemic failure. Why will I be going from one office to another, and be intentionally delayed because I want to do the right thing when I can get the same card within two minutes at the airport for less amount?” he said.
The rise of vaccine hesitancy
Vaccine hesitancy — a reluctance or refusal to be immunized — was named by the World Health Organization as one of the top 10 threats to global health in 2019. The reasons are complex and vary by location and community, but a WHO advisory group pointed to complacency, inconvenience, and falling confidence in vaccines and health authorities as underlying causes. Left unchecked, it could undermine health gains made over many decades.
While much attention has been paid to the situation in Europe and the United States, which is experiencing a surging measles outbreak, it is also a growing problem elsewhere.
In Nigeria, poor services and a lack of knowledge about the importance of vaccines have been identified as the biggest challenges.
“In the northern parts of Nigeria where vaccine coverage is lowest, immunization services are not being rendered in both the health facilities and outreach sites [as] regularly [or] qualitatively as needed. There are not enough health workers, not enough logistics to support their operations, not enough supervision to keep them accountable,” said Dr. Chizoba Wonodi, Nigeria country director for Johns Hopkins School of Public Health's International Vaccine Access Center.
Wonodi added that demand is missing because women — typically responsible for family health care — often lack the education to understand that vaccines could protect their children.
Why and how is vaccine hesitancy impacting immunization efforts in different parts of the world?
“If you look at the data, children of uneducated women are three times less likely to be vaccinated. If you combine this with poor service delivery, you get low rates of vaccine uptake,” she said.
But as the situation at the airport shows, even those who have ready access to vaccines are failing to get them.
At the end of last year, the Nigerian health ministry took steps to introduce electronic verification into the vaccination card system. “The introduction of an electronic version of the yellow card stemmed from the ubiquitous fake versions of the card that are notoriously being issued by unauthorized personnel for years,” a health ministry spokesperson told Devex.
Although the new system was expected to kick in from April 1, the deadline has been extended to the end of June to give people more time to sign up.
Dr. Lawal Bakare, founder of EpidAlert, a Nigerian nonprofit working on disease prevention, said it will be more easily available, affordable, and verifiable, with registration and payment made online.
To prevent health authority staff selling falsified documents, cash has been removed from the system. “You cannot pay cash. Money goes directly to government wallet. A reference code is generated and is linked to a traveler’s passport number which can be checked against [a] database which those that are selling the fake cards will not have access to,” Bakare explained.
Despite the government’s investment in the new portal, adoption has been limited. “People were not aware of the new card and we advocated for the shift of the deadline,” Bakare said, adding that the distraction of the Nigerian election at the start of the year “did not allow the new yellow cards to get much attention.”
His organization is now planning awareness sessions for frequent travelers, multinational companies, universities, and embassies to drive adoption. “We have a duty as a country to protect the global health system,” he said.
But he added that the new system does not directly tackle the underlying problem behind the emergence of a market for fake vaccine cards — the hesitancy among travelers to be immunized.
To tackle that, Bakare said travelers need to know the dangers of falsifying vaccine cards, and be encouraged to apply for legitimate cards earlier. “There is no excuse for not receiving necessary immunization and we need a sense of patriotism — doing the right thing and not putting others at risk,” he said.
Wonodi advocated for good, regular data and strong coordinating platforms to ensure vaccination programs are reaching the right areas, and that work is happening to engage communities.
She expressed optimism about the future of vaccination in Nigeria and across Africa, but added that hesitancy remains a risk with the rise of technologies that can spread false information fast.
“The good news is that this same technology ... can also be used to coordinate a response fast. It can also be used to train health workers and community volunteers to deliver services better. It can be used to remind parents to vaccinate their children. It can be used to educate community leaders to support immunization and religious leaders to preach immunization,” Wonodi said.