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Perspectives from Zamfara State: Only a significant investment in Primary Health Care can protect us from future outbreaks

As I look at the numbers again this week, I take heart that the efforts of many different teams working on the outbreak has started to yield some results as we see positive signs that the CSM outbreak may indeed be receding. But now is the time to get bac

In the field of public health, data appropriately put into context should guide what we do. Data from the field should help us quantify and understand problems, think through different solutions and direct how we spend our limited resources. However, sometimes data can only go so far. For more than two months, the Nigeria Centre for Disease Control (NCDC) has been leading the Federal Government’s efforts to control an outbreak of cerebrospinal meningitis (CSM) in some states in the country. The outbreak was recognised in February 2017, when NCDC received reports of an increase in cases of CSM, which actually started in December 2016. In March, these numbers began to escalate rapidly and by then, things were not looking good: hundreds of new cases of meningitis were being reported through our surveillance systems. Worried by the numbers, I decided to go on an emergency visit to Zamfara, the State most affected by the outbreak.

I arrived in Gusau, the State capital of Zamfara after an eight-hour drive from Abuja. I was delighted to see the hard work and steps the state government was taking to address the problem, as well as an NCDC team that was providing support to the state government. The Secretary to the State Government who led the Zamfara State Committee on meningitis outbreak control described in detail some of the steps the state had taken to control the outbreak.

The next day, we drove for more than two hours from the state capital of Gusau to Shinkafi/Birnin Magaji, one of the worst affected Local Government Areas (LGAs) in the State. After our courtesy visits to the LGA secretariat and a visit to the Emir; we arrived at a health facility that was then doubling as an emergency treatment centre. There, I met a doctor and some nurses struggling to provide care for several patients in a makeshift facility. Equipped with little more than compassion, willpower and a few drugs, the team told me how they had been battling to save the lives of so many adults and children in the community.

“Night and day, people are streaming in, bringing in their sick children and their relatives. We are doing all we can to try to help”, one of the nurses told me, as she wiped the sweat that was streaming down her face.

As we walked into the make-shift treatment centre, I met Hassan, a seven year-old boy who had been admitted at the treatment centre for ten days. Hassan’s parents brought him here when he developed a fever and could not move his neck. Hassan had not attended school for more than two weeks and his mother had no choice but to leave three other children at home so that she could care for him at the treatment centre. As I looked around the facility, I saw patients young and old, lying down on makeshift mats, all surrounded by anxious family and friends, all worried about this ‘new disease’ that had struck the community. Speaking with the only doctor at the centre, he estimated that more than 300 people had been admitted and treated at the centre, with several new patients seen every day. Many came to the hospital in a critical situation, many died en-route to the hospital. Although laboratory confirmation is important for confirming cases prior to treatment, the good doctor and his hardworking colleagues rarely took samples before starting treatment. Even if these samples were taken, there was no reliable way to take them to the laboratory in Gusau. I realised that our problems are very deep indeed. The Director of Public Health in Zamfara State told me;

“I have never seen anything like this”

Timely and accurate collection and reporting of outbreak data is important to quickly detect, respond and monitor outbreaks. However, the State Disease Surveillance and Notification Officer (DSNO) had been finding it difficult to keep up with these core requirements. Despite his best efforts, he had not managed to get the requisite data from all health facilities on suspected cases of meningitis. He spent considerable time chasing reports from the LGAs every day, in order to provide summary reports to the state, which are then sent to NCDC. The State DSNO was willing to learn more about how to manage his data, but had not received adequate training on this. The situation was not too different at the State Epidemiologist’s office. The team despite their commitment and dedication, had very little to work with! Yet, they must overcome the challenges related to providing their reports to the national level in order to guide the response.

When I visited the laboratories in Gusau the next day, I could see how issues I witnessed in the field manifested in the laboratory. Specimen transportation to the laboratory was poor and sometimes non-existent. Some testing equipment was just not available, therefore at best specimen samples were sent further away to Sokoto for confirmation. We definitely have a problem with the laboratory confirmation of samples - from collection, to testing and then to reporting.

At my debrief meetings with State officials working to control the outbreak, I was filled with hope but also conscious of the scale of the challenges that they faced. We reviewed our findings from the field and had a common understanding of the issues that contributed to the size of this outbreak. Cases were not picked up early, and when they were, accurate and complete reports were not sent in a timely manner to the appropriate local and national agencies. Although health care workers put in their best, adequate human resource capacity needed to tackle the outbreak was also not available in places where they were most needed. Laboratory capacity was weak and specimen transportation systems failed. But, my hope was rooted in the willingness of the state officials to work with the Federal Ministry of Health, NCDC, National Primary Health Care Development Agency (NPHCDA), and other partners to ensure that we expedite actions to stop the current outbreak and to prepare for the future.

As we left Zamfara State to get back to the work of coordinating the outbreak response in Abuja, my mind could not get away from the many patients affected by this outbreak. I thought of the families that have had to go through the pain of seeing their loved ones live through the pain of meningitis. I thought of families that had lost loved ones during this outbreak. And more importantly, I reflected on what government at the Local, State and National levels needed to do to prevent the recurrence of a similar outbreak in the future.

For all the progress we have made strengthening our health systems over the past few years, a lot more still needs to be done—and urgently—to support basic health care delivery in most of our rural areas. This is particularly important in disease surveillance and early detection and response systems at the community level. While we focus on building our workforce and development capacity for outbreak response across the entire country, we will need to prioritize immediate investments in appropriate manpower at the primary health care level. Without a strong primary health care system, we cannot have strong surveillance.

I have written extensively about the need for us to develop laboratory capacity to support surveillance activities. During this outbreak, with support of the World Health Organisation we have significantly grown our laboratory capacity in Gusau. In Sokoto, we have supported an innovative public private partnership with eHealth Africa. Our new National Reference Laboratory in Abuja has come to life. The current CSM outbreak shines a bright light on the need to continue to develop our laboratory architecture, as well as the urgent need to revamp how we collect and transport specimen samples to facilitate diagnosis, especially in emergencies. This continues to be one of my major priorities.

As I look at the numbers again this week, I take heart that the efforts of many different teams working on the outbreak has started to yield some results as we see positive signs that the CSM outbreak may indeed be receding. But now is the time to get back to work, to help prevent the next CSM outbreak-and to be better prepared when the next emergency comes knocking.