Research & Publications

  • Electronic Reporting of Integrated Disease Surveillance and Response: Lessons Learned from Northeast, Nigeria, 2019

    Authors: Luka Mangveep Ibrahim, Ifeanyi Okudo, Mary Stephen, Brazzaville, Congo Opeayo Ogundiran, Jerry Shitta Pantuvo, Daniel Rasheed Oyaol, Sisay Gashu Tegegne, Abdelrahim Khalid, Elsie Ilori, Olubunmi Ojo, Chikwe Ihekweazu, Fiona Baraka, Walter Kazadi Mulombo, Clement Lugala Peter Lasuba, Peter Nsubuga
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    Electronic reporting of integrated disease surveillance and response (eIDSR) was implemented in two states in North-East Nigeria as an innovative strategy to improve disease reporting. Its objectives were to improve the timeliness and completeness of IDSR reporting by health facilities, prompt identication of public health events, timely information sharing, and public health action. We evaluated the project to determine whether it met its set objectives. Method: We conducted a cross-sectional study to assess and document the lessons learned from the project. We reviewed the performance of the Local Government Areas (LGAs) on rumors identication and reporting of IDSR data on the eIDSR and the traditional system using a checklist. Respondents were interviewed online on the relevance; eciency; sustainability; project progress and effectiveness; effectiveness of management; and potential impact and scalability of the strategy using structured questionnaires. Quantitative data were analyzed and presented as proportions using an MS Excel spreadsheet. Qualitative data was cleaned, converted into an MS Excel database, and analyzed using Epi Info version 7.2 to obtain frequencies. Responses were also presented as direct quotes or word clouds. Results: The number of health facilities reporting IDSR increased from 103 to 228 (117%) before and after implementation of the eIDSR respectively. The completeness of IDSR reports in the last six months before the evaluation was ≥ 85%. Of the 201 rumors identied and veried, 161 (80%) were from the eIDSR pilot sites. The majority of the stakeholders interviewed believed that eIDSR met its predetermined objectives for public health surveillance. The benets of eIDSR included timely reporting and response to alerts and disease outbreaks, improved completeness, and timeliness of reporting, and supportive. supervision to the operational levels. The strategy helped the stakeholders to appreciate their roles in public health surveillance. Conclusion: The eIDSR increased the number of health facilities reporting IDSR, enabled early identication, reporting, and verication of alerts, improved completeness of reports, and supportive supervision on staff at the operational levels. It was well accepted by the stakeholder as a system that made reporting easy with the potential to improve the public health surveillance system in Nigeria.

  • Field notes from the Nigeria Centre for Disease Control 2019 pilot internship program for resident doctors

    Authors: Oluwatomi Funbi Iken, Kelly Elimian, Chinwe Ochu, Chikwe Ihekweazu
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    The 10-week internship for the pilot cohort of resident doctors from various teaching hospitals in Nigeria was a very rewarding experience. The internship was a beautiful immersion into field epidemiology, rumor surveillance, risk communication, digital tools for surveillance, developing strategic documents, line lists interpretation, weekly presentations and outbreak response coordination alongside working briefly as an incident manager for the Yellow Fever technical working group. Some of the learning points included: meeting coordination, contributions to ongoing research, review of training documents for surveillance officers and the mechanisms of escalating and de-escalating technical working groups in the face of outbreaks and working as an incident manager. There is the need to continue this internship to strengthen the capacity of our emerging health workforce in residency training to address our public health priorities in Nigeria

  • A rapid assessment of the implementation of integrated disease surveillance and response system in Northeast Nigeria, 2017

    Authors: Luka Mangveep Ibrahim1, Mary Stephen, Ifeanyi Okudo, Samuel Mutbam Kitgakka, Ibrahim Njida Mamadu, Isha Fatma Njai, Saliu Oladele, Sadiq Garba, Olubunmi Ojo, Chikwe Ihekweazu, Clement Lugala Peter Lasuba, Ali Ahmed Yahaya, Peter Nsubuga and Wondimagegnehu Alemu
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    Integrated disease surveillance and response (IDSR) is the strategy adopted for public health surveillance in Nigeria. IDSR has been operational in Nigeria since 2001 but the functionality varies from state to state. The outbreaks of cerebrospinal meningitis and cholera in 2017 indicated weakness in the functionality of the system. A rapid assessment of the IDSR was conducted in three northeastern states to identify and address gaps to strengthen the system. Method: The survey was conducted at the state and local government areas using standard IDSR assessment tools which were adapted to the Nigerian context. Checklists were used to extract data from reports and records on resources and tools for implementation of IDSR. Questionnaires were used to interview respondents on their capacities to implement IDSR. Quantitative data were entered into an MS Excel spreadsheet, analysed and presented in proportions. Qualitative data were summarised and reported by thematic area. Results: A total of 34 respondents participated in the rapid survey from six health facilities and six local government areas (LGAs). Of the 2598 health facilities in the three states, only 606 (23%) were involved in reporting IDSR. The standard case definitions were available in all state and LGA offices and health facilities visited. Only 41 (63%) and 31 (47.7%) of the LGAs in the three states had rapid response teams and epidemic preparedness and response committees respectively. The Disease Surveillance and Notification Officers (DSNOs) and clinicians’ knowledge were limited to only timeliness and completeness among over 10 core indicators for IDSR. Review of the facility registers revealed many missing variables; the commonly missed variables were patients’ age, sex, diagnosis and laboratory results. Conclusions: The major gaps were poor documentation of patients’ data in the facility registers, inadequate reporting tools, limited participation of health facilities in IDSR and limited capacities of personnel to identify, report IDSR priority diseases, analyze and interpret IDSR data for decision making. Training of surveillance focal persons, provision of IDSR reporting tools and effective supportive supervisions will strengthen the system in the country.

  • Identification of co-circulating pathogens that are clinically indistinguishable from Lassa Fever during the 2018 Lassa outbreak in Nigeria

    Authors: J. Ashcroft, E. Ndodo, C. Dannwafor, B. Gannon, H. Bagnall, N. Mba, E. Ilori, A. Olayinka, C. Ihekweazu
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    Results from this study indicate that there was no one specific pathogen responsible for patients developing clinical presentations indistinguishable from LF. Rather, a variety of pathogens (both viral and bacterial) were found to be co-circulating at the time of heightened LF transmission resulting in both single and co-infections (particularly in the immunocompromised).

    Conclusion: We anticipate that this study will help ensure proper and expedited diagnosis of diseases in the differential diagnosis for LF, helping to target treatment of patients with both LF and non-LF acute febrile illnesses in Nigeria.

  • 52. Descriptive epidemiology of coronavirus disease 2019 in Nigeria, 27 February – 6 June 2020

    Authors: K. O. Elimian, C. L. Ochu1, E. Ilori, J. Oladejo, E. Igumbor, L. Steinhardt, J. Wagai, C. Arinze, W. Ukponu, C. Obiekea, O. Aderinola, E. Crawford, A. Olayinka, C. Dan-Nwafor, T. Okwor1, Y. Disu1, A. YinkaOgunleye, N. E. Kanu, O. A. Olawepo, O. Aruna, C. A. Michael, L. Dunkwu, O. Ipadeola, D. Naidoo, C. D. Umeokonkwo, A. Matthias, O. Okunromade, S. Badaru, A. Jinadu, O. Ogunbode, A. Egwuenu, A. Jafiya, M. Dalhat, F. Saleh, G. B. Ebhodaghe, A. Ahumibe, R. U. Yashe, R. Atteh, W. E. Nwachukwu, C. Ezeokafor, D. Olaleye, Z. Habib, I. Abdus-Salam, E. Pembi, D. John, U. J. Okhuarobo, H. Assad, Y. Gandi, B. Muhammad, C. Nwagwogu, I. Nwadiuto, K. Sulaiman, I. Iwuji, A. Okeji, S. Thliza, S. Fagbemi, R. Usman, A. A. Mohammed, O. Adeola-Musa, M. Ishaka U. Aketemo, K. Kamaldeen, C. E. Obagha, A. O. Akinyode, P. Nguku, N. Mba and C. Ihekweazu
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    The objective of this study was to describe the epidemiology of COVID-19 in Nigeria with a view of generating evidence to enhance planning and response strategies. A national surveillance dataset between 27 February and 6 June 2020 was retrospectively analysed, with confirmatory testing for COVID-19 done by real-time polymerase chain reaction (RT-PCR). The primary outcomes were cumulative incidence (CI) and case fatality (CF). A total of 40 926 persons (67% of total 60 839) had complete records of RT-PCR test across 35 states and the Federal Capital Territory, 12 289 (30.0%) of whom were confirmed COVID-19 cases. Of those confirmed cases, 3467 (28.2%) had complete records of clinical outcome (alive or dead), 342 (9.9%) of which died. The overall CI and CF were 5.6 per 100 000 population and 2.8%, respectively. The highest proportion of COVID-19 cases and deaths were recorded in persons aged 31–40 years (25.5%) and 61–70 years (26.6%), respectively; and males accounted for a higher proportion of confirmed cases (65.8%) and deaths (79.0%). Sixty-six per cent of confirmed COVID-19 cases were asymptomatic at diagnosis. In conclusion, this paper has provided an insight into the early epidemiology of COVID-19 in Nigeria, which could be useful for contextualising public health planning.

  • Antimicrobial use and resistance in Nigeria: situation analysis and recommendations, 2017

    Authors: Abiodun Egwuenu, Joshua Obasanya, Iruka Okeke, Oladipo Aboderin, Adebola Olayinka, Dooshima Kwange, Abiodun Ogunniyi, Estelle Mbadiwe, Love Omoniyei, Hamzat Omotayo, Mercy Niyang, Fatima Abba, Frank Kudla, AMR-TWG, Chikwe Ihekweazu
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    Introduction: it is projected that by 2050, 40% of 10 million deaths from Antimicrobial Resistance (AMR) will occur in Africa. Understanding the AMR situation in Nigeria will provide an excellent case study of the challenges faced by low-income countries.

    Methods: the information was derived from review of reports, programmatic data and documents, literature search, key informant interviews and a series of systematic reviews. Data was entered into purpose-built templates and synthesized thematically. 

    Results: in Nigeria, the ratio of licensed pharmacies to over-the-counter medicine stores was 15 to 1 in 2016. A systematic review determined that median prevalence of persons using antibiotics without prescription to be 46.8%. In animals, antibiotics such as tetracyclines constituted over 80% of antimicrobials sold or used in 2014 and 2015. Antibiotic resistance was documented in humans, to drugs recommended by the countrys treatment guidelines for commonly occurring infections such as cholera and cerebrospinal meningitis. Majority of the studies documented recovery E. coli, non-typhoidal Salmonella and antibiotic residues from livestock, pets and animal products, most commonly in poultry. The drivers of AMR included unregulated antibiotic sales, proliferation of unlicensed medicine stores, shortage of licensed prescribers, poor AMR awareness and use of antibiotics in animals without prescription.

    Conclusion: we recommend that the government enforce regulations on antibiotic sales of antibiotics to humans and animals and increase awareness on AMR in Nigerian communities. Identified gaps from the situation analysis were used to develop a National Action Plan for AMR.

  • Real-time Metagenomic Analysis of Undiagnosed Fever Cases Unveils a Yellow Fever Outbreak in Edo State, Nigeria

    Authors: Fehintola V. Ajogbasile, Judith U. Oguzie, Paul E. Oluniyi, Philomena E. Eromon, Jessica N. Uwanibe, Samar B. Mehta, Katherine J. Siddle, Ikponmwosa Odia, Sarah M. Winnicki, Nosa Akpede, George Akpede, Sylvanus Okogbenin, Ephraim Ogbaini-Emovon, Bronwyn L. MacInnis, Onikepe A. Folarin, Kayvon Modjarrad, Stephen F. Schaffner, Oyewale Tomori, Chikwe Ihekweazu, Pardis C. Sabeti & Christian T. Happ
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    Fifty patients with unexplained fever and poor outcomes presented at Irrua Specialist Teaching Hospital (ISTH) in Edo State, Nigeria, an area endemic for Lassa fever, between September 2018 - January 2019. After ruling out Lassa fever, plasma samples from these epidemiologically-linked cases were sent to the African Centre of Excellence for Genomics of Infectious Diseases (ACEGID), Redeemer’s University, Ede, Osun State, Nigeria, where we carried out metagenomic sequencing which implicated yellow fever virus (YFV) as the etiology of this outbreak. Twenty-nine of the 50 samples were confirmed positive for YFV by reverse transcriptase-quantitative polymerase chain reaction (RT-qPCR), 14 of which resulted in genome assembly. Maximum likelihood phylogenetic analysis revealed that these YFV sequences formed a tightly clustered clade more closely related to sequences from Senegal than sequences from earlier Nigerian isolates, suggesting that the YFV clade responsible for this outbreak in Edo State does not descend directly from the Nigerian YFV outbreaks of the last century, but instead reflects a broader diversity and dynamics of YFV in West Africa. Here we demonstrate the power of metagenomic sequencing for identifying ongoing outbreaks and their etiologies and informing real-time public health responses, resulting in accurate and prompt disease management and control.

  • Epidemiologic and Clinical Features of Lassa Fever Outbreak in Nigeria, January 1–May 6, 2018

    Authors: Elsie A. Ilori, Yuki Furuse, Oladipupo B. Ipadeola, Chioma C. Dan-Nwafor, Anwar Abubakar, Oboma E. Womi-Eteng, Ephraim Ogbaini-Emovon, Sylvanus Okogbenin, Uche Unigwe, Emeka Ogah, Olufemi Ayodeji, Chukwuyem Abejegah, Ahmed A. Liasu, Emmanuel O. Musa, Solomon F. Woldetsadik, Clement L.P. Lasuba, Wondimagegnehu Alemu, Chikwe Ihekweazu
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    Lassa fever (LF) is endemic to Nigeria, where the disease causes substantial rates of illness and death. In this article, we report an analysis of the epidemiologic and clinical aspects of the LF outbreak that occurred in Nigeria during January 1–May 6, 2018. A total of 1,893 cases were reported; 423 were laboratory-confirmed cases, among which 106 deaths were recorded (case-fatality rate 25.1%). Among all confirmed cases, 37 occurred in healthcare workers. The secondary attack rate among 5,001 contacts was 0.56%. Most (80.6%) confirmed cases were reported from 3 states (Edo, Ondo, and Ebonyi). Fatal outcomes were significantly associated with being elderly; no administration of ribavirin; and the presence of a cough, hemorrhaging, and unconsciousness. The findings in this study should lead to further LF research and provide guidance to those preparing to respond to future outbreaks.

  • Lay media reporting of monkeypox in Nigeria

    Authors: Oyeronke Oyebanji1, Ugonna Ofonagoro2, Oluwatosin Akande3, Ifeanyi Nsofor2, Chika Ukenedo4, Tarik Benjamin Mohammed1, Chimezie Anueyiagu5, Jeremiah Agenyi1, Adesola Yinka-Ogunleye6, Chikwe Ihekweazu
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    Summary box

    ·        Risk communication is an important but under-appreciated aspect of outbreak response, therefore, understanding the nature and impact of media coverage can assist in modifying messages.

    ·        Media reports from unauthorised sources during the ongoing monkeypox outbreak in Nigeria were sensationalised and led to increased anxiety in the population.

    ·        Because of the tendency of the media to amplify, rather than correct rumours, media personnel should be trained prior to an outbreak to reduce distorted reporting.

    ·        The Nigerian government should maintain an up-to-date communication platform for outbreak reporting, to routinely provide accurate information to the public.

    ·        There should be a well-defined approach of using event-based surveillance for decision-making, effective communication and for informing how disease outbreaks are reported by the media.

  • 47. Use of Surveillance Outbreak Response Management and Analysis System for Human Monkeypox Outbreak, Nigeria, 2017-2019.

    Authors: Silenou, Bernard C; Tom-Aba, Daniel; Adeoye, Olawunmi; Arinze, Chinedu C; Oyiri, Ferdinand; Suleman, Anthony K; YinkaOgunleye, Adesola; Dörrbecker, Juliane; Ihekweazu, Chikwe; Krause, Gérard
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    In November 2017, the mobile digital Surveillance Outbreak Response Management and Analysis System was deployed in 30 districts in Nigeria in response to an outbreak of monkeypox. Adaptation and activation of the system took 14 days, and its use improved timeliness, completeness, and overall capacity of the response.

  • Human monkeypox - After 40 years, an unintended consequence of smallpox eradication

    Authors: Karl Simpson, David Heymann, Colin S Brown, W John Edmunds, Jesper Elsgaard, Paul Fine, Hubertus Hochrein, Nicole A Hoff, Andrew Green, Chikwe Ihekweazu, Terry C Jones, Swaib Lule, Jane Maclennan, Andrea McCollum, Barbara Mühlemann, Emily Nightingale, Dimie Ogoina, Adesola Ogunleye, Brett Petersen, Jacqueline Powell, Ollie Quantick, Anne W Rimoin, David Ulaeato, Andy Wapling
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    Smallpox eradication, coordinated by the WHO and certified 40 years ago, led to the cessation of routine smallpox vaccination in most countries. It is estimated that over 70% of the world's population is no longer protected against smallpox, and through cross-immunity, to closely related orthopox viruses such as monkeypox. Monkeypox is now a re-emerging disease. Monkeypox is endemic in as yet unconfirmed animal reservoirs in sub-Saharan Africa, while its human epidemiology appears to be changing. Monkeypox in small animals imported from Ghana as exotic pets was at the origin of an outbreak of human monkeypox in the USA in 2003. Travellers infected in Nigeria were at the origin of monkeypox cases in the UK in 2018 and 2019, Israel in 2018 and Singapore in2019. Together with sporadic reports of human infections with other orthopox viruses, these facts invite speculation that emergent or re-emergent human monkeypox might fill the epidemiological niche vacated by smallpox. An ad-hoc and unofficial group of interested experts met to consider these issues at Chatham House, London in June 2019, in order to review available data and identify monkeypox-related research gaps. Gaps identified by the experts included:The experts further agreed on the need for a better understanding of the genomic evolution and changing epidemiology of orthopox viruses, the usefulness of in-field genomic diagnostics, and the best disease control strategies, including the possibility of vaccination with new generation non-replicating smallpox vaccines and treatment with recently developed antivirals

  • Large Outbreak of Neisseria meningitidis Serogroup C - Nigeria, December 2016-June 2017

    Authors: Chimeremma Nnadi, John Oladejo, Sebastian Yennan, Adesola Ogunleye, Chidinma Agbai, Lawal Bakare, Mohammed Abdulaziz, Amina Mohammed, Mary Stephens, Kyadindi Sumaili, Olivier Ronveaux, Helen Maguire, Debra Karch, Mahmood Dalhat, Martin Antonio, Andre Bita, Ifeanyi Okudo, Patrick Nguku, Ryan Novak, Omotayo Bolu, Faisal Shuaib, Chikwe Ihekweazu
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    During the West African Ebola virus disease outbreak in 2014-15, health agencies had severe challenges with case notification and contact tracing. To overcome these, we developed the Surveillance, Outbreak Response Management and Analysis System (SORMAS). The objective of this study was to measure perceived quality of SORMAS and its change over time. We ran a 4-week-pilot and 8-week-implementation of SORMAS among hospital informants in Kano state, Nigeria in 2015 and 2018 respectively. We carried out surveys after the pilot and implementation asking about usefulness and acceptability. We calculated the proportions of users per answer together with their 95% confidence intervals (CI) and compared whether the 2015 response distributions differed from those from 2018. Total of 31 and 74 hospital informants participated in the survey in 2015 and 2018, respectively. In 2018, 94% (CI: 89-100%) of users indicated that the tool was useful, 92% (CI: 86-98%) would recommend SORMAS to colleagues and 18% (CI: 10-28%) had login difficulties. In 2015, the proportions were 74% (CI: 59-90%), 90% (CI: 80-100%), and 87% (CI: 75-99%) respectively. Results indicate high usefulness and acceptability of SORMAS. We recommend mHealth tools to be evaluated to allow repeated measurements and comparisons between different versions and users.

  • Lassa virus RNA detection from suspected cases in Nigeria, 2011-2017

    Authors: Salu Olumuyiwa Babalola, James Ayorinde Babatunde, Orenolu Mercy Remilekun, Anyanwu Roosevelt Amaobichukwu, Abdullah Mariam Abiodun, Idris Jide, Abdus-Salam Ismail Adeshina , Ihekweazu Chikwe, Omilabu Sunday Aremu
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    Introduction: The diagnosis of Lassa fever is crucial to confirm cases, as well as to control/prevent nosocomial and community-based transmission and initiation of treatment, which is still limited in the country. Thus, we aimed at providing some information on the laboratory detection of Lassa from suspected cases in Nigeria.

    Methods: This was a retrospective study of seasonal Lassa fever outbreaks data from 1,263 samples analyzed using Reverse Transcription-Polymerase Chain Reaction (RT-PCR) at the Virology Research Laboratory, College of Medicine, University of Lagos/Lagos University Teaching Hospital between year 2011 and 2017. Data were analyzed using the 21st edition of SPSS statistical software (2015).

    Results: The RT-PCR test confirmed the presence of Lassa in 112 (8.9%) comprising 61 (54.4%) males, 48 (42.9%) females and 3 (2.7%) individuals without gender information. Those aged between 18 and 49 years were mostly affected. There was a decline in the detection of Lassa from 4.7% in 2011/2012 to less than 1% by the 2014/2015. However, during the 2015/2016 and 2016/2017 seasons the detection rates increased to 10.4% and 15.1% respectively. The Northern region of Nigeria reported high confirmed cases of Lassa. The South Western region also witnessed an increased Lassa fever positivity rate of 13.4% of which Lagos and Ogun states being the focal state of Lassa activity in the region.

    Conclusion: These established the need for heightening the continued surveillance for Lassa as well as the establishment of other testing facilities within these endemic regions for prompt diagnosis of Lassa fever.

  • A description of HIV prevalence trends in Nigeria from 2001 to 2010: what is the progress, where is the problem?

    Authors: Adebobola Bashorun, Patrick Nguku, Issa Kawu, Evelyn Ngige, Adeniyi Ogundiran, Kabir Sabitu, Abdulsalam Nasidi, Peter Nsubuga
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    Introduction: Nigeria's population of 160 million and estimated HIV prevalence of 3.34% (2011) makes Nigeria the second highest HIV burden worldwide, with 3.2 million people living with HIV (PLHIV). In 2010, US government spent about US$456.5 million on the Nigerian epidemic. Antenatal clinic (ANC) HIV sero-prevalence sentinel survey has been conducted biennially in Nigeria since 1991 to track the epidemic. This study looked at the trends of HIV in Nigeria over the last decade to identify progress and needs.

    Methods: We conducted description of HIV sero-prevalence sentinel cross-sectional surveys conducted among pregnant women attending ANC from 2001 to 2010, which uses consecutive sampling and unlinked-anonymous HIV testing (UAT) in 160 sentinel facilities. 36,000 blood samples were collected and tested. We used Epi-Info to determine national and state HIV prevalence and trends. The Estimation and Projection Package with Spectrum were used to estimate/project the burden of infection.

    Results: National ANC HIV prevalence rose from 1.8% (1991) to 5.8% (2001) and dropped to 4.1% (2010). Since 2001, states in the center, and south of Nigeria had higher prevalence than the rest, with Benue and Cross Rivers notable. Benue was highest in 2001 (14%), 2005 (10%), and 2010 (12.7%). Overall, eight states (21.6%) showed increased HIV prevalence while six states (16.2%) had an absolute reduction of at least 2% from 2001 to 2010. In 2010, Nigeria was estimated to have 3.19 million PLHIV, with the general population prevalence projected to drop from 3.34% in 2011 to 3.27% in 2012.

    Conclusion: Examining a decade of HIV ANC surveillance in Nigeria revealed important differences in the epidemic in states that need to be examined further to reveal key drivers that can be used to target future interventions.

  • Knowledge, Care-Seeking Behavior, and Factors Associated With Patient Delay Among Newly-Diagnosed Pulmonary Tuberculosis Patients, Federal Capital Territory, Nigeria, 2010

    Authors: Oladayo Biya, Saheed Gidado, Ajibola Abraham, Ndadilnasiya Waziri, Patrick Nguku, Peter Nsubuga, Idris Suleman, Akin Oyemakinde, Abdulsalami Nasidi, Kabir Sabitu
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    Introduction: Early treatment of Tuberculosis (TB) cases is important for reducing transmission, morbidity and mortality associated with TB. In 2007, Federal Capital Territory (FCT), Nigeria recorded low TB case detection rate (CDR) of 9% which implied that many TB cases were undetected. We assessed the knowledge, care-seeking behavior, and factors associated with patient delay among pulmonary TB patients in FCT.

    Methods: We enrolled 160 newly-diagnosed pulmonary TB patients in six directly observed treatment short course (DOTS) hospitals in FCT in a cross-sectional study. We used a structured questionnaire to collect data on socio-demographic variables, knowledge of TB, and care-seeking behavior. Patient delay was defined as > 4 weeks between onset of cough and first hospital contact.

    Results: Mean age was 32.8 years (± 9 years). Sixty two percent were males. Forty seven percent first sought care in a government hospital, 26% with a patent medicine vendor and 22% in a private hospital. Forty one percent had unsatisfactory knowledge of TB. Forty two percent had patient delay. Having unsatisfactory knowledge of TB (p = 0.046) and multiple care-seeking (p = 0.02) were significantly associated with patient delay. After controlling for travel time and age, multiple care-seeking was independently associated with patient delay (Adjusted Odds Ratio = 2.18, 95% CI = 1.09-4.35).

    Conclusion: Failure to immediately seek care in DOTS centers and having unsatisfactory knowledge of TB are factors contributing to patient delay. Strategies that promote early care-seeking in DOTS centers and sustained awareness on TB should be implemented in FCT.

  • Importance of Epidemiological Research of Monkeypox: Is Incidence Increasing

    Authors: Chikwe Ihekweazu, Adesola Yinka-Ogunleye, Swaib Lule, Abubakar Ibrahim
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  • The Prevalence of Noma in Northwest Nigeria

    Authors: Elise Farley, Modupe Juliana Oyemakinde, Jorien Schuurmans, Cono Ariti, Fatima Saleh, Gloria Uzoigwe, Karla Bil, Bukola Oluyide, Adolphe Fotso, Mohana Amirtharajah, Jorieke Vyncke, Raphael Brechard, Adeniyi Semiyu Adetunji, Koert Ritmeijer, Saskia van der Kam, Denise Baratti-Mayer, Ushma Mehta, Shafi\'u Isah, Chikwe Ihekweazu, Annick Lenglet
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    Background: Noma, a rapidly progressing infection of the oral cavity, mainly affects children. The true burden is unknown. This study reports estimated noma prevalence in children in northwest Nigeria.

    Methods: Oral screening was performed on all ≤15 year olds, with caretaker consent, in selected households during this cross-sectional survey. Noma stages were classified using WHO criteria and caretakers answered survey questions. The prevalence of noma was estimated stratified by age group (0-5 and 6-15 years). Factors associated with noma were estimated using logistic regression.

    Results: A total of 177 clusters, 3499 households and 7122 children were included. In this sample, 4239 (59.8%) were 0-5 years and 3692 (52.1%) were female. Simple gingivitis was identified in 3.1% (n=181; 95% CI 2.6 to 3.8), acute necrotising gingivitis in 0.1% (n=10; CI 0.1 to 0.3) and oedema in 0.05% (n=3; CI 0.02 to 0.2). No cases of late-stage noma were detected. Multivariable analysis in the group aged 0-5 years showed having a well as the drinking water source (adjusted odds ratio (aOR) 2.1; CI 1.2 to 3.6) and being aged 3-5 years (aOR 3.9; CI 2.1 to 7.8) was associated with being a noma case. In 6-15 year olds, being male (aOR 1.5; CI 1.0 to 2.2) was associated with being a noma case and preparing pap once or more per week (aOR 0.4; CI 0.2 to 0.8) was associated with not having noma. We estimated that 129120 (CI 105294 to 1 52 947) individuals <15 years of age would have any stage of noma at the time of the survey within the two states. Most of these cases (93%; n=120 082) would be children with simple gingivitis.

    Conclusions: Our study identified a high prevalence of children at risk of developing advanced noma. This disease is important but neglected and therefore merits inclusion in the WHO neglected tropical diseases list. 

  • Knowledge and Risk Perception Towards Lassa Fever Infection Among Residents of Affected Communities in Ebonyi State, Nigeria: Implications for Risk Communication

    Authors: Ifeoma Sophia Usuwa, Christian Obasi Akpa, Chukwuma David Umeokonkwo, MaryJoy Umoke, Chukwuemeka Steve Oguanuo, Abdulhakeem Abayomi Olorukooba, Eniola Bamgboye, Muhammad Shakir Balogun
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    Background: Lassa fever (LF) is an epidemic-prone zoonotic disease prevalent in Nigeria and Ebonyi State is a high burden area in Nigeria. Low risk perceptions have been reported to prevent appropriate preventive behaviours. We investigated the knowledge and risk perception of residents towards LF and determined the factors influencing their risk perception in communities that have reported confirmed cases of LF.

    Methods: We conducted a cross-sectional study in the affected wards in Abakaliki Local Government Area (LGA). We interviewed 356 adult respondents recruited across 6 settlements in 3 of the affected wards through multistage sampling technique. Information on participants' knowledge of LF, their risk perception using the health belief model as well as factors influencing risk perception were obtained. We estimated the proportions of respondents with good knowledge and high risk perceptions. We also explored the relationship between risk perception, knowledge and sociodemographic characteristics using Chi Square and logistic regression at 5% level of significance.

    Results: The mean age of the participants was 33.3 ± 12.2 years, 208 (63.2%) were females, 230 (69.9%) were married and 104 (31.6%) had attained tertiary education. Though 99.1% were aware of LF infection, 50.3% among them had poor knowledge of LF symptoms and risk factors, 92.9% had high risk perception of severity, 72.4% had a high feeling of susceptibility towards LF infection, 82.5% had a high perceived self-efficacy towards LF infection, 63.5% had a low perceived benefit of LF preventive practices and 31.8% had high perceived barrier towards LF preventive practices. Good knowledge of LF was the only significant factor influencing risk perception; perceived severity: (COR: 3.0, 95%CI: 1.2-7.8), perceived susceptibility (AOR: 2.0, 95%CI: 1.25-3.3) and perceived benefit (COR: 2.1, 95%CI: 1.3-3.3).

    Conclusions: Good knowledge of LF influences risk perception towards LF which has great import on LF preventive practices. A gap exists in the content and acceptance of LF risk communication information in the LGA. There is a need to review the risk communication messages in the state towards LF in the community with special focus on the males and younger population

  • Action-Based Costing for National Action Plans for Health Security: Accelerating Progress Toward the International Health Regulations (2005)

    Authors: Christopher T Lee, Rebecca Katz, Stephanie Eaneff, Michael Mahar , Olubunmi Ojo
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    Multiple costing tools have been developed to understand the resources required to build and sustain implementation of the International Health Regulations (IHR), including a detailed costing tool developed by WHO ("WHO Costing Tool") and 2 action-based costing tools, Georgetown University's IHR Costing Tool and CDC's Priority Actions Costing Tool (PACT). The relative performance of these tools is unknown. Nigeria costed its National Action Plan for Health Security (NAPHS) using the WHO Costing Tool. We conducted a desktop review, using the other tools to compare the cost estimates generated using different costing approaches. Technical working groups developed activity plans and estimated component costs using the WHO Costing Tool during a weeklong workshop with approximately 60 participants from various ministries, departments, and federal agencies. We retrospectively applied the IHR Costing Tool and PACT to generate rapid cost estimates required to achieve a Joint External Evaluation (JEE) score of "demonstrated capacity" (level 4). The tools generated similar activities for implementation. Cost estimates varied based on the anticipated procurement and human resources requirements and by the level of implementation (eg, health facility-level versus local government area-level procurement). The desktop IHR Costing Tool and PACT tools required approximately 2 and 8 person-hours to complete, respectively. A strategic costing approach, wherein governments select from a menu of recommended and costed actions following the JEE to develop a NAPHS, could accelerate implementation of plans. Major cost drivers, including procurement and human resources, should be prioritized based on anticipated resource availability and countries' priorities.

  • Are Patients With Pulmonary Tuberculosis Who Are Identified Through Active Case Finding in the Community Different Than Those Identified in Healthcare Facilities?

    Authors: S T Abdurrahman, L Lawson, M Blakiston, J Obasanya, M A Yassin, R M Anderson, O Oladimeji, A Ramsay, L E Cuevas
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    The lack of healthcare access contributes to large numbers of tuberculosis (TB) cases being missed and has led to renewed interest in outreach approaches to increase detection. It is however unclear whether outreach activities increase case detection or merely identify patients before they attend health facilities. We compared adults with cough of >2 weeks' duration recruited in health facilities (1202 participants) or in urban slums (2828 participants) in Nigeria. Participants provided demographic and clinical information and were screened using smear microscopy. The characteristics of smear-positive and smear-negative individuals were compared stratified by place of enrolment. Two hundred nine health facility participants (17.4%) and 485 community-based participants (16.9%) were smear positive for pulmonary TB. Community-based smear-positive cases were older (mean age, 36.3 vs. 31.8 years), had longer cough duration (10.3 vs. 6.8 weeks) and longer duration of weight loss (4.6 vs. 3.6 weeks) than facility-based cases; and they complained more of fever (87.4% vs. 74.6%), chest pain (89.0% vs. 67.0%) and anorexia (79.5% vs. 55.5%). Community smear-negative participants were older (mean, 39.4 vs. 34.0 years), were more likely to have symptoms and were more likely to have symptoms of longer duration than smear-negative facility-based participants. Patients with pulmonary TB identified in the community had more symptoms and longer duration of illness than facility-based patients, which appeared to be due to factors differentially affecting access to healthcare. Community-based activities targeted at urban slum populations may identify a different TB case population than that accessing stationary services.

  • Ebola Virus Disease - Gaps in Knowledge and Practice Among Healthcare Workers in Lagos, August 2014

    Authors: Abisola M Oladimeji, Saheed Gidado, Patrick Nguku, Iruoma Genevieve Nwangwu, Nikhil D Patil, Femi Oladosu, Alero Ann Roberts, Ndadilnasiya E Waziri, Faisal Shuaib, Olukayode Oguntimehin, Emmanuel Musa, Abdulsalami Nasidi, Peter Adewuyi, Adebola Olayinka, Oladoyin Odubanjo, N-FELTP Residents; Gabriele Poggensee
    Read Abstract | Read Article

    Objective: Healthcare workers (HCWs) play pivotal roles in outbreak responses. Ebola virus disease (EVD) outbreak spread to Lagos, Nigeria, in July 2014, infecting 11 HCWs (case fatality rate of 45%). This study was conducted during the outbreak to assess HCWs' EVD-related knowledge and practices.

    Methods: A health facility-based cross-sectional study was conducted among HCWs across Lagos State using stratified sampling technique. An interviewer-administered questionnaire was administered to elicit respondents' socio-demographic characteristics, knowledge and practices. A checklist assessing health facility's level of preparedness and HCWs' EVD-related training was employed. HCWs' knowledge and practices were scored and classified as either good or poor. Multivariate analysis was performed with confidence interval set at 95%.

    Results: A total of 112 health facilities with 637 HCWs were recruited. Mean age of respondents was 40.1 ± 10.9 years. Overall, 72.5% had good knowledge; doctors knew most. However, only 4.6% of HCWs reported good practices. 16.6% reported having been trained in identifying suspected EVD patient(s); 12.2% had a triaging area for febrile patients in their facilities. Higher proportions of HCWs with good knowledge and training reported good practices. HCWs with EVD-related training were three times more likely to adopt good practices.

    Conclusion: Lagos State HCWs had good knowledge of EVD without a corresponding level of good practices. Training was a predictor of good practices

  • What Are the Drivers of Recurrent Cholera Transmission in Nigeria? Evidence From a Scoping Review

    Authors: Kelly Osezele Elimian, Somto Mezue, Anwar Musah, Oyeronke Oyebanji, Ibrahima Soce Fall, Sebastian Yennan, Michel Yao, Patrick Okumu Abok, Nanpring Williams, Lynda Haj Omar, Thieno Balde, Kobina Ampah, Ifeanyi Okudo, Luka Ibrahim, Arisekola Jinadu, Wondimagegnehu Alemu, Clement Peter, Chikwe Ihekweazu
    Read Abstract | Read Article

    Background: The 2018 cholera outbreak in Nigeria affected over half of the states in the country, and was characterised by high attack and case fatality rates. The country continues to record cholera cases and related deaths to date. However, there is a dearth of evidence on context-specific drivers and their operational mechanisms in mediating recurrent cholera transmission in Nigeria. This study therefore aimed to fill this important research gap, with a view to informing the design and implementation of appropriate preventive and control measures.

    Methods: Four bibliographic literature sources (CINAHL (Plus with full text), Web of Science, Google Scholar and PubMed), and one journal (African Journals Online) were searched to retrieve documents relating to cholera transmission in Nigeria. Titles and abstracts of the identified documents were screened according to a predefined study protocol. Data extraction and bibliometric analysis of all eligible documents were conducted, which was followed by thematic and systematic analyses.

    Results: Forty-five documents met the inclusion criteria and were included in the final analysis. The majority of the documents were peer-reviewed journal articles (89%) and conducted predominantly in the context of cholera epidemics (64%). The narrative analysis indicates that social, biological, environmental and climatic, health systems, and a combination of two or more factors appear to drive cholera transmission in Nigeria. Regarding operational dynamics, a substantial number of the identified drivers appear to be functionally interdependent of each other.

    Conclusion: The drivers of recurring cholera transmission in Nigeria are diverse but functionally interdependent; thus, underlining the importance of adopting a multi-sectoral approach for cholera prevention and control. 

  • Learning From the Epidemiological Response to the 2014/15 Ebola Virus Disease Outbreak

    Authors: Maya Holding, Chikwe Ihekweazu, James MacNaughton Stuart, Isabel Oliver
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    A large international response was needed to bring the 2014/15 West African Ebola virus disease outbreak under control. This study sought to learn lessons from this epidemic to strengthen the response to future outbreaks of international significance by identifying priorities for future epidemiology training and response. Epidemiologists who were deployed to West Africa were recruited through a snowball sampling method and surveyed using an online anonymous questionnaire. Associations between demographics, training, qualifications, and role while in-country were explored alongside respondents' experience during deployment. Of 128 responses, 105 met the inclusion criteria. Respondents originated from 25 countries worldwide, for many (62%), this was their first deployment abroad. The most common tasks carried out while deployed were surveillance, training, contact tracing, and cluster investigation. Epidemiologists would value more detailed predeployment briefings including organizational aspects of the response. Gaps in technical skills reported were mostly about geographical information systems; however, epidemiologists identified the need for those deployed in future to have greater knowledge about roles and responsibilities of organizations involved in the response, better cultural awareness, and leadership and management skills. Respondents felt that the public health community must improve the timeliness of the response in future outbreaks and strengthen collaboration and coordination between organizations.

  • Building a Public Health Workforce in Nigeria Through Experiential Training

    Authors: Akin Oyemakinde, Patrick Nguku, Rebecca Babirye, Sheba Gitta, Peter Nsubuga, Joseph Nyager, Abdulsalami Nasidi
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  • Lassa Fever: Epidemiology, Clinical Features, Diagnosis, Management and Prevention

    Authors: Danny A Asogun, Stephan Günther, George O Akpede, Chikwe Ihekweazu, Alimuddin Zumla
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    Lassa fever outbreaks West Africa have caused up to 10,000 deaths annually. Primary infection occurs from contact with Lassa virus-infected rodents and exposure to their excreta, blood, or meat. Incubation takes 2 to 21 days. Symptoms are difficult to distinguish from malaria, typhoid, dengue, yellow fever, and other viral hemorrhagic fevers. Clinical manifestations range from asymptomatic, to mild, to severe fulminant disease. Ribavirin can improve outcomes. Overall mortality is between 1% and 15%. Lassa fever should be considered in the differential diagnosis with travel to West Africa. There is an urgent need for rapid field-friendly diagnostics and preventive vaccine.

  • Meningococcal Meningitis Outbreaks in the African Meningitis Belt After Meningococcal Serogroup A Conjugate Vaccine Introduction, 2011-2017

    Authors: Katya Fernandez, Clément Lingani, Olaolu Moses Aderinola, Kadadé Goumbi, Brice Bicaba, Zewdu Assefa Edea, Clément Glèlè, Badu Sarkodie, Agbeko Tamekloe, Armelle Ngomba, Mamoudou Djingarey, Ado Bwaka, William Perea, Olivier Ronveaux
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    Background: In 2010-2017, meningococcal serogroup A conjugate vaccine (MACV) was introduced in 21 African meningitis belt countries. Neisseria meningitidis A epidemics have been eliminated here; however, non-A serogroup epidemics continue.

    Methods: We reviewed epidemiological and laboratory World Health Organization data after MACV introduction in 20 countries. Information from the International Coordinating Group documented reactive vaccination.

    Results: In 2011-2017, 17 outbreaks were reported (31 786 suspected cases from 8 countries, 1-6 outbreaks/year). Outbreaks were of 18-14 542 cases in 113 districts (median 3 districts/outbreak). The most affected countries were Nigeria (17 375 cases) and Niger (9343 cases). Cumulative average attack rates per outbreak were 37-203 cases/100 000 population (median 112). Serogroup C accounted for 11 outbreaks and W for 6. The median proportion of laboratory confirmed cases was 20%. Reactive vaccination was conducted during 14 outbreaks (5.7 million people vaccinated, median response time 36 days).

    Conclusion: Outbreaks due to non-A serogroup meningococci continue to be a significant burden in this region. Until an affordable multivalent conjugate vaccine becomes available, the need for timely reactive vaccination and an emergency vaccine stockpile remains high. Countries must continue to strengthen detection, confirmation, and timeliness of outbreak control measures. 

  • The Multi-Sectorial Emergency Response to a Cholera Outbreak in Internally Displaced Persons Camps in Borno State, Nigeria, 2017

    Authors: Moise Chi Ngwa, Alemu Wondimagegnehu, Ifeanyi Okudo, Collins Owili, Uzoma Ugochukwu, Peter Clement, Isabelle Devaux, Lorenzo Pezzoli, Chikwe Ihekweazu, Mohammed Abba Jimme, Peter Winch, David A Sack
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    Introduction: In August 2017, a cholera outbreak started in Muna Garage Internally Displaced Persons camp, Borno state, Nigeria and >5000 cases occurred in six local government areas. This qualitative study evaluated perspectives about the emergency response to this outbreak.

    Methods: We conducted 39 key informant interviews and focus group discussions, and reviewed 21 documents with participants involved with surveillance, water, sanitation, hygiene, case management, oral cholera vaccine (OCV), communications, logistics and coordination. Qualitative data analysis used thematic techniques comprising key words in context, word repetition and key sector terms.

    Results: Authorities were alerted quickly, but outbreak declaration took 12 days due to a 10-day delay waiting for culture confirmation. Outbreak investigation revealed several potential transmission channels, but a leaking latrine around the index cases' house was not repaired for more than 7 days. Chlorine was initially not accepted by the community due to rumours that it would sterilise women. Key messages were in Hausa, although Kanuri was the primary local language; later this was corrected. Planning would have benefited using exercise drills to identify weaknesses, and inventory sharing to avoid stock outs. The response by the Rural Water Supply and Sanitation Agency was perceived to be slow and an increased risk from a religious festival was not recognised. Case management was provided at treatment centres, but some partners were concerned that their work was not recognised asking, 'Who gets the glory and the data?' Nearly one million people received OCV and its distribution benefited from a robust infrastructure for polio vaccination. There was initial anxiety, rumour and reluctance about OCV, attributed by many to lack of formative research prior to vaccine implementation. Coordination was slow initially, but improved with activation of an emergency operations centre (EOC) that enabled implementation of incident management system to coordinate multisectoral activities and meetings held at 16:00 hours daily. The synergy between partners and government improved when each recognised the government's leadership role.

    Conclusion: Despite a timely alert of the outbreak, delayed laboratory confirmation slowed initial response. Initial responses to the outbreak were not well coordinated but improved with the EOC. Understanding behaviours and community norms through rapid formative research should improve the effectiveness of the emergency response to a cholera outbreak. OCV distribution was efficient and benefited from the polio vaccine infrastructure. 

  • Complete Genome Sequence of a Hepatitis E Virus Genotype 1e Strain From an Outbreak in Nigeria, 2017

    Authors: Olusola Anuoluwapo Akanbi, Dominik Harms, Bo Wang, Oluyinka Oladele Opaleye, Olufisayo Adesina, Folakemi Abiodun Osundare, Abiodun Ogunniyi, Dhamari Naidoo, Isabelle Devaux, Alemu Wondimagegnehu, Clement Peter, Okudo Ifeanyi, Opeayo Ogundiran, Uzoma Ugochukwu, Nwando Mba, Sunday A Omilabu, Chikwe Ihekweazu, C-Thomas Bock
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    Hepatitis E virus genotype 1 (HEV-1) is associated with large epidemics. Notably, HEV subtype 1e (HEV-1e) has caused HEV outbreaks in sub-Saharan Africa. We report here the second full-length genome sequence of an HEV-1e strain (NG/17-0503) from a recent outbreak in Nigeria in 2017. It shares 94.2% identity with an HEV-1e strain from Chad

  • Association of Blood Lead Level With Neurological Features in 972 Children Affected by an Acute Severe Lead Poisoning Outbreak in Zamfara State, Northern Nigeria

    Authors: Jane Greig, Natalie Thurtle, Lauren Cooney, Cono Ariti, Abdulkadir Ola Ahmed, Teshome Ashagre, Anthony Ayela, Kingsley Chukwumalu, Alison Criado-Perez, Camilo Gómez-Restrepo, Caitlin Meredith, Antonio Neri, Darryl Stellmach, Nasir Sani-Gwarzo, Abdulsalami Nasidi, Leslie Shanks, Paul I Dargan
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    Background: In 2010, Médecins Sans Frontières (MSF) investigated reports of high mortality in young children in Zamfara State, Nigeria, leading to confirmation of villages with widespread acute severe lead poisoning. In a retrospective analysis, we aimed to determine venous blood lead level (VBLL) thresholds and risk factors for encephalopathy using MSF programmatic data from the first year of the outbreak response.

    Methods and findings: We included children aged ≤5 years with VBLL ≥45 µg/dL before any chelation and recorded neurological status. Odds ratios (OR) for neurological features were estimated; the final model was adjusted for age and baseline VBLL, using random effects for village of residence. 972 children met inclusion criteria: 885 (91%) had no neurological features; 34 (4%) had severe features; 47 (5%) had reported recent seizures; and six (1%) had other neurological abnormalities. The geometric mean VBLLs for all groups with neurological features were >100 µg/dL vs 65.9 µg/dL for those without neurological features. The adjusted OR for neurological features increased with increasing VBLL: from 2.75, 95%CI 1.27-5.98 (80-99.9 µg/dL) to 22.95, 95%CI 10.54-49.96 (≥120 µg/dL). Neurological features were associated with younger age (OR 4.77 [95% CI 2.50-9.11] for 1-<2 years and 2.69 [95%CI 1.15-6.26] for 2-<3 years, both vs 3-5 years). Severe neurological features were seen at VBLL <105 µg/dL only in those with malaria.

    Interpretation: Increasing VBLL (from ≥80 µg/dL) and age 1-<3 years were strongly associated with neurological features; in those tested for malaria, a positive test was also strongly associated. These factors will help clinicians managing children with lead poisoning in prioritising therapy and developing chelation protocols. 

  • Caseload and Case Fatality of Lassa Fever in Nigeria, 2001-2018: A Specialist Center\'s Experience and Its Implications

    Authors: George O Akpede, Danny A Asogun , Sylvanus A Okogbenin, Simeon O Dawodu, Mojeed O Momoh, Andrew E Dongo, Chiedozie Ike, Ekaete Tobin, Nosa Akpede, Ephraim Ogbaini-Emovon, Adetunji E Adewale, Oboratare Ochei, Frank Onyeke, Martha O Okonofua, Rebecca O Atafo, Ikponmwosa Odia, Donatus I Adomeh, George Odigie, Caroline Ogbeifun, Ekene Muebonam, Chikwe Ihekweazu, Michael Ramharter, Andres Colubri, Pardis C Sarbeti, Christian T Happi, Stephan Günther, Dennis E Agbonlahor
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    Background: The general lack of comprehensive data on the trends of Lassa fever (LF) outbreaks contrasts with its widespread occurrence in West Africa and is an important constraint in the design of effective control measures. We reviewed the contribution of LF to admissions and mortality among hospitalized patients from 2001 to 2018 in the bid to address this gap.

    Methods: Observational study of LF caseload and mortality from 2001 to 18 in terms of the contribution of confirmed LF to admissions and deaths, and case fatality (CF) among patients with confirmed LF at a specialist center in Nigeria. The diagnosis of LF was confirmed using reverse transcription polymerase chain reaction (RT-PCR) test, and medians and frequencies were compared using Kruskal-Wallis, Mann-Whitney and χ2 tests, with p-values <0.05 taken as significant.

    Results: The contribution of confirmed LF to deaths (362/9057, 4.0%) was significantly higher than to admissions (1,298/185,707, 0.7%; OR [95% CI] = 5.9 [5.3, 6.7], p < 0.001). The average CF among patients with confirmed LF declined from 154/355 (43%) in 2001–09 to 183/867 (21.1%) (OR [95% CI] = 2.9 [2.2, 3.7], p < 0.001) in 2011–18. The annual CF declined from 94% in 2001 to 15% in 2018 whereas the caseload increased from 0.3 to 3.4%. The outbreaks were characterized by irregular cycles of high caseload in 2005–2007, 2012–2014, and 2016–2018, and progressive blurring of the seasonality.

    Conclusion: LF outbreaks in Nigeria have upgraded spatially and temporally, with the potential for cycles of increasing severity. The strategic establishment of LF surveillance and clinical case management centers could be a pragmatic and cost-effective approach to mitigating the outbreaks, particularly in reducing the associated CF. Urgent efforts are needed in reinvigorating extant control measures while the search for sustainable solutions continues.

  • Lessons Learnt From the Management of a Case of Lassa Fever and Follow-Up of Nosocomial Primary Contacts in Nigeria During Ebola Virus Disease Outbreak in West Africa

    Authors: Michael O Iroezindu, Uche S Unigwe, Celestine C Okwara, Gladys A Ozoh, Anne C Ndu, Martin E Ohanu, Ugochukwu O Nwoko, Uwadiegwu W Okoroafor, Esinulo Ejimudo, Ekaete A Tobin , Danny A Asogun
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    Objective: To describe our experiences in the management of a case of Lassa fever (LF) and follow-up of nosocomial primary contacts during the 2014 Ebola outbreak in West Africa.

    Methods: Clinical management of the index case and infection control/surveillance activities for primary contacts are described. Laboratory confirmation was by Lassa virus-specific reverse-transcriptase PCR.

    Results: A 28-year-old man with a 10-day history of febrile illness was referred to a major tertiary hospital in south-east Nigeria from a city that previously experienced a LF outbreak and was recently affected by Ebola. On observation of haemorrhagic features, clinicians were at a crossroads. Diagnosis of LF was confirmed at a National Reference Centre. The patient died despite initiation of ribavirin therapy. Response activities identified 121 primary contacts comprising 78 (64.5%) hospital staff/interns, 19 (15.7%) medical students, 18 (14.9%) inpatients and 6 (5.0%) relatives. Their mean age was 32.8 ± 6.6 years, and 65.3% were women. Twenty (16.5%) had high-risk exposure and were offered ribavirin as post-exposure prophylaxis. No secondary case of LF occurred. Fatigue (43.8%) and dizziness (31.3%) were the commonest side effects of ribavirin.

    Conclusions: Response activities contained nosocomial spread of LF, but challenges were experienced including lack of a purpose-built isolation facility, absence of local Lassa virus laboratory capacity, failure to use appropriate protective equipment and stigmatisation of contacts. A key lesson is that the weak health systems of Africa should be comprehensively strengthened; otherwise, we might win the Ebola battle but lose the one against less virulent infections for which effective treatment exists. 

  • Improving Cross-Border Preparedness and Response: Lessons Learned From 3 Lassa Fever Outbreaks Across Benin, Nigeria, and Togo, 2017-2019

    Authors: Clement Glèlè Kakaī, Oyeladun Funmi Okunromade, Chioma Cindy Dan-Nwafor, Ali Imorou Bah Chabi, Godjedo Togbemabou Primous Martial, Mahmood Muazu Dalhat, Sarah Ward, Ouyi Tante, Patrick Mboya Nguku, Assane Hamadi, Elsie Ilori, Virgil Lokossou, Carlos Brito, Olubunmi Eyitayo Ojo, Idrissa Kone, Tamekloe Tsidi Agbeko, Chikwe Ihekweazu, Rebecca D Merrill
    Read Abstract | Read Article

    Long-standing cultural, economic, and political relationships among Benin, Nigeria, and Togo contribute to the complexity of their cross-border connectivity. The associated human movement increases the risk of international spread of communicable disease. The Benin and Togo ministries of health and the Nigeria Centre for Disease Control, in collaboration with the Abidjan Lagos Corridor Organization (a 5-country intergovernmental organization) and the US Centers for Disease Control and Prevention, sought to minimize the risk of cross-border outbreaks by defining and implementing procedures for binational and multinational public health collaboration. Through 2 multinational meetings, regular district-level binational meetings, and fieldwork to characterize population movement and connectivity patterns, the countries improved cross-border public health coordination. Across 3 sequential cross-border Lassa fever outbreaks identified in Benin or Togo between February 2017 and March 2019, the 3 countries improved their collection and sharing of patients' cross-border travel histories, shortened the time between case identification and cross-border information sharing, and streamlined multinational coordination during response efforts. Notably, they refined collaborative efforts using lessons learned from the January to March 2018 Benin outbreak, which had a 100% case fatality rate among the 5 laboratory-confirmed cases, 3 of whom migrated from Nigeria across porous borders when ill. Aligning countries' expectations for sharing public health information would assist in reducing the international spread of communicable diseases by facilitating coordinated preparedness and responses strategies. Additionally, these binational and multinational strategies could be made more effective by tailoring them to the unique cultural connections and population movement patterns in the region.

  • Accelerating Action in Global Health Security: Global Biosecurity Dialogue as a Model for Advancing the Global Health Security Agenda

    Authors: Sabrina Brizee, Katherine Budeski, Wilmot James, Michelle Nalabandian, Diederik A Bleijs, Scott J Becker, Sacha Wallace-Sankarsingh, Anthony Ahumibe, Emmanuel Agogo, Chikwe Ihekweazu, Simo Nikkari, Maureen Ellis, Ernesto Gozzer, Immaculate Sware Semesi, Zibusiso M Masuku, Aamer Ikram, Faheem Tahir, Irma Makalinao, Hayley Anne Severance, Mark W J van Passel, Elizabeth E Cameron
    Read Abstract | Read Article

    Biosecurity and biosafety measures are designed to mitigate intentional and accidental biological risks that pose potentially catastrophic consequences to a country's health system, security, and political and economic stability. Unfortunately, biosecurity and biosafety are often under-prioritized nationally, regionally, and globally. Security leaders often deemphasize accidental and deliberate biological threats relative to other challenges to peace and security. Given emerging biological risks, including those associated with rapid technological advances and terrorist and state interest in weapons of mass destruction, biosecurity deserves stronger emphasis in health and security fora. The Global Biosecurity Dialogue (GBD) was initiated to align national and regional donor initiatives toward a common set of measurable targets. The GBD was launched by the Nuclear Threat Initiative (NTI), with support from Global Affairs Canada's Weapons Threat Reduction Program and the Open Philanthropy Project, and in coordination with the government of The Netherlands as the 2018-19 Chair of the Global Health Security Agenda (GHSA) Action Package Prevent-3 (APP3) on Biosafety and Biosecurity. The GBD provides a multisectoral forum for sharing models, enabling new actions to achieve biosecurity-related targets, and promoting biosecurity as an integral component of health security. The GBD has contributed to new national and continent-wide actions, including the African Union and Africa Centres for Disease Control and Prevention's new regional Initiative to Strengthen Biosafety and Biosecurity in Africa. Here we present the GBD as a model for catalyzing action within APP3. We describe how the benefits of this approach could expand to other GHSA Action Packages and international health security initiatives.

  • A New Hepatitis E Virus Genotype 2 Strain Identified From an Outbreak in Nigeria, 2017

    Authors: Bo Wang, Olusola Anuoluwapo Akanbi, Dominik Harms, Olufisayo Adesina, Folakemi Abiodun Osundare, Dhamari Naidoo, Isabel Deveaux, Opeayo Ogundiran, Uzoma Ugochukwu, Nwando Mba, Chikwe Ihekweazu, C-Thomas Bock
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    Background: In 2017 the Nigerian Ministry of Health notified the World Health Organization (WHO) of an outbreak of hepatitis E located in the north-east region of the country with 146 cases with 2 deaths. The analysis of the hepatitis E virus (HEV) genotypes responsible for the outbreak revealed the predominance of HEV genotypes 1 (HEV-1) and 2 (HEV-2). Molecular data of HEV-2 genomes are limited; therefore we characterized a HEV-2 strain of the outbreak in more detail.

    Finding: The full-length genome sequence of an HEV-2 strain (NG/17-0500) from the outbreak was amplified using newly designed consensus primers. Comparison with other HEV complete genome sequences, including the only HEV-2 strain (Mex-14) with available complete genome sequences and the availability of data of partial HEV-2 sequences from Sub-Saharan Africa, suggests that NG/17-0500 belongs to HEV subtype 2b (HEV-2b).

    Conclusions: We identified a novel HEV-2b strain from Sub-Saharan Africa, which is the second complete HEV-2 sequence to date, whose natural history and epidemiology merit further investigation. 

  • A New Twenty-First Century Science for Effective Epidemic Response

    Authors: Juliet Bedford, Jeremy Farrar, Chikwe Ihekweazu, Gagandeep Kang, Marion Koopmans, John Nkengasong
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    With rapidly changing ecology, urbanization, climate change, increased travel and fragile public health systems, epidemics will become more frequent, more complex and harder to prevent and contain. Here we argue that our concept of epidemics must evolve from crisis response during discrete outbreaks to an integrated cycle of preparation, response and recovery. This is an opportunity to combine knowledge and skills from all over the world-especially at-risk and affected communities. Many disciplines need to be integrated, including not only epidemiology but also social sciences, research and development, diplomacy, logistics and crisis management. This requires a new approach to training tomorrow's leaders in epidemic prevention and response.

  • Epidemiology and Case-Control Study of Lassa Fever Outbreak in Nigeria From 2018 to 2019

    Authors: Oladipupo Ipadeola, Yuki Furuse, Elsie A Ilori, Chioma C Dan-Nwafor, Kachikwulu O Akabike, Anthony Ahumibe, Winifred Ukponu, Lawal Bakare, Gbenga Joseph, Muhammad Saleh, Esther Namukose Muwanguzi, Adebola Olayinka, Geoffrey Namara, Dhamari Naidoo, Akanimo Iniobong, Michael Amedu, Nkem Ugbogulu, Favour Makava, Olawunmi Adeoye, Chukwuemeka Uzoho, Chimezie Anueyiagu, Tochi J Okwor, Nwando G Mba, Adejoke Akano, Abiodun Ogunniyi, Amina Mohammed, Ayodele Adeyemo, Dike K Ugochukwu, Emmanuel Agogo, Chikwe Ihekweazu
    Read Abstract | Read Article

  • The Reactive Vaccination Campaign Against Cholera Emergency in Camps for Internally Displaced Persons, Borno, Nigeria, 2017: A Two-Stage Cluster Survey

    Authors: Moise Chi Ngwa, Wondimagegnehu Alemu, Ifeanyi Okudo, Collins Owili, Uzoma Ugochukwu, Peter Clement, Isabelle Devaux, Lorenzo Pezzoli, James Agada Oche, Chikwe Ihekweazu, David A Sack
    Read Abstract | Read Article

    Introduction: In 2017, amidst insecurity and displacements posed by Boko Haram armed insurgency, cholera outbreak started in the Muna Garage camp for Internally Displaced Persons (IDPs) in Borno State, Nigeria. In response, the Borno Ministry of Health and partners determined to provide oral cholera vaccine (OCV) to about 1 million people in IDP camps and surrounding communities in six Local Government Areas (LGAs) including Maiduguri, Jere, Konduga, Mafa, Dikwa, and Monguno. As part of Monitoring and Evaluation, we described the coverage achieved, adverse events following immunisation (AEFI), non-vaccination reasons, vaccination decisions as well as campaign information sources.

    Methods: We conducted two-stage probability cluster surveys with clusters selected without replacement according to probability-proportionate-to-population-size in the six LGAs targeted by the campaign. Individuals aged ≥1 years were the eligible study population. Data sources were household interviews with vaccine card verification and memory recall, if no card, as well as multiple choice questions with an open-ended option.

    Results: Overall, 12 931 respondents participated in the survey. Overall, 90% (95% CI: 88 to 92) of the target population received at least one dose of OCV, range 87% (95% CI: 75 to 94) in Maiduguri to 94% (95% CI: 88 to 97) in Monguno. The weighted two-dose coverage was 73% (95% CI: 68 to 77) with a low of 68% (95% CI: 46 to 86) in Maiduguri to a high of 87% (95% CI: 74 to 95) in Dikwa. The coverage was lower during first round (76%, 95% CI: 71 to 80) than second round (87%, 95% CI: 84 to 89) and ranged from 72% (95% CI: 42 to 89) and 82% (95% CI: 82 to 91) in Maiduguri to 87% (95% CI: 75 to 95) and 94% (95% CI: 88 to 97) in Dikwa for the respective first and second rounds. Also, coverage was higher among females of age 5 to 14 and ≥15 years than males of same age groups. There were mild AEFI with the most common symptoms being fever, headache and diarrhoea occurring up to 48 hours after ingesting the vaccine. The most common actions taken after AEFI symptoms included 'did nothing' and 'self-medicated at home'. The top reason for taking vaccine was to protect from cholera while top reason for non-vaccination was travel/work. The main source of campaign information was a neighbour. An overwhelming majority (96%, 95% CI: 95% to 98%) felt the campaign team treated them with respect. While 43% (95% CI: 36% to 50%) asked no questions, 37% (95% CI: 31% to 44%) felt the team addressed all their concerns.

    Conclusion: The campaign achieved high coverage using door-to-door and fixed sites strategies amidst insecurity posed by Boko Haram. Additional studies are needed to improve how to reduce non-vaccination, especially for the first round. While OCV provides protection for a few years, additional actions will be needed to make investments in water, sanitation and hygiene infrastructure. 

  • Sharing Experiences From the Field: Updates From the Nigeria Field Epidemiology and Laboratory Training Program

    Authors: Patrick Mboya Nguku, Chukwuma David Umeokonkwo, Muhammad Shakir Balogun, Ndadilnasiya Endie Waziri, Adebobola Toluwalashe Bashorun, Godwin Ntadom, Chikwe Ihekweazu
    Read Abstract | Read Article

    Field Epidemiology and Laboratory Training Programs (FELTP) or Applied Epidemiology Training Programs (AETP) is based on the philosophy of “learning while doing” and application of epidemiology methods to improve public health and health care [1]. Trainees or residents in FELTP are required to conduct field investigations, data analysis, surveillance evaluations and other field-based activities while being mentored by experienced epidemiologists. Residents' work is not completed until they have shared their unique field experiences, findings and recommendations with relevant public health authorities for action. Additionally, publishing their field experiences and evidence based public health actions ensures that these training experiences are shared with the wider scientific and public health audience. In this second supplement from the Nigeria Field Epidemiology and Laboratory Training Program (NFELTP), we present investigations and studies carried out by these early career epidemiologists as a way of disseminating important public health findings [2, 3]. The supplement covers summaries of a surveillance system evaluation, secondary data analyses and several protocol-based studies. The output represents the product of field-based interactions that the residents had in the course of their experiential training in applied epidemiology. This builds up on the first NFELTP supplement published in July 2014 [3] and the progress that the program has made since its inception in 2008. This collection of articles comprises a wide variety of subjects ranging from infectious disease epidemiology (malaria, HIV, measles, rubella, tuberculosis, Ebola virus disease, pertussis) to non-communicable diseases and injuries (road traffic crashes, intimate partner violence). It also represents the work carried out in nine states and the Federal Capital Territory in Nigeria (Abuja, Anambra, Enugu, Gombe, Kano, Kaduna, Niger, Ogun & Ondo) and Sierra Leone. Most of the studies involving HIV, tuberculosis and malaria were conducted in response to national priorities set by stakeholders in Nigeria [4]. This demonstrates the integration of the FETP in the national health system and ensures that it continues to be relevant in protecting the health of the populace. The NFELTP is part of the newly created Nigeria Centre for Disease Control, the country's National Public Health Institute [5]. We expect that these articles will stimulate further discussion and help to identify other relevant research questions to be addressed across Nigeria and the African region on these important public health issues. We also hope that the wider public health audience will find in them the needed information to provide solutions to various public health challenges. We appreciate the leadership the Federal Ministry of Health in supporting the ongoing training and utilization of field epidemiologists through the NFELTP. We also acknowledge the funding and technical support provided by the African Field Epidemiology Network and the US Centers for Disease Control and Prevention.

  • The Response to Re-Emergence of Yellow Fever in Nigeria, 2017

    Authors: William E Nwachukwu, H Yusuff, U Nwangwu, A Okon, A Ogunniyi, J Imuetinyan-Clement, M Besong, P Ayo-Ajayi, J Nikau, A Baba, F Dogunro, B Akintunde, M Oguntoye, K Kamaldeen, O Fakayode, O Oyebanji, O Emelife, J Oteri, O Aruna, E Ilori, O Ojo, N Mba, P Nguku, C Ihekweazu
    Read Abstract | Read Article

    Yellow fever (YF) is an acute viral hemorrhagic disease caused by the YF virus (arbovirus) which continues to cause severe morbidity and mortality in Africa. A case of YF was confirmed in Nigeria on the 12th of September 2017, 21 years after the last confirmed case. The patient belongs to a nomadic population with a history of low YF vaccination uptake, in the Ifelodun Local Government Area (LGA) of Kwara State, Nigeria. An active case search in Ifelodun and its five contiguous LGAs led to the listing of 55 additional suspect cases of YF within the period of the outbreak investigation between September 18 to October 6, 2017. The median age of cases was 15 years, and 54.4% were males. Of these, blood samples were collected from 30 cases; nine tested positive in laboratories in Nigeria and six were confirmed positive for YF by the WHO reference laboratory in the region; Institut Pasteur, Dakar. A rapid YF vaccination coverage assessment was carried out, resulting in a coverage of 46% in the LGAs, with 25% of cases able to produce their vaccination cards. All stages of the yellow fever vector, Aedes mosquito were identified in the area, with high larval indices (House and Breteau) observed. In response to the outbreak, YF surveillance was intensified across all States in Nigeria, as well as reactive vaccination and social mobilisation campaigns carried out in the affected LGAs in Kwara State. A state-wide YF preventive campaign was also initiated

  • Lay Media Reporting of Monkeypox in Nigeria

    Authors: Oyeronke Oyebanji, Ugonna Ofonagoro, Oluwatosin Akande, Ifeanyi Nsofor, Chika Ukenedo, Tarik Benjamin Mohammed, Chimezie Anueyiagu, Jeremiah Agenyi, Adesola Yinka-Ogunleye, Chikwe Ihekweazu
    Read Abstract | Read Article

    ·  Risk communication is an important but under-appreciated aspect of outbreak response, therefore, understanding the nature and impact of media coverage can assist in modifying messages.

    ·    Media reports from unauthorised sources during the ongoing monkeypox outbreak in Nigeria were sensationalised and led to increased anxiety in the population.

    ·   Because of the tendency of the media to amplify, rather than correct rumours, media personnel should be trained prior to an outbreak to reduce distorted reporting.

    ·   The Nigerian government should maintain an up-to-date communication platform for outbreak reporting, to routinely provide accurate information to the public.

    ·       There should be a well-defined approach of using event-based surveillance for decision-making, effective communication and for informing how disease outbreaks are reported by the media.

  • Outbreak of Human Monkeypox in Nigeria in 2017-18: A Clinical and Epidemiological Report

    Authors: Adesola Yinka-Ogunleye, Olusola Aruna, Mahmood Dalhat, Dimie Ogoina, Andrea McCollum, Yahyah Disu, Ibrahim Mamadu, Afolabi Akinpelu, Adama Ahmad, Joel Burga, Adolphe Ndoreraho 8 , Edouard Nkunzimana 8 , Lamin Manneh 8 , Amina Mohammed 6 , Olawunmi Adeoye, Daniel Tom-Aba, Bernard Silenou, Oladipupo Ipadeola, Muhammad Saleh, Ayodele Adeyemo, Ifeoma Nwadiutor, Neni Aworabhi, Patience Uke, Doris John, Paul Wakama, Mary Reynolds, Matthew R Mauldin, Jeffrey Doty, Kimberly Wilkins, Joy Musa, Asheena Khalakdina, Adebayo Adedeji, Nwando Mba, Olubunmi Ojo, Gerard Krause, Chikwe Ihekweazu
    Read Abstract | Read Article

    Background: In September, 2017, human monkeypox re-emerged in Nigeria, 39 years after the last reported case. We aimed to describe the clinical and epidemiological features of the 2017-18 human monkeypox outbreak in Nigeria.

    Methods: We reviewed the epidemiological and clinical characteristics of cases of human monkeypox that occurred between Sept 22, 2017, and Sept 16, 2018. Data were collected with a standardised case investigation form, with a case definition of human monkeypox that was based on previously established guidelines. Diagnosis was confirmed by viral identification with real-time PCR and by detection of positive anti-orthopoxvirus IgM antibodies. Whole-genome sequencing was done for seven cases. Haplotype analysis results, genetic distance data, and epidemiological data were used to infer a likely series of events for potential human-to-human transmission of the west African clade of monkeypox virus.

    Findings: 122 confirmed or probable cases of human monkeypox were recorded in 17 states, including seven deaths (case fatality rate 6%). People infected with monkeypox virus were aged between 2 days and 50 years (median 29 years [IQR 14]), and 84 (69%) were male. All 122 patients had vesiculopustular rash, and fever, pruritus, headache, and lymphadenopathy were also common. The rash affected all parts of the body, with the face being most affected. The distribution of cases and contacts suggested both primary zoonotic and secondary human-to-human transmission. Two cases of health-care-associated infection were recorded. Genomic analysis suggested multiple introductions of the virus and a single introduction along with human-to-human transmission in a prison facility.

    Interpretation: This study describes the largest documented human outbreak of the west African clade of the monkeypox virus. Our results suggest endemicity of monkeypox virus in Nigeria, with some evidence of human-to-human transmission. Further studies are necessary to explore animal reservoirs and risk factors for transmission of the virus in Nigeria

  • Performance of the Public Health System During a Full-Scale Yellow Fever Simulation Exercise in Lagos State, Nigeria, in 2018: How Prepared Are We for the Next Outbreak?

    Authors: Oyeladun Funmi Okunromade, Virgil K Lokossou, Ike Anya, Augustine Olajide Dada, Ahmad M Njidda, Yahya O Disu, Mahmood Muazu Dalhat, Carlos Faria De Brito, Muhammad Shakir Balogun, Patrick Nguku, Olubunmi Eyitayo Ojo, Chikwe Ihekweazu, Stanley Okolo
    Read Abstract | Read Article

    Recurring outbreaks of infectious diseases have characterized the West African region in the past 4 decades. There is a moderate to high risk of yellow fever in countries in the region, and the disease has reemerged in Nigeria after 21 years. A full-scale simulation exercise of the outbreak of yellow fever was conducted to assess preparedness and response in the event of a full-scale outbreak. The exercise was a multi-agency exercise conducted in Lagos, and it involved health facilities, points of entry, state and national public health emergency operation centers, and laboratories. An evaluation of the exercise assessed the capability of the system to identify, respond to, and recover from the emergency using adapted WHO tools. The majority of participants, observers, and evaluators agreed that the exercise was well-structured and organized. Participants also strongly agreed that the exercise helped them to identify strengths and gaps in their understanding of the emergency response systems and plans. Overall, the exercise identified existing gaps in the current capabilities of several thematic areas involved in a yellow fever response. The evaluation presented an opportunity to assess the response capabilities of multisectoral collaborations in the national public health system. It also demonstrated the usefulness of the exercise in understanding public health officials' roles and responsibilities; enabling knowledge transfer among these individuals and organizations; and identifying specific public health systems-level strengths, weaknesses, and challenges.

  • Monkeypox - Enhancing Public Health Preparedness for an Emerging Lethal Human Zoonotic Epidemic Threat in the Wake of the Smallpox Post-Eradication Era

    Authors: Eskild Petersen, Ibrahim Abubakar, Chikwe Ihekweazu, David Heymann, Francine Ntoumi, Lucille Blumberg, Danny Asogun, Victor Mukonka, Swaib Abubaker Lule, Matthew Bates, Isobella Honeyborne, Sayoki Mfinanga, Peter Mwaba, Osman Dar, Francesco Vairo, Maowia Mukhtar, Richard Kock, Timothy D McHugh, Giuseppe Ippolito, Alimuddin Zumla
    Read Abstract | Read Article

    The identification of monkeypox in 3 separate patients in the United Kingdom in September raised media and political attention on an emerging public health threat. Nigeria, whose last confirmed case of monkeypox was in 1978, is currently experiencing an unusually large and outbreak of human monkeypox cases, a 'One Human-Environmental-Animal Health' approach is being effectively used to define and tackle the outbreak. As of 13th October 2018, there have been one hundred and sixteen confirmed cases the majority of whom are under 40 years. Over the past 20 years ten Central and West African countries have reported monkeypox cases which have risen exponentially. We review the history and evolution of monkeypox outbreaks in Africa and USA, the changing clinical presentations, and discuss possible factors underlying the increasing numbers being detected including the cessation of smallpox vaccination programs. Major knowledge gaps remain on the epidemiology, host reservoir, and emergence, transmission, pathogenesis and prevention of monkeypoz.

  • Clinical Profile and Containment of the Ebola Virus Disease Outbreak in Two Large West African Cities, Nigeria, July-September 2014

    Authors: Chima Ohuabunwo, Celestine Ameh, Oyin Oduyebo, Anthony Ahumibe, Bamidele Mutiu, Adebola Olayinka, Wasiu Gbadamosi, Erika Garcia, Carolina Nanclares, Wale Famiyesin, Abdulaziz Mohammed, Patrick Nguku, Richard I Koko, Joshua Obasanya, Durojaye Adebayo, Yemi Gbadegesin, Oni Idigbe, Olukayode Oguntimehin, Sara Nyanti, Charles Nzuki, Ismail Abdus-Salam, Joseph Adeyemi, Nnanna Onyekwere, Emmanuel Musa, David Brett-Major, Faisal Shuaib, Abdulsalami Nasid
    Read Abstract | Read Article

    Introduction: The Ebola virus disease (EVD) outbreak in Nigeria began when an infected diplomat from Liberia arrived in Lagos, the most populous city in Africa, with subsequent transmission to another large city.

    Methods: First-, second-, and third-generation contacts were traced, monitored, and classified. Symptomatic contacts were managed at Ebola treatment centers as suspected, probable, and confirmed EVD cases using standard operating procedures adapted from the World Health Organization EVD guidelines. Reverse transcription PCR tests confirmed EVD. Socio-demographic, clinical, hospitalization, and outcome data of the July-September 2014 Nigeria EVD cohort were analyzed.

    Results: The median age of the 20 EVD cases was 33 years (interquartile range 26-62 years). More females (55%), health workers (65%), and persons <40 years old (60%) were infected than males, non-health workers, and persons aged ≥40 years. No EVD case management worker contracted the disease. Presenting symptoms were fever (85%), fatigue (70%), and diarrhea (65%). Clinical syndromes were gastroenteritis (45%), hemorrhage (30%), and encephalopathy (15%). The case-fatality rate was 40% and there was one mental health complication. The average duration from symptom onset to presentation was 3±2 days among survivors and 5±2 days for non-survivors. The mean duration from symptom onset to discharge was 15±5 days for survivors and 11±2 days for non-survivors. Mortality was higher in the older age group, males, and those presenting late.

    Conclusion: The EVD outbreak in Nigeria was characterized by the severe febrile gastroenteritis syndrome typical of the West African outbreak, better outcomes, rapid containment, and no infection among EVD care-providers. Early case detection, an effective incident management system, and prompt case management with on-site mobilization and training of local professionals were key to the outcome.

  • Ebola Virus Epidemiology and Evolution in Nigeria

    Authors: Onikepe A Folarin, Deborah Ehichioya, Stephen F Schaffner, Sarah M Winnicki, Shirlee Wohl, Philomena Eromon, Kendra L West, Adrianne Gladden-Young, Nicholas E Oyejide, Christian B Matranga, Awa Bineta Deme, Ayorinde James, Christopher Tomkins-Tinch, Kenneth Onyewurunwa, Jason T Ladner, Gustavo Palacios, Iguosadolo Nosamiefan , Kristian G Andersen, Sunday Omilabu, Daniel J Park, Nathan L Yozwiak, Abdusallam Nasidi, Robert F Garry, Oyewale Tomori, Pardis C Sabeti, Christian T Happi
    Read Abstract | Read Article

    Containment limited the 2014 Nigerian Ebola virus (EBOV) disease outbreak to 20 reported cases and 8 fatalities. We present here clinical data and contact information for at least 19 case patients, and full-length EBOV genome sequences for 12 of the 20. The detailed contact data permits nearly complete reconstruction of the transmission tree for the outbreak. The EBOV genomic data are consistent with that tree. It confirms that there was a single source for the Nigerian infections, shows that the Nigerian EBOV lineage nests within a lineage previously seen in Liberia but is genetically distinct from it, and supports the conclusion that transmission from Nigeria to elsewhere did not occur.

  • Elimination of Mother-To-Child Transmission of Syphilis: Is It a Reality in Nigeria by 2020?

    Authors: Daniel A Adeyinka, Babayemi O Olakunde, Chamberline E Ozigbu, Emmanuel A Agogo , Mercy Morka, Temitope Atoba, Chris Obanubi, Gideon Okorie, Abiola Davies, Olanrewaju Oladimeji
    Read Abstract | Read Article

    Background: Congenital syphilis is a global health problem, yet it has received little attention in recent years. Despite cost-effective syphilis screening and treatment, it continues to contribute hugely to perinatal morbidity and mortality worldwide.

    Aims: To determine the prevalence and treatment coverage trend for syphilis among pregnant women in the national prevention of mother-to-child transmission programme in Nigeria and to evaluate progress towards the elimination of congenital syphilis in the country.

    Methods: A retrospective analysis of validated national health sector performance data on pregnant women attending antenatal care at prevention of mother-to-child transmission clinics from 2013 to 2016 in Nigeria.

    Results: The proportion of new antenatal care attendees who annually received serological testing for syphilis increased from 12.2% in 2013 to 16.3% in 2016 (p-trend<0.0001). Although the prevalence of maternal syphilis decreased from 3.2% in 2013 to 1.4% in 2016 (p-trend<0.0001), the syphilis treatment coverage during pregnancy has decreased from 71.3% in 2013 to 54.9% in 2016 (p-trend<0.0001).

    Conclusions: Maternal syphilis screening and treatment in Nigeria are inadequate to meet the elimination aspirations. A rapid scale-up of antenatal care syphilis screening and treatment are crucial to averting an epidemic in Nigeria by 2020. 

  • Nigeria\'s Joint External Evaluation and National Action Plan for Health Security

    Authors: Olubunmi Eyitayo Ojo, Mahmoud Dalhat, Richard Garfield, Chris Lee, Oyeronke Oyebanji, Ajani Oyetunji, Chikwe Ihekweazu
    Read Abstract | Read Article

    Nigeria is working to protect against and respond more effectively to disease outbreaks. Quick mobilization and control of the Ebola epidemic in 2014, at least 4 major domestic outbreaks each year, and significant progress toward polio eradication led to adoption of the World Health Organization's Global Health Security Joint External Evaluation (JEE) and National Action Plan for Health Security (NAPHS). The process required joint assessment and planning among many agencies, ministries, and sectors over the past 2 years. We carried out a JEE of 19 core programs in 2017 and launched a detailed NAPHS to improve prevention, detection, and response in December 2018, which required us to create topic-specific groups to document work to date and propose JEE scores. We then met with an international team for 5 days to review and revise scoring and recommendations, created a 5-year implementation plan, developed a management team to oversee implementation, drafted legislation to manage outbreaks, trained professionals at state and local levels of government, and set priorities among the many possible activities recommended. Management software and leadership skills were developed to monitor global health security programs. We learned to use international assistance strategically to strengthen planning and mentor national staff. Finally, a review of every major disease outbreak was used to prepare for the next challenge. Review and adaptation of this plan each year will be critical to ensure sustained momentum and progress. Many low-income countries are skilled at managing vertical disease control programs. Balancing and combining the 19 core activities of a country's public health system is a more demanding challenge.

  • Assessing the Concepts and Designs of 58 Mobile Apps for the Management of the 2014-2015 West Africa Ebola Outbreak: Systematic Review

    Authors: Daniel Tom-Aba, Patrick Mboya Nguku, Chinedu Chukwujekwu Arinze, Gerard Krause
    Read Abstract | Read Article

    Background: The use of mobile phone information technology (IT) in the health sector has received much attention especially during the 2014-2015 Ebola virus disease (EVD) outbreak. mHealth can be attributed to a major improvement in EVD control, but there lacks an overview of what kinds of tools were available and used based on the functionalities they offer.

    Objective: We aimed to conduct a systematic review of mHealth tools in the context of the recent EVD outbreak to identify the most promising approaches and guide further mHealth developments for infectious disease control.

    Methods: Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, we searched for all reports on mHealth tools developed in the context of the 2014-2015 EVD outbreak published between January 1, 2014 and December 31, 2015 on Google Scholar, MEDLINE, CAB Abstracts (Global Health), POPLINE, and Web of Science in any language using the search strategy: ("outbreak" OR "epidemic") AND ("mobile phone" OR "smartphone" OR "smart phone" OR "mobile phone" OR "tablet" OR "mHealth") AND ("Ebola" OR "EVD" OR "VHF" OR "Ebola virus disease" OR "viral hemorrhagic fever") AND ("2014" OR "2015"). The relevant publications were selected by 2 independent reviewers who applied a standardized data extraction form on the tools' functionalities.

    Results: We identified 1220 publications through the search strategy, of which 6.31% (77/1220) were original publications reporting on 58 specific mHealth tools in the context of the EVD outbreak. Of these, 62% (34/55) offered functionalities for surveillance, 22% (10/45) for case management, 18% (7/38) for contact tracing, and 6% (3/51) for laboratory data management. Only 3 tools, namely Community Care, Sense Ebola Followup, and Surveillance and Outbreak Response Management and Analysis System supported all four of these functionalities.

    Conclusions: Among the 58 identified tools related to EVD management in 2014 and 2015, only 3 appeared to contain all 4 key functionalities relevant for the response to EVD outbreaks and may be most promising for further development

  • Descriptive Epidemiology of Cholera Outbreak in Nigeria, January-November, 2018: Implications for the Global Roadmap Strategy

    Authors: Kelly Osezele Elimian, Anwar Musah, Somto Mezue, Oyeronke Oyebanji, Sebastian Yennan, Arisekola Jinadu, Nanpring Williams, Adesola Ogunleye, Ibrahima Soce Fall, Michel Yao, Womi-Eteng Eteng, Patrick Abok, Michael Popoola, Martin Chukwuji, Linda Haj Omar, Eme Ekeng, Thieno Balde, Ibrahim Mamadu, Ayodele Adeyemo, Geoffrey Namara, Ifeanyi Okudo, Wondimagegnehu Alemu, Clement Peter, Chikwe Ihekweazu
    Read Abstract | Read Article

    Background: The cholera outbreak in 2018 in Nigeria reaffirms its public health threat to the country. Evidence on the current epidemiology of cholera required for the design and implementation of appropriate interventions towards attaining the global roadmap strategic goals for cholera elimination however seems lacking. Thus, this study aimed at addressing this gap by describing the epidemiology of the 2018 cholera outbreak in Nigeria.

    Methods: This was a retrospective analysis of surveillance data collected between January 1st and November 19th, 2018. A cholera case was defined as an individual aged 2 years or older presenting with acute watery diarrhoea and severe dehydration or dying from acute watery diarrhoea. Descriptive analyses were performed and presented with respect to person, time and place using appropriate statistics.

    Results: There were 43,996 cholera cases and 836 cholera deaths across 20 states in Nigeria during the outbreak period, with an attack rate (AR) of 127.43/100,000 population and a case fatality rate (CFR) of 1.90%. Individuals aged 15 years or older (47.76%) were the most affected age group, but the proportion of affected males and females was about the same (49.00 and 51.00% respectively). The outbreak was characterised by four distinct epidemic waves, with higher number of deaths recorded in the third and fourth waves. States from the north-west and north-east regions of the country recorded the highest ARs while those from the north-central recorded the highest CFRs.

    Conclusion: The severity and wide-geographical distribution of cholera cases and deaths during the 2018 outbreak are indicative of an elevated burden, which was more notable in the northern region of the country. Overall, the findings reaffirm the strategic role of a multi-sectoral approach in the design and implementation of public health interventions aimed at preventing and controlling cholera in Nigeria. 

  • Measures to Control Protracted Large Lassa Fever Outbreak in Nigeria, 1 January to 28 April 2019

    Authors: Chioma C Dan-Nwafor, Yuki Furuse, Elsie A Ilori, Oladipupo Ipadeola, Kachikwulu O Akabike, Anthony Ahumibe, Winifred Ukponu, Lawal Bakare, Tochi J Okwor , Gbenga Joseph , Nwando G Mba, Adejoke Akano, Adebola T Olayinka, Ihekerenma Okoli, Rita A Okea, Favour Makava, Nkem Ugbogulu, Saliu Oladele, Geoffrey Namara, Esther N Muwanguzi, Dhamari Naidoo, Samuel K Mutbam , Ifeanyi Okudo, Solomon F Woldetsadik, Clement Lp Lasuba, Chikwe Ihekweazu
    Read Abstract | Read Article

    Lassa fever cases have increased in Nigeria since 2016 with the highest number, 633 cases, reported in 2018. From 1 January to 28 April 2019, 554 laboratory-confirmed cases including 124 deaths were reported in 21 states in Nigeria. A public health emergency was declared on 22 January by the Nigeria Centre for Disease Control. We describe the various outbreak responses that have been implemented, including establishment of emergency thresholds and guidelines for case management.

  • Metagenomic Sequencing at the Epicenter of the Nigeria 2018 Lassa Fever Outbreak

    Authors: L E Kafetzopoulou, S T Pullan , P Lemey, M A Suchard , D U Ehichioya, M Pahlmann, A Thielebein, J Hinzmann, L Oestereich, D M Wozniak, K Efthymiadis, D Schachten, F Koenig, J Matjeschk, S Lorenzen, S Lumley, Y Ighodalo, D I Adomeh, T Olokor, E Omomoh ,, B Osiemi 8 , S Ehikhametalor 8 , P Akhilomen , M Airende, R Esumeh, E Muoebonam, R Giwa, A Ekanem, G Igenegbale, G Odigie, G Okonofua, R Enigbe, J Oyakhilome, E O Yerumoh, I Odia, C Aire, M Okonofua, R Atafo, E Tobin, D Asogun, N Akpede, P O Okokhere, M O Rafiu, K O Iraoyah, C O Iruolagbe, P Akhideno, C Erameh, G Akpede, E Isibor, D Naidoo, R Hewson, J A Hiscox, R Vipond, M W Carroll, C Ihekweazu, P Formenty, S Okogbenin, E Ogbaini-Emovon, S Günther, S Duraffour
    Read Abstract | Read Article

    The 2018 Nigerian Lassa fever season saw the largest ever recorded upsurge of cases, raising concerns over the emergence of a strain with increased transmission rate. To understand the molecular epidemiology of this upsurge, we performed, for the first time at the epicenter of an unfolding outbreak, metagenomic nanopore sequencing directly from patient samples, an approach dictated by the highly variable genome of the target pathogen. Genomic data and phylogenetic reconstructions were communicated immediately to Nigerian authorities and the World Health Organization to inform the public health response. Real-time analysis of 36 genomes and subsequent confirmation using all 120 samples sequenced in the country of origin revealed extensive diversity and phylogenetic intermingling with strains from previous years, suggesting independent zoonotic transmission events and thus allaying concerns of an emergent strain or extensive human-to-human transmission.

    DOI: 10.1126/science.aau9343 

  • Covid-19: How a Virus is Turning the World Upside Down

    Authors: Ilona Kickbusch, Gabriel M Leung, Zulfiqar A Bhutta, Malebona Precious Matsoso, Chikwe Ihekweazu, Kamran Abbasi
    Read Abstract | Read Article

    The covid-19 pandemic is the biggest threat in living memory to health and wellbeing, social global economy. In a world shaped by neoliberalism the economy has always come first, but many leaders of rich countries are now explicitly prioritising people’s health over the economy. Learning from others and from Asia and Africa is becoming essential. Citizens and experts outside the corridors of power are holding governments to account by comparing their response to that of other countries, to the relative success of South Korea or the relative failure of Italy. African countries with recent experience of Ebola will probably better understand the value of community involvement than the global North. Leaders of public health institutions, virologists, and modellers have rarely been so visible and held so much responsibility. Covid-19 has taught us that health is the basis of wealth, that global health is no longer defined by Western nations and must also be guided by Africa and Asia, and that international solidarity is an essential response and a superior approach to isolationism. We may emerge from this with a healthier respect for the environment and our common humanity. 


  • COVID-19: Towards Controlling of a Pandemic;

    Authors: Juliet Bedford, Delia Enria, Johan Giesecke, *David L Heymann, Chikwe Ihekweazu, Gary Kobinger, H Clifford Lane, Ziad Memish, Myoung-don Oh, Amadou Alpha Sall, Anne Schuchat, Kumnuan Ungchusak, Lothar H Wieler
    Read Abstract | Read Article

    Over the past 3 weeks, a novel coronavirus disease 2019 (COVID-19), has been identified and is rapidly expanding in Europe, North America, Asia, and the Middle East, with the first confirmed cases being identified in African and Latin American countries. It has been shown that close and unprotected exposure is required for transmission by direct contact or by contact with fomites in the immediate environment of those with infection. In order to prevent the disease from spreading further, the WHO Strategic and Technical Advisory Group for Infectious Hazards (STAG-IH) has recommended that all countries should be prepared for containment, including active surveillance, early detection, isolation and case management, contact tracing and prevention of onward spread of SARSCoV-19 as well as addressing research gaps about the virus.

    doi: 10.1016/S0140-6736(20)30673-5 

  • Africa\'s Response to COVID-19

    Authors: Chikwe Ihekweazu and Emmanuel Agogo
    Read Abstract | Read Article

    African countries are leveraging investments in syndromic surveillance and case-finding through Integrated Disease Surveillance and Response framework (IDSR); scaling molecular testing capacity developed for other diseases; deploying trainees in field epidemiology training programs to lead the field response; and using the young people in the continent to undertake contact tracing, staff isolation centres and provide the supportive care that is available. The management of these resources has shown to be the best fit in national public health institutes, which have been rapidly established and strengthened in the last decade in Africa. So far, the response in Africa has been marked by innovation and resilience in the face of almost insurmountable odds and in the resounding collapse of multilateralism.

    doi: 10.1186/s12916-020-01622-w

  • 1. Is Africa Prepared for Tackling the COVID-19 (SARS-CoV-2) Epidemic? Lessons from Past Outbreaks, Ongoing Pan-African Public Health Efforts, and Implications for the Future;

    Authors: Nathan Kapata, Chikwe Ihekweazu, Francine Ntoumi, Tajudeen Raji, Pascalina Chanda-Kapata, Peter Mwaba, Victor Mukonka, Matthew Bates, John Tembo, Victor Corman, Sayoki Mfinanga, Danny Asogun, Linzy Elton, Li ˜a B´arbara Arruda, Margaret J Thomason, Leonard Mboera, Alexei Yavlinsky, Najmul Haider, David Simons, Lara Hollmann, Swaib A Lule, Francisco Veas, Muzamil Mahdi Abdel Hamid, Osman Dar, Sarah Edwards, Francesco Vairo, Timothy D McHugh, Christian Drosten, Richard Kock, Giuseppe Ippolito, Alimuddin Zumla
    Read Abstract | Read Article

    Coronavirus disease 2019, (now officially named COVID-19) has been declared by the World Health Organisation (WHO) to be a disease of Public Health Emergency of International Concern. It has been a matter of great concern as the potential for the virus to spread to countries with weaker health systems is high. In time past, other preventable emerging and re-emerging infectious diseases with epidemic potential have taken their toll on the health systems of many African countries. Therefore, the question surfaces, ‘Is Africa prepared and equipped to deal with yet another outbreak of a highly infectious disease – COVID-19? It is noteworthy that with the experience gained so far from handling of past epidemics and the high degree of awareness of COVID-19, Africa is better prepared than ever before. The continent now has stronger national public health institutes, the rapid scale-up of testing capacity, better coordination at the continental level, and the capacity of built-in surveillance and contact tracing which has occurred since the 2013–2016 West African Ebola outbreak. It is believed that all the measures put in place so far will result in prolonged containment phase of COVID-19.

    doi: 10.1016/j.ijid.2020.02.049

  • Increase in Lassa Fever Cases in Nigeria, January - March 2018

    Authors: Elsie A. Ilori, Christina Frank, Chioma C. Dan-Nwafor, Oladipupo Ipadeola, Amrei Krings, Winifred Ukponu, Oboma E. Womi-Eteng, Ayodele Adeyemo, Samuel K. Mutbam, Emmanuel O. Musa, Clement L.P. Lasuba, Wondimagegnehu Alemu, Sylvanus Okogbenin, Ephraim Ogbaini, Uche Unigwe, Emeka Ogah, Robinson Onoh, Chukwuyem Abejegah, Olufemi Ayodeji, Chikwe Ihekweazu
    Read Abstract | Read Article

    We reviewed data pertaining to the massive wave of Lassa fever cases that occurred in Nigeria in 2018. No new virus strains were detected, but in 2018, the outbreak response was intensified, additional diagnostic support was available, and surveillance sensitivity increased. These factors probably contributed to the high case count.

  • Improving Epidemiological Response: Lessons Learnt from Successive Outbreaks in Nigeria

    Authors: Assad Hassan, Muhammad Balogun, Mahmood Dalhat, Chikwe Ihekweazu
    Read Abstract | Read Article

    A series of disease outbreaks in Nigeria demonstrated the need for countries to invest more in improving their health security capabilities.1 Nigeria experienced five major disease outbreaks in 2017 which stretched the response capacity of its epidemiologists and its public health system.2 There are three levels of public health delivery in Nigeria: national, state and local government levels. At the national level, the Nigeria Centre for Disease Control (NCDC) coordinates the response to disease outbreaks of public health importance. At the state and local levels, epidemiology teams and disease surveillance officers are responsible for disease prevention and control.

  • Use of the Staged Development Tool for Assessing, Planning, and Measuring Progress in the Development of National Public Health Institutes

    Authors: Ezra J. Barzilay, Henry Vandi, Sue Binder, Ifeyinwa Udo, Martha L. Ospina, Chikwe Ihekweazu, and Shelly Bratton
    Read Abstract | Read Article

    The Staged Development Tool (SDT) was created to help national public health institutes (NPHIs) assess their current capacity and develop roadmaps for achieving a higher level of functioning. This article discusses the current use of the SDT by national public health institutes to establish baseline capacity and inform strategic planning and its proposed use in a 3-step sequence for measuring the impact of capacity-building interventions over time. The article also includes descriptions of how national public health institutes have been using the SDT to assess their baseline capacity in management issues and core public health functions. The first use of the SDT by a national public health institute provides essential baseline information on their capacities and levels of functioning and plans for addressing gaps. By repeating the SDT after time for the plans to be implemented, the SDT can be used to evaluate changes in capacity and the effectiveness of the interventions made. Because the SDT is built to be complementary to existing assessments and public health strengthening tools and guidelines, implementing the SDT provides concrete, complementary information that can help countries achieve global health security goals and address current and future threats to public health.

    There is general acknowledgment that strong health systems require robust public health infrastructures.1,2 Achieving the objectives of the sustainable development goals and ensuring global health security depend on systems that promote, maintain, and restore health. Health systems are stronger and more effective with integrated core functions of public health, including but not limited to surveillance of population health and well-being; monitoring and response to health hazards and emergencies; advancing public health research to develop the evidence to inform policies and programs; and assuring a sufficient and competent public health workforce.1,3,4 Epidemiologic data and public health research data provide an evidence base for decisions and policies affecting all aspects of the larger health system. Furthermore, a strong public health workforce increases the capacity of a country to ensure the existence of the conditions in which people can be healthy.4,5

    In many countries, public health activities are spread across several organizational units, sometimes across several ministries. Even when they are concentrated in the ministry of health, public health priorities are often overshadowed by the perceived greater urgency of providing clinical care. Fragmentation of public health efforts among multiple organizational units hinders effective coordination, leadership, and management of public health activities (eg, public health laboratory services, surveillance, and emergency response and preparedness) for preventing recurring outbreaks. These problems can be mitigated by developing a national public health institute (NPHI) that serves as a single focal point that leads or coordinates public health activities.6-8 National public health institutes are organizations that are typically part of ministries of health, or closely aligned with them, that promote health by coordinating public health functions and programs to prevent, detect, and respond to public health threats, for both infectious and noninfectious conditions. In some countries, they also serve as the public health focal point for One Health and regularly liaise with ministries of agriculture, environment, and other relevant ministries and partners.

    In recent years, many national public health institutes have been created or augmented, often in response to health security concerns or events. For example, the Canadian national public health institute, the Public Health Agency of Canada, was created after what was perceived as a poor response to the severe acute respiratory syndrome (SARS) outbreaks.7 Liberia's national public health institute was created very rapidly following lessons learned from the country's less than optimal response to Ebola.

    In contrast, Nigeria's response to the Ebola virus disease outbreak, with guidance from the Nigerian Centre for Disease Control (NCDC, Nigeria's NPHI) is widely considered a success story.

  • Two Cases of Monkeypox Imported to the United Kingdom, September 2018

    Authors: Aisling Vaughan, Emma Aarons, John Astbury, Sooria Balasegaram, Mike Beadsworth, Charles R Beck, Meera Chand6, Catherine OConnor, Jake Dunning, Sam Ghebrehewet, Nick Harper, Ruth Howlett-Shipley, Chikwe Ihekweazu, Michael Jacobs, Lukeki Kaindama, Parisha Katwa, Saye Khoo, Lucy Lamb, Sharon Mawdsley, Dilys Morgan, Ruth Palmer, Nick Phin, Katherine Russell, Beng Said, Andrew Simpson, Roberto Vivancos, Michael Wade, Amanda Walsh, Jennifer Wilburn
    Read Abstract | Read Article

    In early September 2018, two cases of monkeypox were reported in the United Kingdom (UK), diagnosed on 7 September in Cornwall (South West England) and 11 September in Blackpool (North West England). The cases were epidemiologically unconnected and had recently travelled to the UK from Nigeria, where monkeypox is currently circulating. We describe the epidemiology and the public health response for the first diagnosed cases outside the African continent since 2003.

  • Notes from the Field: Responding to an Outbreak of Monkeypox Using the One Health Approach Nigeria, 20172018

    Authors: Womi-Eteng Eteng, MSc; Anna Mandra, DVM; Jeff Doty; Adesola Yinka-Ogunleye, DDS; Sola Aruna, MD; Mary G. Reynolds, PhD; Andrea M. McCollum, PhD; Whitni Davidson, MPH; Kimberly Wilkins; Muhammad Saleh, MPH; Oladipupo Ipadeola, MSc; Lamin Manneh; Uchenna Anebonam, MPH; Zainab Abdulkareem, DVM; Nma Okoli, DVM; Jeremiah Agenyi; Chioma Dan-Nwafor, MPH; Ibrahim Mahmodu, MPH; Chikwe Ihekweazu, MD
    Read Abstract | Read Article

    On September 22, 2017, a suspected human case of monkeypox was reported to the Nigeria Centre for Disease Control (NCDC) from Bayelsa State in southern Nigeria. Because monkeypox had not been reported in Nigeria since 1978 (1), the case raised national and international concern. A multisectoral, international outbreak investigation was undertaken to identify sources and risk factors, establish surveillance, and enhance preparedness. A suspected case was defined as the sudden onset of fever, followed by a vesiculopustular rash primarily on the face, palms, and soles. A confirmed case was any suspected case with laboratory confirmation (by serology, molecular detection of viral DNA, or virus isolation). A probable case was a suspected case epidemiologically linked to a confirmed case. As of February 25, 2018, a total of 228 suspected cases (including 89 confirmed and three probable cases) had been investigated in 24 of Nigeria’s 36 states and the Federal Capital Territory. Six deaths (6.7%) were recorded among the 89 confirmed cases. The outbreak has not been declared over, and NCDC continues to collect data to develop a baseline level for this disease, which had not been reported in 40 years and now might be endemic to Nigeria. Given the zoonotic nature of the disease, this outbreak has required a robust One Health outbreak collaboration among human, animal, and environmental health institutions.

  • Time Delays in the Response to the Neisseria Meningitidis Serogroup C Outbreak in Nigeria - 2017

    Authors: Assad Hassan , G. U. Mustapha, Bola B. Lawal, Aliyu M. Nauzo, Raji Ismail, Eteng Womi-Eteng Oboma, Oyeronke Oyebanji, Jeremiah Agenyi, Chima Thomas, Muhammad Shakir Balogun, Mahmood M. Dalhat, Patrick Nguku, Chikwe Ihekweazu
    Read Abstract | Read Article


    Nigeria reports high rates of mortality linked with recurring meningococcal meningitis outbreaks within the African meningitis belt. Few studies have thoroughly described the response to these outbreaks to provide strong and actionable public health messages. We describe how time delays affected the response to the 2016/2017 meningococcal meningitis outbreak in Nigeria.


    Using data from Nigeria Centre for Disease Control (NCDC), National Primary Health Care Development Agency (NPHCDA), World Health Organisation (WHO), and situation reports of rapid response teams, we calculated attack and death rates of reported suspected meningococcal meningitis cases per week in Zamfara, Sokoto and Yobe states respectively, between epidemiological week 49 in 2016 and epidemiological week 25 in 2017. We identified when alert and epidemic thresholds were crossed and determined when the outbreak was detected and notified in each state. We examined response activities to the outbreak.


    There were 12,535 suspected meningococcal meningitis cases and 877 deaths (CFR: 7.0%) in the three states. It took an average time of three weeks before the outbreaks were detected and notified to NCDC. Four weeks after receiving notification, an integrated response coordinating centre was set up by NCDC and requests for vaccines were sent to International Coordinating Group (ICG) on vaccine provision. While it took ICG one week to approve the requests, it took an average of two weeks for approximately 41% of requested vaccines to arrive. On the average, it took nine weeks from the date the epidemic threshold was crossed to commencement of reactive vaccination in the three states.


    There were delays in detection and notification of the outbreak, in coordinating response activities, in requesting for vaccines and their arrival from ICG, and in initiating reactive vaccination. Reducing these delays in future outbreaks could help decrease the morbidity and mortality linked with meningococcal meningitis outbreaks.

  • The Nigeria Centre for Disease Control

    Authors: Ahmad Muhammad Njidda, Oyeronke Oyebanji, Joshua Obasanya, Olubunmi Ojo, Adebayo Adedeji, Nwando Mba, John Oladejo, Chikwe Ihekweazu
    Read Abstract | Read Article

    Summary box

    • Nigeria and several other African countries have been battling with public health challenges for decades. These challenges came to fore during the Ebola virus disease (EVD) crisis that affected many countries in the West African region, including Nigeria.

    • As a result, many African countries have established their National Public Health Institutes as a focal point to prevent, detect and respond to diseases of public health importance, but currently, only 9 of the 15 countries in West Africa have a designated national public health institute.

    • Before the EVD crisis, Nigeria established the Nigeria Centre for Disease Control (NCDC), which played a pivotal role in the control of the EVD outbreak in Nigeria, as well as provided support to other countries that were affected by the crisis.

    • Modelled on the US Centre for Disease Control and Prevention (CDC), the NCDC has institutionalised Nigeria’s capacity to respond to the increasing threats of outbreaks of infectious diseases and other public health emergencies. This is achieved through building collaborations and taking the lead in prevention, preparedness and surveillance, and also coordinating the public health laboratory networks.

    • African public health institutes are currently in early stages of evolution. Building a national public health institute requires strong commitment, clarity of vision. The experience of setting up the public health institute of Nigeria can inform similar efforts in other African countries.


    Only a few African countries like Ethiopia and Mozambique have long standing National Public Health Institutes (NPHI). However, since the large 2014–2016 Ebola virus disease (EVD) outbreak in West Africa, many African countries have been setting up NPHI1 2to optimise the use of scarce resources to prevent, detect and respond to infectious disease threats. The Africa Union and the Economic Community of West African States (ECOWAS) have also set up regional disease control centres.3

    The Nigeria Centre for Disease Control (NCDC) was conceived much earlier in 2007 as an attempt to establish an institution that can effectively mobilise its resources to respond to these outbreaks and other public health emergencies. Modelled after the US Centre for Disease Control and Prevention (CDC), Atlanta, the first formal step to establish NCDC took place in 2011 when units of Federal Ministry of Health—the Epidemiology Division, the Avian Influenza Project and its laboratories—and the Nigeria Field Epidemiology and Laboratory Training Program (NFELTP) were moved to form the nucleus of NCDC.

    Detecting and responding to infectious disease outbreaks has long presented a major public health challenge in Nigeria, given its size and complexity. Several large infectious disease outbreaks have been reported in Nigeria, including the yellow fever outbreak in 19864 and 19875 that affected 9800 and 1249 people, respectively, the large meningitis outbreak in 1996 with 109 580 cases and 11 717 deaths,6 cholera outbreaks in 2001 and 20047 and more recently, the meningitis outbreak in 2017.8 9 In between these was the much acclaimed successful response to the outbreak of EVD in September 2014.10

    Nigeria’s public health challenges continue to grow—rapid population growth, increasing movement of people and destruction of infrastructure in the North East of Nigeria following the ‘Boko Haram’ insurgency and outbreaks from new and re-emerging pathogens. The year 2017 saw an increase in the rate of infectious diseases like Lassa fever,11 yellow fever, monkey pox, cholera and new strains/subtypes/serotypes of existing pathogens like Neisseria meningitidis serogroup C in Nigeria.12 In addition, Nigeria has had to address emerging public health threats, such as increasing antimicrobial resistance,13 and increasing incidence of non-communicable diseases14 and high maternal mortality rates.15

    The establishment of NCDC is indeed more justifiable now than when it was conceived in 2007. The value of the NCDC to the country became most obvious from its role in the coordination of the response to the 2014 EVD outbreak in Nigeria16 17 and coordinating the support that Nigeria provided to the Governments of Sierra Leone and Liberia during the EVD outbreak in those countries. This outbreak and the need for strong, country-led coordination become the basis for further growth of the NCDC. Notably, NCDC now takes the front seat in preventing and preparing for public health emergencies, and in managing the surveillance and reference laboratory architecture for Nigeria. NCDC has strong partnerships with the WHO and the US CDC, which support various activities at the Centre through grants and technical assistance to support disease surveillance, establishment of reference laboratory systems, outbreak response activities and others.

    Together with the African Field Epidemiology Network, NCDC also manages the delivery of the Nigeria Field Epidemiology and Laboratory Training Programme (NFELTP). The NFELTP is a 2-year in-service training in applied epidemiology and laboratory practice within the NCDC/Federal Ministry of Health and Federal Ministry of Agriculture. The programme also offers basic epidemiology training to health workers at Local Government levels to improve surveillance and response to priority diseases.18The NFELTP is modelled after the US-CDC Epidemiology Intelligence Service and has been replicated in >80 countries around the world. In Nigeria, NFELTP has developed a pool of Field Epidemiologists and Laboratory experts with skills to gather critical information and turn it into public health action, and it is a major public health asset within Nigeria’s national public health institute.19

    The NCDC also has a very strong relationship with the new ECOWAS Regional Centre for Disease control which is also the regional hub for the Africa Centre for Disease Control. Other partnerships that the Centre has recently developed include with the University of Maryland, Baltimore, the Robert Koch Institute, the Global Outbreak and Response Network and Public Health England, all focusing on specific aspects of its mandate.

    The NCDC has strengthened its focus on prevention and preparedness; stockpiling and prepositioning of supplies for outbreak response in the states; development of guidelines and checklists for emergency preparedness; and generally increasing its role in supporting the States. NCDC also provides guidance and support to other professionals and sub-national government public health organisations and officials.

    One way that NCDC has been able to coordinate preparedness and response activities is the establishment of its Incident Coordination Centre. This serves as a location to review outbreak reports and decide on preparedness and response activities. Dashboards are available to display data from the subnational level, which provides a snapshot of disease trends in the country. The Incident Coordination Centre is also tasked with daily intelligence gathering and risk analysis of public health events to identify potential threats. It serves as an Emergency Operations Centre during outbreaks, with an incident manager leading the response, bringing together the various pillars of outbreak response working in a command and control structure.

    The NCDC is also the focal point for the implementation of the International Health Regulations (IHR), which is a global legal agreement that aims to prevent and respond to the spread of diseases and to avoid their becoming international crises. A Joint External Evaluation was carried out in June 2017 to assess Nigeria’s capacity to prevent, detect and respond to treats of public health importance. Several areas of strength were highlighted as well as areas requiring an improvement in capacity.20Subsequently, a National Action Plan is being developed to strengthen areas of weakness.

    The journey of NCDC shows that building NPHI takes clarity of vision, perseverance, commitment and a strong legal mandate. Achieving a legal mandate will demonstrate Nigeria’s commitment to providing a strong scientific focus for ensuring the health security of Africa’s most populous nation. Over the next 5 years, the NCDC’s mission is to work in partnership with other arms of Government and partners to protect the health of Nigerians. This will be accomplished through integrated disease surveillance; a linked and connected public health laboratory network within the country and the sub region; and the coordination of emergency preparedness and response activities.

    NPHI help to concentrate a country’s resources for the prevention, detection and response to infectious diseases in a single organisation. Nigeria’s experience of setting up its NCDC can inform similar efforts in other African countries.

  • Tackling Viral Haemorrhagic Fever in Africa

    Authors: Chikwe Ihekweazu, Ibrahim Abubakar
    Read Abstract | Read Article

    Outbreaks of viral haemorrhagic fevers, such as the Ebola virus disease epidemic in west Africa, have caught the attention of the global health community because of perceived and real threats to local, national, and global health security and their economic impact.1 Although viral haemorrhagic fever outbreaks primarily affect settings in which pathogens emerge from animal hosts, they also have the potential to spread worldwide. Consequently, models that accurately predict the emergence and spread of viruses that cause viral haemorrhagic fevers are needed. In The Lancet, David Pigott and colleagues2 use a combination of approaches to assess and understand the threat of viral haemorrhagic fevers across Africa by identifying locations that have the greatest potential for zoonotic spillover, regions that are susceptible to ongoing secondary transmission, and areas with the highest potential for local and global spread. A key strength of this study is the provision of subnational estimates of risks.


    The use of models to inform the distribution of resources to prevent or respond to outbreaks requires prospective validation. Gaps and bias in surveillance data on viral haemorrhagic fevers in human beings in most African settings3 limit the ability to correctly predict zoonotic spillover. Pigott and colleagues predicted probable zoonotic transmission from animal hosts to human beings by combining geographical information on index cases of outbreaks and viral detection in animals and related this information to drivers in the environment to generate profiles that characterise where disease is likely to be found. In the absence of unbiased prospective surveillance, using similarities between environmental profiles to predict disease spread and which areas to focus surveillance should be used with appropriate caution. Nevertheless, this comprehensive assessment justifies investment in better surveillance and further animal–host surveys.

    Projects such as the US Agency for International Development's (USAID's) PREDICT programme4provide an opportunity to improve the quality of viral reservoir data, but these data must be combined with better local disease surveillance and human–animal interaction behavioural data. By contrast, the quality of data on human connectivity, especially for air travel, is more robust and predictions of subsequent spread after emergence are therefore likely to be accurate.

    In Pigott and colleagues' study,2 countries that have the greatest potential for spillover from animals reflect the original zoonotic niche of the viral haemorrhagic fevers examined, as expected. Analysis of outbreak receptivity, which relates to susceptibility to ongoing secondary transmission, showed that 90% of districts in the Central African Republic, Chad, Somalia, and South Sudan ranked in the top 90th percentile. These countries stand out for their political instability. Strikingly, estimating epidemic potential based on local and international connectivity showed that at-risk districts in Nigeria represented many of those with the highest potential for global spread of viral haemorrhagic fevers.2

    Pigott and colleagues suggest that this work should inform investment at each stage of potential epidemic progression and propose areas in which they should be made. However, the authors did not mention where the investment will come from or which institutions should be the primary recipients.

    Sustainable action to prevent the emergence and spread of viral haemorrhagic fevers requires investment to include local sources and to strengthen national and local capacity. Science-led national public health institutes (NPHIs) are needed to use complex information to make informed decisions on preparedness and response. NPHIs can provide leadership in disease surveillance and outbreak investigations, reference laboratory services, including specialist diagnostic services for rare organisms, and advise their governments on development and evaluation of public health interventions. These institutes need scientists who are knowledgable in the local context. Many African countries already recognise the need to bring the requisite expertise together into one institute, which led to the establishment of several NPHIs.5 Equally pertinent is the need for regional cooperation and resilience, which has led to new regional bodies such as the West African Regional Centre for Surveillance and Disease Control and the Africa Centres for Disease Control. These institutes are supported with modest resources compared with similar entities in high-income countries, despite the increased risk of major outbreaks from zoonotic and human sources.

    Not enough emphasis in the post-Ebola narrative has been placed on strengthening NPHIs to fulfil their global health security mandate. Instead, too much responsibility has been placed on WHO, which, despite improvements in technical expertise on emergency response,6 does not have sufficient resources—should they be expected—to respond to all threats in a continent as vast as Africa, or the local presence to rapidly deal with emerging viral haemorrhagic fever threats. What if Guinea had a strong NPHI with the right expertise to respond to information on infectious disease risk and use this information to persuade its own government to act? An outbreak of the size and scale experienced might never have happened.

    Establishment of NPHIs provides the crucial national resources required to underpin the prevention, detection, and response to outbreaks of emerging infections. These organisations should be designed with relevant disciplines and expertise to ensure they are fit for purpose, such as technical, epidemiological, microbiological, research, and communication skills, and supported by adequate and stable financing.7 To build strong, science-based institutions takes time and effort; however, it is the only sustainable way that research can lead to the development of a robust global health response capacity to emerging infections including viral haemorrhagic fevers. Although Pigott and colleagues2 did not explore specific interventions, such as the ability to respond to outbreaks or the use of protective equipment with their model, future research using such models should investigate measures to mitigate spread.

    CI is the Chief Executive Officer of the Nigeria Centre for Disease Control and acting lead for the West Africa Regional Centre for Surveillance and Disease Control. IA and CI are investigators on the European & Developing Countries Clinical Trials Partnership-funded Pandora consortium and the UK Space Agency-funded scoping study to develop tools for predicting zoonotic infections.

  • Genomic Characterisation of Human Monkeypox Virus in Nigeria

    Authors: Ousmane Faye, Catherine B Pratt, Martin Faye, Gamou Fall, Joseph A Chitty, Moussa M Diagne, Michael R Wiley, Adesola F Yinka-Ogunleye , Sola Aruna, Ebitimitula N Etebu , Neni Aworabhi, Dimie Ogoina, Wari Numbere, Nwando Mba, Gustavo PalaciosEmail the author Gustavo Palacios, Amadou A Sall, Chikwe Ihekweazu
    Read Abstract | Read Article

    Monkeypox virus (MPXV) is a large, double-stranded DNA virus belonging to the Orthopox genus in the family Poxviridae. First identified in 1958, MPXV has caused sporadic human outbreaks in central and west Africa, with a mortality rate between 1% and 10%.1 Viral genomes from west Africa and the Congo Basin separate into two clades, the latter being more virulent.2 Recently, MPXV outbreaks have occurred in Sudan (2005), the Republic of the Congo and Democratic Republic of the Congo (2009), and the Central African Republic (2016).

  • Reemergence of Human Monkeypox in Nigeria, 2017

    Authors: Adesola Yinka-Ogunleye, Olusola Aruna, Dimie Ogoina, Neni Aworabhi, Womi Eteng, Sikiru Badaru, Amina Mohammed, Jeremiah Agenyi, E.N. Etebu, Tamuno-Wari Numbere, Adolphe Ndoreraho, Eduard Nkunzimana, Yahyah Disu, Mahmood Dalhat, Patrick Nguku, Abdulaziz Mohammed, Muhammad Saleh, Andrea M. McCollum, Kimberly Wilkins, Ousmane Faye, Amadou Sall, Christian Happi, Nwando Mba, Olubumi Ojo, and Chikwe Ihekweazu
    Read Abstract | Read Article

    In Nigeria, before 2017 the most recent case of human monkeypox had been reported in 1978. By mid-November 2017, a large outbreak caused by the West African clade resulted in 146 suspected cases and 42 laboratory-confirmed cases from 14 states. Although the source is unknown, multiple sources are suspected.

  • Human Monkeypox: Epidemiologic and Clinical Characteristics, Diagnosis, and Prevention

    Authors: Eskild Petersen, Anu Kantele, Marion Koopmans, Danny Asogun, Adesola Yinka-Ogunleye, Chikwe Ihekweazu, Alimuddin Zumla
    Read Abstract | Read Article

    Recently, concern has been raised about the emergence of human monkeypox virus and the occasionally severe clinical presentation bearing resemblance to that of smallpox. In 2018 3 patients in the UK were diagnosed with monkeypox, and the frequency and geographic distribution of cases across West and Central Africa have increased in recent years. In Nigeria, most monkeypox patients are aged <40 years and lack cross-protective immunity because they were born after discontinuation of the smallpox eradication campaign. This article reviews the epidemiology, clinical features, and management of monkeypox and discusses its growing public health threat in this context

  • A Cluster of Nosocomial Lassa Fever Cases in a Tertiary Health Facility in Nigeria: Description and Lessons Learned, 2018

    Authors: Authors: Chioma C. Dan-Nwafor, Oladipupo Ipadeola, Elizabeth Smout, Elsie Ilori, Ayodele Adeyemo, Chukwuma Umeokonkwo, Damian Nwidi, Williams Nwachukwu, Winifred Ukponu, Emeka Omabe, Uchenna Anaebonam, Nneka Igwenyi, Gordon Igbodo, Womi Eteng, Ikemefule Uzoma, Muhammed Saleh, Joseph Agboeze, Samuel Mutbam, Tanyth de Gooyer, Rosie Short, Everistus Aniaku, Robinson Onoh, Emeka Ogah, Patrick Nguku, John Oladejo, Clement Peter, Olubunmi Ojo, Chikwe Ihekweazu
    Read Abstract | Read Article


    Lassa fever is an acute viral haemorrhagic disease endemic in Nigeria. The 2018 Lassa fever outbreak in Nigeria was unprecedented, with 8% of all cases occurring among healthcare workers (HCWs). A disproportionately high number of these infections occurred in HCWs working in a tertiary health facility in Nigeria. This paper describes the cluster of Lassa fever infections among HCWs in a treatment centre and the lessons learnt.


    We analysed clinical, epidemiological and laboratory data from surveillance and laboratory records kept during the 2018 outbreak. Interviews were conducted with surviving HCWs using a questionnaire developed specifically for the investigation of Lassa fever infections in HCWs. Descriptive analysis of the data was performed in Microsoft excel.


    The index case was a 15-year-old male who presented at the health facility with fever and uncontrolled nasopharyngeal bleeding, following a recent uvulectomy by a traditional healer. Overall, 16 HCWs were affected (15 confirmed and 1 probable) with five deaths (CFR-31.6%). Of the 15 confirmed cases, five (33.3%) were asymptomatic. Nine HCWs were direct contacts of the index case; the remaining six HCWs had no direct contact with the index case. HCW interviews identified a low index of suspicion for Lassa fever leading to inadequate infection prevention and control (IPC) practices as possible contributing factors to nosocomial transmission.


    Maintaining a high index of suspicion for Lassa fever in all patients especially in endemic areas, is essential in maintaining adequate IPC practices in health facilities in order to prevent nosocomial transmission of Lassa fever among HCWs. There is need to continually train and sensitise HCWs on strict adherence to IPC measures while providing care, irrespective of a patient’s provisional diagnosis.

  • The 2017 Human Monkeypox Outbreak in Nigeria - Report of Outbreak Experience and Response in the Niger Delta University Teaching Hospital, Bayelsa State, Nigeria

    Authors: Dimie Ogoina, James Hendris Izibewule, Adesola Ogunleye, Ebi Ederiane, Uchenna Anebonam, Aworabhi Neni, Abisoye Oyeyemi, Ebimitula Nicholas Etebu, Chikwe Ihekweazu
    Read Abstract | Read Article


    In September 2017, Nigeria experienced a large outbreak of human monkeypox (HMPX). In this study, we report the outbreak experience and response in the Niger Delta University Teaching Hospital (NDUTH), Bayelsa state, where the index case and majority of suspected cases were reported.


    In a cross-sectional study between September 25th and 31st December 2017, we reviewed the clinical and laboratory characteristics of all suspected and confirmed cases of HMPX seen at the NDUTH and appraised the plans, activities and challenges of the hospital in response to the outbreak based on documented observations of the hospital’s infection control committee (IPC). Monkeypox cases were defined using the interim national guidelines as provided by the Nigerian Centre for Disease Control (NCDC).


    Of 38 suspected cases of HMPX, 18(47.4%) were laboratory confirmed, 3(7.9%) were probable, while 17 (18.4%) did not fit the case definition for HMPX. Majority of the confirmed/probable cases were adults (80.9%) and males (80.9%). There was concomitant chicken pox, syphilis and HIV-1 infections in two confirmed cases and a case of nosocomial infection in one healthcare worker (HCW). The hospital established a make-shift isolation ward for case management, constituted a HMPX response team and provided IPC resources. At the outset, some HCWs were reluctant to participate in the outbreak and others avoided suspected patients. Some patients and their family members experienced stigma and discrimination and there were cases of refusal of isolation. Repeated trainings and collaborative efforts by all stakeholders addressed some of these challenges and eventually led to successful containment of the outbreak.


    While the 2017 outbreak of human monkeypox in Nigeria was contained, our report reveals gaps in outbreak response that could serve as lessons to other hospitals to strengthen epidemic preparedness and response activities in the hospital setting.

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