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.
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
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.
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.
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.
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
country’s 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.
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.
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.
·
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.
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.
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
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.
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.
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.
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.
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.
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
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.
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.
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
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.
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.
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.
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.
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.
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
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.
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.
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.
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.
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.
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.
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.
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.
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.
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
· 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.
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
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.
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
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.
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.
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).
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.
Background
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.
Methods
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).
Results
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.
Conclusion
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.