Health  

‘Nigeria’s level of preparedness, detection, response to epidemics is improving’

CEO of NCDC, Dr. Chikwe Ihekweazu

The fear that a new disease will emerge or existing ones will mutate into deadlier and untreatable versions has become even more palpable. Bill Gates had in April 2018 warned that a new disease could kill 30 million people in six months. Several studies had predicted that a deadly new disease will arise and spread around the globe and that could happen easily within the next decade.

Bill Gates told listeners at a discussion about epidemics hosted by the Massachusetts Medical Society, United States (U.S.) and the New England Journal of Medicine back in April, that humanity is not ready. “We are lifting children out of poverty around the globe and getting better at eliminating diseases like polio and malaria. But there is one area though where the world is not making much progress and that is pandemic preparedness,” he said. Indeed, the likelihood that such a disease will appear continues to rise. New pathogens emerge all the time as the world population increases and humanity encroaches on wild environments. It is becoming easier and easier for individual people or small groups to create weaponised diseases that could spread like wildfire around the globe. Gates presented a simulation by the Institute for Disease Modelling that found that a new flu like the one that killed 50 million people in the 1918 pandemic would now most likely kill 30 million people within six months.

In Nigeria, concerns are growing because some of the seasonal endemic diseases such as Lassa fever and Yellow fever have persisted throughout the year. Even emerging ones like monkeypox has persisted and has even been transported from Rivers State to the United Kingdom (U.K.).

Also, a fresh outbreak of Cerebro Spinal Meningitis (CSM) has killed nine and infected 72 other Nigerians in ten states- Katsina, Zamfara, Jigawa, Yobe, Bauchi, Ebonyi, Sokoto, Kano, Bayelsa, and Ondo. A further breakdown of the figures released this week by the Nigeria Centre for Disease Control (NCDC) Abuja showed that Katsina accounted for most of the cases and deaths followed by Zamfara, Jigawa, Ebonyi and Bauchi. No deaths were recorded in Sokoto, Kano, Yobe, Bayelsa and Ondo. Also, the NCDC) Abuja, this week, reported 15 new suspected monkey pox cases out of which six confirmed cases were recorded in five states: Rivers -one, Bayelsa -two, Delta -one, Cross Rivers -one, and Edo –one. Meanwhile, the World Health Organisation (WHO) regional reference laboratory and Institut Pasteur (IP) Dakar, Senegal have confirmed 13 new positive cases of Yellow fever from Edo (nine), FCT Abuja (three) and Ekiti (one). Also, latest figures on Lassa fever from the NCDC showed that the dreaded viral disease has killed seven new persons and infected another 14 is five states and the Federal Capital Territory (FCT) Abuja. The Centre noted that from January 1 to December 23, 2018, a total of 3,441 suspected cases have been reported. According to the NCDC, 23 states have recorded at least one confirmed case across 93 Local Government Areas (Edo, Ondo, Bauchi, Nasarawa, Ebonyi, Anambra, Benue, Kogi, Imo, Plateau, Lagos, Taraba, Delta, Osun, Rivers, FCT, Gombe, Ekiti, Kaduna, Abia, Adamawa, Enugu and Kano). Eleven States – Edo, Ondo, Plateau, Gombe, Bauchi, Kano, Kaduna, Nasarawa, Adamawa, FCT and Delta are in active phase of the outbreak.

However, the Chief Executive Officer (CEO) of the Nigeria Centre for Disease Control (NCDC), Dr. Chikwe Ihekweazu, told The Guardian in an exclusive interview that the Centre is working to improve Nigeria’s level of preparedness, detection and response to epidemics. Ihekweazu said although Meningitis serogroup C vaccines are not sufficient globally for preventive vaccination campaign, the NCDC is better positioned to prevent, prepare for, detect, and respond to outbreaks of infectious diseases. The consultant epidemiologist told The Guardian what the Centre is doing to improve the level of preparedness, detection and response to the ongoing meningitis, Lassa fever, Yellow fever and monkey pox outbreaks.

Unfortunately, very soon meningitis will again start causing havoc in Nigeria. Are you ready to contain this menace?
Historically, we know that there is an increase in meningitis cases during the dry season, usually from December to May. It may however start as early as November and last till June. Since the last outbreak of meningitis in Nigeria in 2017, the Nigeria Centre for Disease Control has been working with states and our partners to improve the level of preparedness, detection and response.

In 2017, we developed a well-defined preparedness and response plan clearly stating the roles of all levels of the health system from the health facilities to Departments of health of Local Government Areas, State Ministries of Health and agencies of the Federal Ministry of Health including NCDC and National Primary Health Care Development Agency (NPHCDA).

This year, we sent out letters of alert to all states at the beginning of November. We have been monitoring reports of cases and providing support as needed. In high-risk states, we trained clinicians on sample collection, laboratory staff on diagnosis and surveillance officers on reporting. All these are aimed at strengthening our level of preparedness and response to cases. We have also supported states by providing supplies needed for response. A public health advisory was issued at the beginning of the season to inform Nigerians on the need to protect themselves against meningitis.

Our National Technical Working Group has been monitoring the situation in states, ensuring improved preparedness and is ready to escalate to an emergency operations centre as needed.

Do we have the vaccine for the sero-type C that was not available early enough last year?
Our sister agency NPHCDA that is responsible for vaccination has been working closely with NCDC, to ensure we are better prepared in the event of an outbreak, The Neisseria meningitides serogroup C vaccines are not sufficient globally for a preventive vaccination campaign. However, in the event of an outbreak, we are working to improve the capacity to diagnose and report quickly, so that a reactive vaccination campaign can be initiated as needed.

With the limited availability of vaccines, it is important for Nigerians to protect themselves. Avoid overcrowding, sleep in well-ventilated rooms and importantly, visit a health facility immediately if you experience symptoms such as sudden high fever and neck stiffness.

The weather is now very dry, hot and humid. This is associated with so many epidemics. What are you doing about this?
While we cannot control nature, we can protect ourselves from the adverse effects of the weather. At the moment, we have a better understanding of when certain outbreaks occur- related to seasonal characteristics and community practices such as bush burning for the farming season.

At NCDC, we have set up Technical Working Groups for the six priority diseases that cause outbreaks in Nigeria- meningitis, Lassa fever, cholera, monkeypox, measles and yellow fever. These groups are constantly working with states and partners to monitor the trends of diseases, improve capacity to detect and respond, and inform the public on how to protect themselves.

We know there is usually an increase in meningitis and Lassa fever cases during the dry season. To prevent the spread of these diseases, it is important to visit a health facility and get tested if you experience sudden high fever. Not every fever is malaria, and should be tested for to enable prompt treatment. These diseases are treatable but early presentation to a health facility and proper management is very important.

There are fears that there will be an outbreak of another deadly infection like Ebola, plague or any other. A school of thought claims that nature abhors vacuum. Is Nigeria prepared to contain such? How prepared?
‘A disease outbreak anywhere is a threat everywhere’ is a common quote in the public health space. The current Ebola outbreak in the Democratic Republic of Congo (DRC), which has been described as the second largest outbreak ever recorded globally, has pushed countries including Nigeria to review their level of preparedness in the event of an outbreak.

We are grateful that Mr. President signed into law, the Bill establishing NCDC. What this means is that there is a stronger foundation for Nigeria’s public health institute to protect the health of Nigerians. With our legal mandate, we are better positioned to prevent, prepare for, detect and respond to outbreaks of infectious diseases.

We have a National Reference Laboratory that works with a network of state public health laboratories, for diagnosis. The laboratory has capacity to test for all epidemic prone diseases in the country and quickly expand as needed. Our Incident Coordination Centre has responded to several outbreaks and participated in global simulation exercises to test our level of preparedness and improve on lessons learned, to respond to a pandemic if it occurs. In addition, we are building a network of state emergency operations centres to strengthen state capacity for outbreak coordination.

In 2018, NCDC deployed about 60 Rapid Response Teams to support states in response to outbreaks. We are continually building experience and learning from every response mission to improve our capacity. To deliver our mandate, we work closely with the states, other ministries, departments, agencies as well as partners.

Through the recently developed national action plan for health security, we have developed a blueprint across the international health regulations work areas to ensure Nigeria is better prepared in the event of a pandemic.

We engage closely with the media, and provide public health advisory messages through our website and social media to Nigerians, so they are better informed and take responsibility to protect their health.

It seems there is an upsurge in Yellow fever in the country. Why?
Yellow fever is a vaccine preventable disease. This vaccine is part of the national immunisation scheduled and is usually given at nine months to children. An outbreak of yellow fever occurs in situations where immunity is low as a result of poor vaccination coverage and presence of the yellow fever vector.

As we improve our surveillance and diagnostic architecture in country, we are finding more cases of diseases. Our sister agency NPHCDA is working to improve immunisation coverage in the country, including the introduction of mass vaccination campaigns.

How far with issue of getting a Yellow card before travelling to countries like South Africa?
The yellow card is evidence of immunisation against the disease, required by many countries. This is currently issued and managed by the port health services of the Federal Ministry of Health. It is important that Nigerians are vaccinated against yellow fever, to prevent further spread.

How can one get vaccinated?
Yellow fever is part of the routine immunisation schedule in Nigeria, and available for free to children at nine months in government healthcare facilities. The agency responsible for immunisation, NPHCDA also organises vaccination campaigns across states to ensure a wide coverage. For travellers, the vaccine is available at designated Point of Entries, where yellow cards are also issued.

How frequent should it be?
One dose of yellow fever vaccine confers life-long immunity. The vaccine is effective and safe. Additional doses maybe received and during campaigns every person in the target age group

The Lassa fever international conference is here. What informed it?
In 2019, it will be 50 years since the Lassa fever virus was first discovered in a town in Nigeria. With the recent outbreaks, improved diagnostics and increasing research activities on Lassa fever in Nigeria, this is an important opportunity for the global health community to meet and discuss the future.

The conference is an opportunity to bring national and global experts together, share experiences, identify knowledge gaps and strengthen the approach to the research priorities we are continuously identifying. There are improved expectations for a vaccine for the diseases; better treatment measures, understanding the disease vector etc. We hope this conference will be an opportunity that will drive progress in these areas.

Overview on cerebrospinal meningitis by NCDC and WHO
Cerebrospinal meningitis (CSM) is a disease characterised by inflammation of the meninges (protective membrane covering the brain and the spinal cord) which can be caused by a variety of microbial pathogens including viral and bacterial organisms. The main etiological agents in bacterial meningitis are Neisseria meningitidis, Streptococcus pneumoniae and Haemophilus Influenzae.
Neisseria meningitidis (Meningococcus) is a leading cause of bacterial meningitis. Differences in the chemistry of the polysaccharide capsule allow definition of 13 serologically distinct meningococcal capsular groups, of which six, designated A, B, C, W (previously designated W135), X, and Y, are responsible for almost all cases of the disease.

Meningococcal disease is a global problem, but disease rates vary by a factor of 10-100–fold in different geographic locations at one point in time and in the same location at different times.

Meningococcal disease is of major public health importance in Sub-Saharan
Africa as it is responsible for the occurrence of epidemic Meningitis in the ‘African Meningitis belt’ an area which comprise of 26 countries extending from Senegal in the West to Ethiopia in the East with an estimated population of about 500 million.

For more than a century, this region has experienced large serogroup
‘A’ epidemics every 7-10 years, with annual rates as high as 1,000 per 100,000 population. The onset of cases in the sub-Saharan region typically begins during the dry season, possibly related to drying and damage to the nasopharyngeal mucosa, and subsides with the rainy season, and may re-emerge the following dry season.

In Nigeria, the belt covers all 19 northern States including the Federal capital. In the recent past, the belt has widened to include some southern States namely: Oyo, Cross River, Imo, Anambra, Enugu and Ebonyi States.

Epidemics in the meningitis belt were traditionally associated with Neisseria meningitidis serogroup A. However, the development and deployment of serogroup A meningococcal conjugate vaccine (MenAfriVac-A) in several countries within the meningitis belt of West Africa brought hope for the eradication of the disease in this region.

Unfortunately, progress was set back by the outbreak of serogroup C disease during the dry season of 2014–15 in Niger, with more than 8,500 cases and 550 deaths. Since then sequential outbreaks of type C strain occurred in 2013 and 2014 in North-Western Nigeria caused by sequence type (ST)-10217, which had not been previously identified elsewhere. The outbreak of serogroup C disease in two consecutive years from Nigeria suggests emergence of a new strain. Studies have shown that factors such as low socioeconomic status, climatic conditions, immunological susceptibility, migration and behavioral factors are risk factors for epidemic meningococcal disease.

Over view on Lassa fever by WHO
Lassa fever is an acute viral haemorrhagic illness of 2-21 days duration that occurs in West Africa. The Lassa virus is transmitted to humans via contact with food or household items contaminated with rodent urine or faeces.

Person-to-person infections and laboratory transmission can also occur, particularly in hospitals lacking adequate infection prevention and control measures.

Lassa fever is known to be endemic in Benin, Ghana, Guinea, Liberia, Mali, Sierra Leone, and Nigeria, but probably exists in other West African countries as well.

The overall case-fatality rate is one per cent. Observed case-fatality rate among patients hospitalized with severe cases of Lassa fever is 15 per cent. Early supportive care with rehydration and symptomatic treatment improves survival.

Though first described in the 1950s, the virus causing Lassa disease was not identified until 1969. The virus is a single-stranded Ribo Nucleic Acid (RNA)/genetic material virus belonging to the virus family Arenaviridae.

About 80 per cent of people who become infected with Lassa virus have no symptoms. One in five infections result in severe disease, where the virus affects several organs such as the liver, spleen and kidneys.

Lassa fever is a zoonotic disease, meaning that humans become infected from contact with infected animals. The animal reservoir, or host, of Lassa virus is a rodent of the genus Mastomys, commonly known as the “multimammate rat.” Mastomys rats infected with Lassa virus do not become ill, but they can shed the virus in their urine and faeces.

Overview on Yellow fever by WHO
Yellow fever is an acute viral haemorrhagic disease transmitted by infected mosquitoes. The “yellow” in the name refers to the jaundice that affects some patients.

Symptoms of yellow fever include fever, headache, jaundice, muscle pain, nausea, vomiting and fatigue.

A small proportion of patients who contract the virus develop severe symptoms and approximately half of those die within 7 to 10 days.

The virus is endemic in tropical areas of Africa and Central and South America.

Large epidemics of yellow fever occur when infected people introduce the virus into heavily populated areas with high mosquito density and where most people have little or no immunity, due to lack of vaccination. In these conditions, infected mosquitoes of the Aedes aegypti specie transmit the virus from person to person.

An extremely effective vaccine prevents yellow fever, which is safe and affordable. A single dose of yellow fever vaccine is sufficient to confer sustained immunity and life-long protection against yellow fever disease. A booster dose of the vaccine is not needed. The vaccine provides effective immunity within 10 days for 80-100 per cent of people vaccinated, and within 30 days for more than 99 per cent of people vaccinated.

Good supportive treatment in hospitals improves survival rates. There is currently no specific anti-viral drug for yellow fever.

Overview on monkeypox by WHO
Monkeypox is a rare viral zoonotic disease that occurs primarily in remote parts of central and West Africa, near tropical rainforests.

The monkeypox virus is similar to human smallpox, a disease that has been eradicated in 1980. Although monkeypox is much milder than smallpox, it can be fatal.

The monkeypox virus is mostly transmitted to people from various wild animals such as rodents and primates, but has limited secondary spread through human-to-human transmission.

Typically, case fatality in monkeypox outbreaks has been between one per cent and 10 per cent, with most deaths occurring in younger age groups.

There is no specific treatment or vaccine available although prior smallpox vaccination was highly effective in preventing monkeypox as well.

Monkeypox is a member of the Orthopoxvirus genus in the family Poxviridae.

Monkeypox is a rare viral zoonosis (a virus transmitted to humans from animals) with symptoms similar to those seen in the past in smallpox patients, although it is clinically less severe. With the eradication of smallpox in 1980 and subsequent cessation of smallpox vaccination, it has emerged as the most important orthopoxvirus. Monkeypox occurs sporadically in central and western parts of Africa’s tropical rainforest.

Human monkeypox was first identified in humans in 1970 in the Democratic Republic of Congo (then known as Zaire) in a nine -year -old boy in a region where smallpox had been eliminated in 1968. Since then, the majority of cases have been reported in rural, rainforest regions of the Congo Basin and western Africa, particularly in the Democratic Republic of Congo, where it is considered to be endemic. In 1996–97, a major outbreak occurred in the Democratic Republic of Congo.

Infection of index cases results from direct contact with the blood, bodily fluids, or cutaneous or mucosal lesions of infected animals. In Africa human infections have been documented through the handling of infected monkeys, Gambian giant rats and squirrels, with rodents being the most likely reservoir of the virus. Eating inadequately cooked meat of infected animals is a possible risk factor.

Secondary, or human-to-human, transmission can result from close contact with infected respiratory tract secretions; skin lesions of an infected person or objects recently contaminated by patient fluids or lesion materials. Transmission occurs primarily via droplet respiratory particles usually requiring prolonged face-to-face contact, which puts household members of active cases at greater risk of infection. Transmission can also occur by inoculation or via the placenta (congenital monkeypox). There is no evidence, to date, that person-to-person transmission alone can sustain monkeypox infections in the human population.

In recent animal studies of the prairie dog-human monkeypox model, two distinct clades of the virus were identified – the Congo Basin and the West African clades – with the former found to be more virulent.

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