It is the raining season in Nigeria, and with the season has come the public health challenge of epidemics. In the last one and a half years, more than 1, 500 Nigerians have died from outbreaks of diseases, most of which are vaccine preventable.
Some of the diseases are caused by nature. But many are caused by human activities in relation with the environment. Some of these are of Lassa fever, Meningitis, Monkey pox, Cholera, Yellow Fever, Measles and Hepatitis A.
The epidemics pose a huge challenge for Nigeria’s health delivery system, evident in the high number of deaths, including of health workers.
Five recent outbreaks involving Lassa fever, Meningitis, Monkey pox, Yellow fever and Cholera have exposed Nigeria’s low level of preparedness for tackling epidemics.
In this piece, PREMIUM TIMES examines the lessons learnt from the outbreaks.
Though the latest report from the Nigeria Centre for Disease Control (NCDC) indicates the Lassa fever outbreak is thinning out, the government is yet to declare the epidemic over.
This year’s outbreak recorded the highest casualty and contact tracing surveillance in the country since 1969.
According to situation data from NCDC, 1849 suspected cases were reported from January to April 15 in 21 states. 413 of the cases were confirmed and114 deaths recorded.
The affected states are Edo, Ondo and Ebonyi, which are the three states with the highest recorded cases. The others are Abia, Adamawa, Bauchi, Benue, Delta, Ebonyi, Edo, Ekiti, FCT, Gombe, Imo, Kaduna, Kogi, Nasarawa, Ondo, Osun, Plateau, Rivers and Taraba.
Lassa fever is curable if detected early, but it is not vaccine preventable. It is a seasonal disease and has been persistent in Nigeria over the last 30 years. The disease is caused by rats and can be transmitted through body fluid and human contacts.
Unfortunately, health workers have also been succumbing to the disease. This year, 27 health workers in seven states (Abia, Benue, Ebonyi, Edo, Kogi, Nasarawa and Ondo) were affected, eight of whom died.
According to the World Health Organisation assessment risk, the infection of 27 healthcare workers highlights the crucial need to strengthen infection prevention and control practices in all health care setting for all patients, regardless of their presumed diagnosis.
There are three Lassa fever case management centres in the country, located in Ebonyi, Ondo and Edo states.
Meningitis (Cerebrospinal meningitis ‘CSM’)
CSM is another major public health problem in Nigeria. The outbreak is synonymous with the dry season.
The disease, irrespective of the strain, is vaccine preventable. In spite this, Nigeria last year recorded one of its biggest outbreaks of CSM strain C, with 1,116 people killed before the authorities declared the outbreak over.
CSM strain A and occasionally strain C affect tropical countries, particularly in sub-Saharan Africa. Nigeria has been vaccinating people with strain A vaccine, but it was not prepared for strain C, claiming it is a rare type. Thus, as at the time of the outbreak, there was no strain C vaccine in the country. The authorities had to scramble to acquire the vaccines to contain the disease in states highest hit. As it is, most Nigerians are yet to be vaccinated against this strain.
The 2017 outbreak lasted seven months (December to June) during which 14,513 suspected cases were reported in 25 states. Zamfara, Sokoto and Katsina accounted for nearly 89 percent of the cases. Children between five and 14 years accounted for 6,791 cases.
The Minister of Health, Isaac Adewole, blamed the late detection, and poor CSF collection and case management as reasons for the high causality in last year’s outbreak.
A mass reactive vaccination campaign was later conducted in Zamfara, Sokoto, Yobe and Katsina states where about two million people were vaccinated. The effect of the campaign has been felt this year as there have been less cases reported across the country, especially in states with the highest cases last year.
Last year’s outbreak raised an emergency alarm in the of health care delivery sector in states like Zamfara, which has less than 40 doctors working in the state.
The monkey pox outbreak caught Nigerians by surprise because most people had no knowledge of the disease.
The first confirmed case was in August 2017 in Ebonyi State after the last reported case of the disease in 1978. The cases clustered mostly in South-south states of Bayelsa, Rivers and Cross River. Since 2017, about 89 people have been infected, with six deaths.
Scientists are however still unsure what is behind the rise in the number of cases. Though the outbreak has thinned out, it is far from over. NCDC still receives reports of suspected cases from across the country.
Monkey pox is not vaccine preventable. But it can be prevented by avoiding eating wild animals such as monkeys, squirrels and rodents, among others because animals are the reservoir of the disease.
At the outset of the outbreak, Nigeria had problems diagnosing the disease as samples had to be sent to the WHO laboratory in Dakar, Senegal for confirmation. This stalled treatment of patients as result took about 10 days.
The government has since built a rapid diagnostic capacity, but much still needs to be done in terms early diagnosis of the disease in the country.
Nigeria has been witnessing persistent outbreaks of cholera over the past decades.
This disease is highly infectious. It leads to dehydration and can kill within hours if left untreated. People with low immunity such as malnourished children or people living with HIV are at a greater risk of death if infected.
The symptoms of cholera include diarrhoea, nausea and vomiting and severe dehydration. Diarrhoea due to cholera often has a pale, milky appearance that resembles water in which rice has been rinsed, also known as rice-water stool.
Cholera is associated with water and hygiene and as such can be effectively prevented through good water, sanitation and hygiene. With the arrival of the raining season, Nigeria may record more cholera outbreak. This is due to the poor level of sanitation, open defecation, lack of clean water and ineffective waste disposal.
The disease is most common in places with poor sanitation, urbanization, conflict zones and famine. Effective ways to protect yourself is using water that has been boiled, chemically treated, or bottled water.
There were pockets of outbreaks across the country, but they were prevalent in four states, Kwara, Lagos, Kano and Borno, requiring intervention by the federal government and international partners.
Though the disease is vaccine preventable, it is more cost effective for government to provide amenities such as good water source and public toilets among others that will enhance good and healthy living for the citizens.
For a lasting solution, there is a need for a major intervention in Water, Sanitation and Hygiene (WASH).
In spite of government’s introduction of yellow fever vaccine as part of the routine immunisation since 2014, Nigeria last year recorded an outbreak of the disease. The outbreak caught the country by surprise as the last reported case was 1996.
The first case was confirmed in September 2017 in a seven-year old female in Ifelodun Local Government Area of Kwara state.
Between that time and March 2018, 1,640 suspected cases were recorded and 115 confirmed.
Yellow fever is a mosquito transmitted disease and is vaccine preventable. One shot of the vaccine has the capacity of lifelong prevention from the disease.
According to the Minister of Health, Nigeria took yellow fever for granted and this caused the recent outbreak in many states of the country.
He blamed negligence and persistent poor immunisation coverage for the outbreak.
He lamented that Nigeria went wrong in the campaign against the disease because prior to the recent outbreak in 2017, the last case recorded was in 1996 and this made everyone relax and go to sleep thinking it was over.
“We need to continue preventive vaccination. There is a need for regular immunisation in order to protect our people. For us to be effective, we need to immunise practically everybody and that is a huge challenge for Nigeria,” he said.
Mr Adewole said the government, in collaboration with WHO and GAVI, is planning a large campaign to immunise over 1.3 million people in the affected areas.
He said reactive and preventive vaccination had been taken to six states. These are Kwara, Kogi, Zamfara, Niger, Sokoto and Borno. According to the minister, over 14 million children had been immunised, adding, however, that the target is to immunise 25 million children before the end of 2018.
Challenge of public health in Nigeria
Inadequate laboratory facilities for early diagnosis of diseases is one of the reasons why diseases are not quickly detected and contained in the country.
During a visit by WHO DG to Nigeria, the health minister appealed to him to set up a reference laboratory in the country to assist in early diagnosis of diseases.
He recalled that suspected samples of money pox and yellow fever had to be flown to WHO laboratory in Dakar, Senegal. This he said delayed treatment and quick intervention.
A public health expert, Tolu Fakeye, however, blamed low disease surveillance rate and public responses across states for the high death rate.
Mr. Fakeye, who is the President of Society of Public Health Professionals of Nigeria in the Federal Capital Territory, said the increasing cases of infectious diseases in the country is a result of lack of proper advocacy and knowledge of diseases and prevention among Nigerians.
He said most of the diseases ravaging the country are not new and are well known within its health system.
“Unfortunately, the most important and fundamental measures needed to prevent epidemic is in the scope of the environment and most Nigerians are not adhering to it. A cleaner environment, better housing, safe water supply, and these are not issues of rocket science.
“These issues are largely outside the direct jurisdiction and influence of health professionals or health sector. We will be talking about the environment now we have a ministry of environment. We will be talking about safe water supply, better housing with good ventilation, all those are outside direct influence and control of the health professionals and even the health authorities,” he said.
Mr. Fakeye called for an effective collaboration between the health sector and those other sectors (environment, housing, water and education).
He lamented that Nigeria is yet to put a disease surveillance unit together since the 1996 disease epidemics, which was simultaneous episode of three disease epidemics of CSM, cholera and yellow fever.
“What used to happen at that time is that even when there are epidemics in one state and spreading to another state, the state would not even know that there is an epidemic in their states.
“Much has not changed because it is the federal government that alerts most sates when there is an epidemic going on in their states. This is unacceptable for disease control. Every state should have the capacity to tackle surveillance because the strength of disease prevention is surveillance,” he said.
He said states should know what to do to prevent epidemics and at the slightest of occurrence before transmission goes haywire. He said NCDC has been doing capacity training but there are still many weaknesses.
“Preparedness means having everything needed for prevention ready: the surveillance system, the laboratory, the network, reference laboratory, they most have all the reagents, staffing and the staffing go through constant capacity building of upgrading and refreshing their knowledge from time to time because diseases keeps playing tricks.
“It can be a particular strain today and the next epidemic another strain. Capacity building must be a continuous exercise,” he said.