In a deeply concerning development, the World Health Organization (WHO) has officially confirmed a severe resurgence of diphtheria in Nigeria, marking a harrowing second wave of the outbreak. The situation demands unwavering attention due to its potential impact on public health in the region.
Since the epidemiological week 26, concluding on July 2, 2023, Nigeria has been grappling with a disconcerting upsurge in diphtheria cases across numerous states. The data is staggering, with a distressing total of 5,898 suspected cases reported between June 30 and August 31, 2023. These cases span 59 Local Government Areas (LGAs) in 11 states. A deep dive into week 34, which concluded on August 27, 2023, reveals a concerning tally of 234 suspected cases, emerging from 20 LGAs across five states. Within this grim statistic, one case has been confirmed through laboratory testing, while 18 cases have been epidemiologically linked, and 141 are classified as clinically compatible.
Diphtheria, a highly contagious disease primarily caused by the bacterium Corynebacterium diphtheriae, is notorious for its potential fatality, particularly among young children. The mortality rate typically ranges between 5-10%, making it a substantial public health threat.
WHO's most recent risk assessment has upheld the gravity of the situation, categorizing the risk as high at the national level while maintaining a low-risk classification regionally and globally. As a response to this alarming outbreak, a concerted effort is underway, spearheaded by the Nigeria Centre for Disease Control (NCDC) in collaboration with the WHO and other key partners.
Nigeria's encounter with diphtheria began in 2022, but the dimensions of this second wave are unparalleled. Shockingly, out of a total of 8,353 suspected cases reported since the initial outbreak, 56.5% have been confirmed. Equally concerning is the revelation that 22.2% of cases were discarded as not compatible with diphtheria, while 12.5% await classification, and 8.8% remain undiagnosed. Despite a slight drop in the case fatality ratio from 6.7% to 6.1%, the gravity of the situation cannot be overstated.
What is particularly distressing is that 73.5% of the confirmed cases are among the vulnerable age group of 1-14 years. Disturbingly, among these cases, 22.8% had received full vaccination against diphtheria, a stark reminder of the challenges in achieving comprehensive vaccination coverage. Over half of the confirmed cases, totaling 59.4%, were unvaccinated, heightening concerns about the level of vulnerability in the population.
Laboratory investigations have identified the culprits behind this outbreak as Corynebacterium diphtheriae and Corynebacterium ulcerans, both displaying resistance to penicillin, and in many cases, to trimethoprim-sulfathiazole and ciprofloxacin. Erythromycin has emerged as the drug of choice for managing this outbreak.
Diphtheria Patient (PHOTO CREDIT: The Guardian Nigeria)
Epidemiology of Diphtheria
Diphtheria is a highly contagious bacterial disease primarily caused by Corynebacterium diphtheriae. Its contagion through direct contact or respiratory droplets makes it especially worrisome. The disease can affect individuals of all age groups, with unvaccinated children being the most vulnerable.
Symptoms typically commence with a sore throat and fever, but in severe cases, the bacteria produce a toxin that results in the formation of a thick grey or white patch in the throat. This can obstruct airways, leading to breathing and swallowing difficulties, often accompanied by a characteristic barking cough. Swelling of the neck may occur due to enlarged lymph nodes. Diphtheria can also affect other organs, leading to potentially life-threatening complications.
Understanding the Challenge
Diphtheria, a potentially fatal infectious disease caused by the bacterium Corynebacterium diphtheriae, has reemerged as a pressing public health concern in Nigeria. The recent data from the World Health Organization (WHO) sheds light on the resurgence of this highly contagious disease and its implications for healthcare and the population at large.
The Data: A Sobering Picture
Epidemiological data reveals a disturbing trend in the prevalence of diphtheria in Nigeria. Since epidemiological week 26, ending on 2 July 2023, there has been a significant uptick in diphtheria cases across multiple states. In the period spanning 30 June to 31 August 2023, a staggering total of 5898 suspected cases were reported from 59 Local Government Areas (LGAs) in 11 states. This surge in cases is concerning as diphtheria is a vaccine-preventable disease, and its resurgence underscores challenges in immunization coverage.
Week 34, ending on 27 August 2023, saw 234 suspected cases reported from 20 LGAs in five states, with one laboratory-confirmed case among the 22 samples collected. Eighteen of these cases were epidemiologically linked, while 141 were classified as clinically compatible. This data paints a dire picture of a rapidly evolving outbreak.
Response to the Diphtheria Crisis
In the face of Nigeria's alarming diphtheria outbreak, a unified and resolute response has been launched to curtail the spread of this highly contagious disease. Led by the Nigeria Centre for Disease Control (NCDC) in collaboration with the World Health Organization (WHO) and other critical partners, this multifaceted response is a beacon of hope amid challenging times.
- Coordination: The first pillar of this response effort is the reinforcement of coordination mechanisms. The WHO Country Office Incident Management System has been revamped to streamline efforts and ensure a harmonized response. Simultaneously, National Emergency Operation Centres have been activated, creating a well-coordinated command structure at both national and state levels. In high-burden states like Kaduna, Katsina, and Borno, state Emergency Operation Centres have been initiated to bolster localized response efforts.
- Surveillance: Vigilant surveillance is the linchpin of early detection and effective response. A critical component of this effort involves the development of terms of reference for surveillance teams, ensuring consistency and uniformity in reporting. Close follow-ups with states to submit weekly situation reports and line-lists are underway. WHO and partner organizations are supporting the NCDC in developing robust contact tracking and harmonized line-list forms, facilitating data collection and analysis. Additionally, a comprehensive database for states reporting on response activities and a dedicated dashboard for monitoring and evaluation are in development, enhancing real-time situational awareness.
- Laboratory: In the battle against diphtheria, swift and accurate diagnosis is essential. As part of the response strategy, procurement of vital laboratory supplies is ongoing, ensuring an uninterrupted supply chain for essential diagnostic tests. The activation of laboratory facilities at the state level, such as the Kano lab, further strengthens the country's diagnostic capacity. Transportation of samples to these facilities is being prioritized, facilitating rapid testing and confirmation of cases.
- Vaccination: A pivotal component of the response plan is a reactive vaccination campaign, targeting high-burden areas. These campaigns are conducted in phases, with the initial phases focused on states with the highest reported cases, such as Kano, Katsina, Bauchi, Yobe, and Kaduna. These efforts aim to rapidly boost immunity in affected populations and contain the outbreak's further spread. Ensuring equitable access to vaccination remains a top priority.
- Risk Communication and Community Engagement: Engaging communities and fostering awareness are essential elements of crisis response. Community leaders play a crucial role in disseminating accurate information and combating misinformation. The response teams are actively engaged in community awareness initiatives, including the development of Information Education and Communication materials. A rigorous monitoring system for rumors and the airing of informative jingles are vital components of this engagement strategy.
- Case Management: Robust case management guidelines have been developed to ensure standardized and effective treatment for confirmed diphtheria cases. As part of this response, Ear, Nose, and Throat (ENT) specialists have been deployed to treatment centers. These specialists are equipped to handle severe cases, offering the best chance of recovery for affected individuals.
- Infection Prevention Control: Maintaining the highest standards of infection prevention control (IPC) is crucial to prevent further transmission within healthcare settings. Rigorous monitoring of treatment centers for adherence to IPC measures is ongoing, ensuring the safety of both patients and healthcare workers.
- Operation Support and Logistics: Procurement of essential medical supplies is a cornerstone of the response. Initiatives are in place to secure critical resources, including the acquisition of 10,050 vials of diphtheria antitoxin and 15,000 vials of erythromycin. A well-prepared delivery plan for Personal Protective Equipment (PPE) to priority states ensures that frontline healthcare workers are adequately protected.
- Preventing and Responding to Sexual Exploitation, Abuse, and Harassment (PRSEAH): Amid the crisis, measures to prevent and respond to sexual exploitation, abuse, and harassment are implemented. Risk assessments are conducted, and preventative actions are in place to safeguard vulnerable populations.
- Staff Health Security and Wellbeing: Healthcare workers on the frontlines are essential assets in this battle. Ensuring their security and wellbeing is paramount. General security briefings, reporting templates, and a Frequently Asked Questions (FAQ) resource specific to diphtheria are all part of the comprehensive support provided to healthcare workers.
As Nigeria confronts this dire diphtheria outbreak, the collective response is a testament to the nation's resilience and determination. With a well-coordinated effort spanning surveillance, laboratory diagnostics, vaccination campaigns, community engagement, and comprehensive case management, Nigeria and its partners stand together to protect the health of its citizens and curb the spread of this menacing disease. The international community's support remains pivotal in this challenging endeavor.
