Nigeria prepared to prevent, contain next pandemic, NCDC boss says

• Explains why Lassa fever persists in Nigeria
• Says Kano, Yobe, Katsina, FCT, Lagos, Sokoto, Zamfara account for 98 per cent of suspected cases of diphtheria
• Blames low immunisation as major cause of recent diphtheria outbreaks in Nigeria
Dr. Ifedayo Morayo Adetifa, a consultant paediatrician and infectious diseases epidemiologist, is the Chief Executive Officer (CEO) and Director General of the Nigeria Centre for Disease Control (NCDC). Adetifa in this interview with CHUKWUMA MUANYA explains how the country is preparing for the next pandemic, tackling diphtheria, Lassa fever, COVID-19, meningitis and other infectious diseases. 

How prepared is Nigeria for the next pandemic compared to pre-COVID-19?
We have achieved great progress, which has set us ahead of our pre-pandemic reality. We have achieved gains in a lot of areas. Before the pandemic, we only had three laboratories with diagnostic capacity for COVID-19 in the country, but now, we have about 200 laboratories (public and private) within our network that can be activated in the event of an emergency. We are also currently developing regional laboratories through the REDISSE project to decentralise the reference laboratory system; we commissioned the zonal laboratory for the South-West region earlier in the year and we intend to commission more before the end of the year. We also have a digitalised surveillance network through Surveillance Outbreak Response    Management and Analysis System (SORMAS), SitAware and other tools in all local governments that help accelerate reporting. For instance, there can be a suspected case in any local government and within minutes of inputting the data, our surveillance team can be alerted, and the necessary investigation can be undergone.    Nigeria also has an adequately trained workforce to respond in case of public health events. Through the Regional Disease Surveillance Systems Enhancement (REDISSE) project, we recently trained all the disease notification officers (DNOs) in all the states in Nigeria.
   
In building a strong frontline of public health workers at subnational level, we have trained Surveillance Officers through Integrated Training of Surveillance Officers in Nigeria (ITSON). Through the Intermediate Field Epidemiology Training Programme, workforce-training capacity continues to be strengthened. Additionally, through training of healthcare workers during the pandemic, we have improved infection prevention and control capacity. We now have more public health emergency operations centres (PHEOCs) enabling coordination of response to public health threats. From 29 nationwide pre-pandemic, we now have in 35 states and FCT. 

How far with diphtheria outbreaks nationwide?  What caused the outbreak?
As at epidemiological week 27, 2023, Kano, Yobe, Katsina, Federal Capital Territory (FCT) Abuja, Lagos, Sokoto, and Zamfara account for 98 per cent of suspected cases. There have been 2,693 suspected cases, 962 confirmed cases and 85 deaths (case fatality ratio/CFR: 9 per cent) in 40 Local Government Areas (LGAs) of 10 states since the onset of the outbreak in December 2022. Historical sub-optimal vaccination coverage is the main driver of the outbreak given the most affected age group (two-14-year-olds) observed, and a national survey of diphtheria immunity that found less than half (41.7 per cent) of children under 15 years old are fully protected from diphtheria.
  
We have made Diphtheria Antitoxin (DAT) available for the first time in the history of outbreaks in Nigeria and will soon receive supplies of parenteral erythromycin to aid case management. We urge the public to remain vigilant and ensure persons with symptoms of diphtheria present early to health facilities for prompt diagnosis and treatment.  Early diagnosis and institution of effective treatment are key predictors of a favourable outcome. Healthcare workers are urged to immediately notify Local Government Area (LGA) disease surveillance officers once they see a suspected case. Parents and guardians are encouraged to ensure that their children are vaccinated against diphtheria with the three doses of diphtheria antitoxin-containing pentavalent vaccine. 

Lassa fever cases and deaths have persisted in the country, why? 
Lassa fever is endemic in Nigeria, meaning it is recurrent in an area or community. Despite this and the number of cases, and deaths, this represents the unfortunate loss of a parent, friend or relative. Consequently, the death of a clinician is a loss not only of a family member but also loss of years of experience and clinical expertise. The persistent recording of Lassa fever in Nigeria is a result of multiple reasons, some of which include climate change, environmental and socio-behavioural drivers.  The primary hosts of the virus are multimammate rats that naturally inhabit our forests and play a key role in the ecosystem. Culturally, these rats also serve as food for people living in many of our communities. 

Finally, we also engage in practices like bush burning that also drive animals out of their habitats to our homes where they consume our raw materials that are not covered, and our food dried outside, which increases the chances of those food items being contaminated by infected rodents through their excreta and urine translating to increased risk of Lassa fever infection. Lassa fever cases have steadily increased over the years; however, fatality has dropped from almost 100 per cent in the early 2000s to 17 per cent now. This has been a result of improvement in diagnostic capacity, overall clinical expertise at our case management site, particularly Irrua and Owo, heightened risk communication and community engagement, development of protocols and   guidelines for case management, infection prevention and control (IPC) to list a few. 

How far with the vaccine for Lassa fever? There are ongoing clinical trials in neighbouring countries. Why is Nigeria not part of it?
Nigeria is currently in the process of completing the Nigeria Lassa Epidemiology (NiLE) study funded by the Coalition for Epidemic Preparedness Innovations (CEPI) through the Enable programme. The study involves the assessment of the disease in Nigeria to aid feasibility of future clinical trials for vaccines. We also recently had a meeting with partners from World Health Organisation (WHO), CEPI and other national stakeholders like the Federal Ministry of Health (FMoH), National Agency for Food and Drug Administration and Control (NAFDAC) on clinical trials and vaccine licensure in Nigeria. Progress continues to be made towards potential Lassa fever use and there is an upcoming WHO Lassa fever Roadmap meeting, which will further discuss this.

Any update on COVID-19 in Nigeria? Is the country still recording fresh cases and deaths? 
As we said in our statement following the announcement by the WHO that COVID-19 is no longer a public health emergency of international concern, we have already deescalated our response in December 2022 in response to local epidemiology, focused on encouraging COVID-19 vaccination and recommended discretionary use of face masks and other public health safety measures according to personal risk assessments. COVID-19 is still here with us.  However, we have a wealth of knowledge on the virus and how to manage it, as well as evidence that   shows a population-level immunity to the virus due to vaccine uptake in the country.
  
As part of its integrated disease surveillance strategy, the NCDC continues to encourage routine COVID-19 testing along with other infectious diseases as may be indicated in healthcare settings, which is part of clinical care for pandemic and influenza preparedness. These were done as part of bi-directional testing during investigations for Human Immuno-deficiency Virus (HIV)/Acquired Immune Deficiency Syndrome (AIDS), tuberculosis and malaria, and in high-risk populations.  Working with partners, the NCDC is also piloting pan-respiratory virus surveillance, which is aligned with the WHO’s recently declared preparedness and resilience for emerging threats (PRET) initiative.  
  
As part of our genomic surveillance, we will introduce wastewater/environmental surveillance to track Severe Acute Respiratory Syndrome Coronavirus type 2 (SARS-CoV-2) cholera, and typhoid (Salmonella).  Finally, we continue to work on consolidating COVID-19 pandemic laboratory investments into a cohesive tiered national network of public health laboratories as prescribed in the NCDC Act (2018).

How about Long-COVID?  Is it an issue in Nigeria?
The NCDC does not have data on this because this is managed by outpatient clinics and hospitals. Those with symptoms indicative of long COVID-19 are encouraged to report to their preferred healthcare provider. 

Dengue fever and other mosquito-borne diseases are becoming more virulent because of climate change. What is the situation in Nigeria?
The NCDC does not actively monitor the virus for virulence. While climate change has been noted to be responsible for increasing mosquito density, our monitoring has not highlighted an increase in virulence due to this. We remain focused on fulfilling our mandate in disease prevention and control by VHF preparedness and response. 

Meningitis used to be a yearly problem in Nigeria.  It seems we have not had any outbreaks this year. What happened?
Meningitis occurs primarily during the dry season. If you may recall earlier in the year, our situation report showed an outbreak of meningitis in Jigsaw as a result of the cross-border outbreak in Niger. As we always do when there is an outbreak in a state, we sent a rapid response team to Jigsaw to support the state team in conducting active case search of people with meningitis, and advocacy to stakeholders to improve timely reporting  of cases and risk    communication activities. 
 
 Similar to diphtheria, meningitis is a vaccine-preventable disease; we continue to work with our sister agency, the National Primary Health Care Development Agency (NPHCDA) as well as other partners to ensure nobody is left behind in the fight against meningitis.