Improving Nigeria’s preparedness to tackle, prevent infectious diseases threat
Human existence is under threat with the recent epidemics of Lassa fever, Cerebro Spinal Meningitis (CSM), Yellow fever, Monkey pox, cholera, and Ebola Virus Disease (EVD) as well as the unknown Pathogen X.
The epidemics, combined, since the 2014 Ebola outbreak in Nigeria, have killed several thousands and maimed hundreds of thousands.
In fact, the repeated outbreaks of zoonotic infectious diseases with epidemic potential in Central and West Africa, such as Ebola, Rift valley fever, Chikungunya and Dengue, continue to pose major public health threats to regional, continental and global health security.
Nigeria, on July 20, marked five years after the arrival of Ebola in Lagos while the World Health Organisation (WHO), on August 1, observed one year since the Government of the DRC declared an outbreak of the Ebola virus disease in North Kivu province of the DRC. A month ago, it was declared as a Public Health Emergency of International Concern (PHEIC).
The latest cases in such a dense population in DRC underscored the very real risk of further disease transmission; perhaps beyond the country’s borders, and the very urgent need for a strengthened global response and increased donor investment.
According to the WHO, the ongoing outbreak of the virus, centred in the North Kivu and Ituri provinces of the DRC, is already the second worst recorded in history. Only the epidemic of 2014-16, which killed at least 11,000 people across the world after it decimated West Africa, has claimed more lives.
Why Nigerians should be worried: Ethiopians Airlines, which has direct flights from DRC, has four destinations in Nigeria. In July, someone came on Ethiopian Airline with a very high fever and suspected Ebola case. The person was quickly isolated and tested for Ebola and other haemorrhagic fevers. The person, however, tested negative to Ebola.
The WHO has warned that all countries especially in Africa should raise their disease surveillance and monitoring especially at the borders; and investigations and several reports have shown that most of the nation’s borders are porous.
Ebola is highly contagious and spreads through the blood or other bodily fluids of patients, or contaminated surfaces.
In Nigeria, in 2014, 20 cases and eight Ebola deaths were confirmed, along with the imported case, who also died. Four of the dead were health care workers who had cared for the index case.
Official figures show half of the Ebola outbreak’s fatalities having occurred since April, with two-thirds of cases leading to death
Virologists have repeatedly warned the current outbreak has the potential to be the worst ever seen, amid claims armed militia are hampering responses.
Also, viral infections like Lassa fever, Yellow fever and Monkey pox that used to be seasonal are now perennial.
Several studies have shown that such diseases that have animal hosts-rodents as carriers and reservoirs like Lassa fever and Monkey Pox are very hard to eliminate without vaccines. It has also been shown that diseases that have been eradicated or almost eradicated such as smallpox and polio were only possible because of effective vaccines. There is currently no WHO approved vaccines for Lassa fever, Monkey pox and Ebola.
Is Nigeria prepared for another EVD epidemic or/and outbreak of deadly diseases? The Guardian investigates with responses from renowned virologist, epidemiologists, consultant public health physicians and medical laboratory scientists.
The experts include: the immediate past Minister of Health, Prof. Isaac Adewole; a foremost virologist and consultant to the WHO, Prof. Oyewale Tomori; immediate past Commissioner for Health in Lagos State, Dr. Jide Idris; a consultant public health physician, epidemiologist and former Chief Medical Director of the Lagos University Teaching Hospital (LUTH), Prof. Akin Osibogun; President, Pharmaceutical Society of Nigeria (PSN), Sam Ohuabunwa; the Director General (DG)/ Chief Executive Officer (CEO), NCDC, Dr. Chikwe Ihekweazu.Others include: Senior Laboratory Technical Adviser at the National Reference Laboratory (NRL), Anthony Ahumibe; Chief Molecular Bioengineer at the NRL, Dr. Nnaemeka Ndondo; Bio-Lead at NRL, Ndidi Agala; Principal Scientific Officer, Data Mining at NCDC, Yashe R. Usman; and Operations Assistant, Emergency Operations Centre (EOC) at NCDC, Anwal Abubakar.
Assessment of preparedness
Tomori said Nigeria has assessed her ability to find, stop and prevent health threats and identified significant gaps. He said in the self-assessment done under Joint Evaluation Exercise (JEE) Nigeria had the following scores: finding and verifying outbreaks (51 per cent); stopping outbreaks (31 per cent); preventing outbreaks (39 per cent); and protecting from other health threats (37 per cent), giving the country an over all score of 39 per cent. This, he said, was interpreted to mean the country was not ready to find, stop and prevent epidemics.
Ihekweazu said the 2017 JEE were carried out to establish International Health Regulations Core Capacities of the Federal Republic of Nigeria. According to him, this is an evaluation where you bring in your peers from different countries to go through with you around all your areas preparedness and there are 19 areas from legislation to coordination, Antimicrobial Resistance (AMR), zoonotic diseases, surveillance among others.
Of all these, the epidemiologist said Nigeria’s average score was 39 per cent. “The good thing is that this happened nearly two and half years ago now. Since then we have been improving on our scores. So this is basically what our baseline was two and half years ago. If we were to redo this evaluation again we will be a lot better placed,” he said.
Ihekweazu said by the end of 2019 the NCDC is going to do a mid-term evaluation of this. “But I think this is actually a demonstration of our openness in terms of our willingness to better understand what are deficits are and then identify those specific areas that require improvements. So if you look at things like our laboratory systems where we scored fairly low at the time, if we were to do this today we will come out with much better scores,” he explained.
Isolation and treatment facilities
It is feared that Lagos has not improved on the containment facilities at the Infectious Disease Hospital (IDH) Yaba that were used in 2014. Why?
Idris said the statement is not correct but he admitted that they could do better in renovation of some wards, also on going development master plan available, establishment of a biosafety level three laboratory, and ongoing training.
Ihekweazu said establishment of comprehensive containment facilities is a longer-term plan but right now they are working with hospitals across the country to improve facilities to manage infectious diseases.
He explained: “Our plan is to have a treatment and isolation facility in every state capital. There are some locations where we already have fairly complex infrastructure in Abakiliki, Ebonyi State; in Owo, Ondo State; and in Irrua, Edo State. This is related to their management of cases of Lassa fever. Now there are two critical locations we are focusing on that are in Lagos and Abuja where we want to build state-of-the-art centres.
“We started the construction of one in University of Abuja Teaching Hospital in Gwagalada. We just completed the foundation phase. It will be a state-of-the-art treatment centre in Nigeria while we continue to support states to put on centres. I hope in the next few months to invite you to the opening of this state-of-the-art treatment and isolation centre at the heart of the nation’s capital.”
Financial implications for epidemic emergency preparedness
In 2017, Nigeria was not be able to get enough vaccines to prevent the spread and fatality of a Cerebro Spinal Meningitis (CSM) type C. Nigeria urgently needed 1.3 million doses of vaccines for meningitis type C strain but took delivery of only 500,000 doses.
Another constraint to the vaccines availability was the cost of the vaccines, which was $50 per dose. So Nigeria needed N396 billion to vaccinate the recommended 22 million people aged between one and 29-years-old.
Even during the last Ebola outbreak in Nigeria, the country needed emergency support by international organisations and the organised private sector in Nigeria led by Dangote Foundation. On August 14, 2014 the Nigerian government said Aliko Dangote have donated $1 million to halt the spread of the Ebola virus outbreak.
But there seems to be improvement now as the NCDC now receiving 2.5 per cent of the Basic Health Care Provision Fund (BHCPF) and the Federal Government has released about N27 billion so far for the BHCPF.
Also, the NCDC, in 2018, budgeted approximately N1.5 billion on epidemic preparedness and response activities and in addition to this, development partners provided, in addition, support worth approximately N10 billion.
To address the frequent shortage of funds during epidemics, the Federal Government in November 2018 inaugurated the National Action Plan for Health Security (NAPHS). The estimated cost of Nigeria’s NAPHS is N134 billion over five years – that is N27 billion per year. This is about 0.3 per cent of the 2018 federal budget.
The Guardian investigation revealed that the country does not have any comprehensive containment facility for highly infectious disease like Ebola. It gathered that the IDH in Yaba, Lagos that was used as an isolation centre during the 2014 outbreak has not received any major renovation and expansion. Also, the national isolation and containment centre in Abuja is still under construction.
Ihekweazu said: “We have many gaps. In every area we have gaps. The work we do if is very complex. A lot of the requirements either from the laboratory side the reagents many of them are not available here. The training costs are enormous. The gaps in the animal side are even worse; you can go any abattoir in Nigeria and see how the conditions are. There are huge gaps but I think now we have a plan, we have a framework to address these gaps. The plan was articulated and we all know what we need to do in terms of preparedness across the country.”
On concerns of getting help from foreign countries to build Nigeria’s health security, Ihekweazu said: “I think it is an important question but most of our funding is not coming from The United States (US) and others. We have over 200 staff here and government funds them all; we are in government buildings and our core funding still comes from government.
“But you see health security is one of those things that everybody agrees globally that nobody can solve the problems on their own. So we need each other. So there is a level of interdependence that you have to have and trust. I think the critical thing for us is to build our own capabilities so that we can actually sit on the table and something to negotiate with. It is not an area you will say, ‘I will just develop myself and leave others’. We are interdependent on each other for those resources.”
On sending samples to laboratories in Senegal and United Kingdom (UK) for diagnoses and confirmation, Ihekweazu said that has almost changed completely. “For polio we do all the diagnoses, for yellow fever all the diagnoses are done here. We are now in process of establishing ourselves as a reference lab. We still send a few samples to Senegal as a quality assurance process for WHO. But from our testing here we can confidently do the diagnosis of most of our epidemic borne diseases,” he said.
How about Ebola? Ihekweazu said: “Yes! We can test and confirm Ebola within 24 hours in Abuja and we also have partners in Lagos and Redeemers University that can do that independently. But we have a process here, we have done simulation, we have tested the process just to assure ourselves that the capabilities are ready to be activated at anytime,” he said.
So we can confidently say that besides yellow fever that we still send to the WHO lab in Senegal that we can test and confirm any other disease here at the NRL? “Well you can never diagnose all but all the commonly transmitted infectious diseases from monkey pox to Lassa fever to bacteria meningitis and many others,” the epidemiologist said.
When The Guardian visited the NRL in Jabi, Abuja, it discovered the facility has the capacity for bio-repository and multiplex assay with more than 70 minus 80 degrees Celsius freezers and could stores more than six million samples.
A bio-repository is a biological materials repository that collects, processes, stores, and distributes bio-specimens to support future scientific investigation Bio-repositories can contain or manage specimens from animals, including humans, and many other living organisms.
A multiplex assay, in the biological sciences, is a type of immunoassay that uses magnetic beads to simultaneously measure multiple analytes in a single experiment. It could be used to test more than 50 diseases with one sample.
Analysis by The Guardian also showed that due to the various interventions by the Federal Government, the number of meningitis, cholera, Lassa fever and Yellow fever cases and deaths recorded in 2017 have dropped by more than 50 per cent this year.
For instance, in synergistic partnership, NCDC and eHealth Africa (eHA) used advanced geographic information systems (GIS) technologies to map disease outbreaks. eHA uses data-driven solutions and tools to improve community health, with specific expertise in the design, development, validation, and deployment of predictive models for diseases like cholera.
GIS allow experts to explore different aspects of a geographical point. The identification of patterns can drive insights and enable health stakeholders to make informed decisions about how to best plan public health interventions.
NCDC and eHA were able to utilise GIS capabilities to enhance the data management within the NCDC National Incident Coordination Centre (ICC). The ICC serves as the EOC for coordinating disease outbreaks at the national level.
eHA’s GIS and Data Analytics team works with the NCDC to map cholera hotspots (areas where cholera persists) across Nigeria’s Local Government Areas (LGAs). At the start of the outbreak, hotspot analysis helps determine where to vaccinate and what quantity of vaccines are required per LGA. This exercise ensures the effectiveness of the oral cholera vaccine immunization campaigns, which are rolled out to stop the spread of disease.
When The Guardian visited the EOC in Abuja, it witnessed real time monitoring of the 774 LGAs in the country for disease outbreaks through mapping.
Tomori, however, said the country is showing commitment to improving epidemic preparedness, such as enacting the bill establishing the NCDC and great efforts by NCDC to address identified gaps still remain especially at State and LGA levels in the following areas- biosafety and biosecurity, preparedness, medical countermeasures and personnel deployment, emergency response operations, laboratory system, financing, among others.
The virologist said the occurrence of any disease outbreak could cause numerous deaths and perhaps spread to neighboring countries, examples yellow fever, Lassa fever and meningitis.
Ihekweazu said: “In July 2014 we did not have a NRL in Nigeria, We had a few laboratories in specific universities that have developed their capacities like the ones at Redeemer’s University and the Lagos University Teaching Hospital (LUTH) but we did not have a NRL. But now we have a full-fledged NRL at Jabi in Abuja where we have the capabilities of doing the diagnoses of most causes of epidemic diseases both bacterial and viral causes.
“So our capability of making that diagnoses in Nigeria has increased exponentially. We have a mobile laboratory that we can deploy to any part of the country if needed.
“The final part is about the response. In the July outbreak in 2014 we had to rely on two groups of people. Firstly are graduates of the Nigeria Field Epidemiology Training Programme (NFETP) and secondly our people that happen to be working on the polio response at the time through the Polio EOC who were then repurposed for Ebola. Now we have built on all of those and we have teams in NCDC that are used to responding. We have a new EOC and we are supporting every state in Nigeria to develop one. We have done that in 16 states.
“We have people that are now used to responding all the time. To tie all of these together is a communication and digital surveillance platform that we call Surveillance and Outbreak Response Management System (SORMAS). So there is information is sent online across the country on a daily basis. Across the three spheres of prevention, detection and response we are a lot more prepared and this you can demonstrate from our response for all the commonly occurring outbreaks in Nigeria.”
Ahumibe told The Guardian: “We manage a lot of high containment and infectious diseases that are prone to be used for as security threat. NCDC has two reference labs, one in Lagos and another in Abuja. All our laboratories that are doing public health work are domiciled to this lab. So we have a lot of collaborating labs outside the country and these labs help us work on different epidemic prone diseases. These labs are organized as scoops that is contribute samples to the reference lab and they are divided into different networks depending on the particular diseases that they are taking care of.
“We have our Lassa fever, viral haemorrhagic fever network, we have our yellow fever, rubella, measles network, which is one network. We have another network for cholera and CSM. We also have a monkey pox hub, which is here because this is the only place we are testing for monkey pox. We also have a kind of network for influenza. The primary thing is that we serve as a national reference lab for all these other collaborating labs. ”
So you have the capacity to detect and confirm Ebola? “Yes, for viral haemorrhagic fevers such as Lassa and Ebola. Then for vaccine-preventable diseases, which include measles, yellow fever and all that. We also have capacity to test for that,” he said.
On the NRL serving as a bio-repository, the medical laboratory scientist said: “Last year there was a community-based survey on Human Immuno-deficiency Virus (HIV) by the National Agency for the Control of AIDS (NACA) in conjunction with NCDC and with funding from the United States Government (USG) and the Global Fund. The idea then was that a lot of money is being put into HIV programmes and they needed to have real figures on the impact of the programme.
“Before then, the methods used were irregular. Some people measured HIV prevalence based on pregnant women attending antenatal clinics while others measured based on people who came to the hospital. So, the figures were not reliable. So there was this drive to do a community survey that will give us a more reliable indicator of what the prevalence is. So that was the origin of the 2018 Nigeria HIV/AIDS Indicator and Impact Survey (NAISS) that was done last year. It was done in all states and it was community based. It was not just testing for HIV; there were other auxiliary tests that needed to be done.
“So all those samples were brought here. So this centre was the central laboratory for those testing and also primed to be able to house all these samples. So that is how the initial concept of our bio-repository was created. So at the moment we have more than 70 minus 80 degrees Celsius freezers where samples from the NAISS were stored…”
On the capacity for multiplex, Ndondo told The Guardian that there is need for the NCDC to do differential diagnoses. He explained: “Like you bring a sample and test it for Lassa fever and it test negative and the person is sick having the case definition of Lassa and yet you test it using real time Polymerase chain reaction (PCR) tests and you have negative result. So what actually is it? So we are looking at the platform for detection of those similar kinds of conditions or diseases that look like Lassa fever. If you are doing single detection you are only targeting on specific diseases.
“We are now looking at a time when we can test all diseases maybe Ebola, Lassa, yellow fever, all the haemorrhagic fevers we can test them at once on one platform. So that is really the challenge we have been having but in this NRL recently with collaboration from partners in the UK and the US we are now being able to find platform where we can test more than fifty diseases at once. So that is what is called multiplex. The new technology is being deployed to Nigeria from the US Centre for Disease Control (CDC).
“It has the capacity of getting up to 50 different diseases with one sample. With one small quantity of the sample you can test and confirm more than 50 different diseases. With this we can test whether HIV is type one or type two and whether it is a new or old infection. We also intend to use it for other diseases like measles, malaria, and hepatitis B. We are hoping that as the technology evolves we will be able to develop our own beads in country so that we will be able to solve these problems and this is a very highly reliable technology.”
To improve Nigeria’s preparedness against deadly epidemic like Ebola, Lassa fever, Yellow fever, Monkey pox and others, Idris recommended: emergency preparedness by governments at all levels; build public health infrastructure; health systems strengthening; look at health as a security issue and adopt the concept of “one health” (health, environment, agriculture and animal health); invest massively in the health sector; health is everyone’s business and not government alone; and tackle issues of poverty, environment, water and other areas that have effect on health.
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