Furore over ‘tripledemic’ of COVID-19, flu, RSV in Nigeria

•NCDC allays fears, alerts to possible epidemics of meningitis, Yellow fever, Lassa fever as country enters dry season
•RSV responsible for 12.5% to 34.5% acute lower respiratory infection cases in children under five years in Nigeria

Despite worldwide concerns over tripledemic of COVID-19, influenza (flu) and re-emergent respiratory syncytial virus (RSV), the Nigeria Centre for Disease Control (NCDC) has allayed fears. The centre said the country is at mild and moderate risk of such occurrence and menace. It, however, warned that the country is now prone to epidemics of meningitis, measles, Yellow fever, Lassa fever, monkeypox and chickenpox as she enters the dry season/harmattan.

The Delaware Division of Public Health (DPH) had, last week, raised concerns over increases in respiratory viruses in the state, particularly flu and RSV. For the week of October 16, 2022, through October 22, 2022, there were 44 laboratory-confirmed cases of the flu, compared to 19 cases the week before, bringing the statewide total for the season, which began October 2, to 69. For the same week, there were 98 cases of RSV, for a season total of 250. With COVID-19 continuing to circulate, DPH officials are concerned about the impact a ‘Tripledemic’ of these respiratory viruses could have on the state’s overall health and hospital capacity.

Delaware is a state in the Mid-Atlantic region of the United States, bordering Maryland to its south and west; Pennsylvania to its north; and New Jersey and the Atlantic Ocean to its east.

RSV is a respiratory virus that causes acute lower respiratory tract infection (LRTI) with symptoms including: cough, fever, difficulty breathing, loss of appetite and parlor. It occurs frequently in children under five years of age and usually resolves within a week or two with supportive care. Infants who had limited exposure to the virus as a result of the pandemic and older children who have pre-existing medical conditions or illnesses may present with more severe symptoms requiring hospital admission, intranasal oxygen and intravenous fluids. In a few cases, mechanical ventilation and Intensive Care Unit (ICU) admission are necessary.

The flu and COVID-19 have many similar symptoms, including fever or feeling feverish/chills, cough, shortness of breath or difficulty breathing, fatigue (tiredness), sore throat, runny or stuffy nose, muscle pain or body aches and headaches. Other signs and symptoms of COVID-19 that are different from flu include a change in or loss of taste or smell.

Director General/Chief Executive Officer of NCDC, Dr. Ifedayo Adetifa, told The Guardian: “This is the cold season in the Western world, especially in the United States and United Kingdom. Flu and RSV is very common during this period and COVID-19 has joined the list. So, they are burdened with the three deadly but preventable diseases now.

“RSV is not common in Nigeria except for some hospital induced infections reported sparingly. I can tell you that COVID-19 and flu are still big concerns here but not RSV.

“What we are concerned about now is some seasonal outbreaks like meningitis, measles, Yellow fever, Lassa fever, chickenpox and so on. We have started sensitisation and nationwide campaigns.”

A virologist and former Vice Chancellor of Redeemer’s University Ede, Osun State, Prof. Oyewale Tomori, acknowledged there are fresh concerns of the threat of tripledemic of COVID-19, flu and RSV.

Tomori said available information indicates that RSV is responsible for 12.5 per cent -34.5 per cent of cases of acute lower respiratory infections (ALRI) in children under five years in Nigeria. “This could be quite a significant cause of ALRI. More studies are called for, to accurately estimate the burden of RSV as a cause of ALRI in Nigerian children,” he said.

The virologist said, currently, there is no cure or vaccine for RSV – the medical world is limited to offering only supportive care, such as oxygen and fluids, for those with the illness.

Tomori said the latter is suddenly claiming so many lives worldwide without established treatment. “Globally, influenza activity remained low with influenza A(H3N2) viruses predominant among detections. In tropical Africa, influenza activity remained low with predominantly influenza B/Victoria lineage and A(H3N2) MY viruses detected but also A(H1N1)pdm09 detections reported in a few countries,” he said.

On the implications for Nigeria, which is also contending with other viral infections such polio, monkeypox, Lassa fever, Yellow fever etc., Tomori said: “Contending with one disease outbreak is a serious public health concern, as we are still reeling from the human and economic costs of COVID-19 pandemic. Having three or four disease outbreaks for a prolonged period of time is a grave emergency of monumental consequences. Nigeria in the past year or two has had to deal with not one disease outbreak, but the following disease outbreaks in varying proportions. It is important to provide official data from NCDC site to bring home the ongoing public health disaster we are experiencing from a host of pathogens and many of these are preventable.

“According to NCDC, Nigeria has reported the following cases and deaths attributed to different diseases: COVID-19 (266,043 cases and 3,155 deaths between February 2020 and October 15 2022); Lassa Fever- 4,654 suspected cases, 516 confirmed with 102 deaths in 2021, and 6,980 suspected cases, 978 confirmed with 173 deaths from January 1 -October 23, 2022; monkeypox 349 cases and seven deaths in 2022 alone, more than all the monkeypox cases we reported between 2017 and 2021; cholera continues to ravage our population with over 10,000 cases reported and 256 deaths in 2022. The number of cholera cases have doubled every of the months of July, August and September 2022.”

The virologist said over 70 per cent of the cases reported these years were reported in the months of July-September. He said perhaps the recent flooding in different parts of the country might be contributing to this dangerously escalating cholera epidemic. “Finally, the situation with polio. Although Nigeria has interrupted the transmission of indigenous wild poliovirus, we still have acute flaccid paralysis reported in 38 of our children from circulating vaccine derived poliovirus.

“It is obvious from above data that infectious diseases are making mince meat of our population. The saddest part of this deplorable and unacceptable situation is that most of these diseases are vaccine preventable.”

Professor of microbiology and immunology at the Department of Medical Microbiology and Immunology, Nile University of Nigeria, Abuja, Boaz Adegboro, told The Guardian that the implications could be dire in Nigeria, where other viral infections such as polio, monkeypox, Lassa fever, Yellow fever amongst others, are circulating.

Adegboro said the implications are: bed space shortages in hospitals as a result of more severe infections in children; shortage of amoxicillin, which though not used to treat any of these viral infections, is often prescribed when symptoms are similar to bacterial infections or in situations where there is secondary bacterial infection; and associated disease complications, increased deaths among children under five especially in rural areas where access to hospitals is limited.

The medical immunologist said a study conducted in 72 Vaccine Alliance (Gavi) countries showed the economic impact of RSV associated infections with treatment costs estimated at $611 million and the Disability-Adjusted Life Years (DALYs), 1.2 million.

Approximately 33 million RSV-associated acute LRTIs were reported globally in 2019 among children younger than five years, while one in five of these infections occurred in infants between zero and six months. Adegboro said majority (95 per cent) of RSV associated LRTI were reported in children living in low-to-medium-income (LMIC) countries and an estimated 97 per cent of RSV related deaths also occurred in Low and Medium Income Countries (LMICs) such as Nigeria.

Adegboro said the overall incidence of RSV in Nigeria is of 125/1000 child years, while the prevalence is 35.4 per cent. He said case incidence is higher in rural areas than in the cities; and most infections occur in the first year of children’s life.

On how best Nigeria can tackle the situation, Adegboro said to adequately manage RSV-associated acute LRTI as a country, the people need to be sensitised about the disease and guided in the appropriate supportive care to provide at home, especially in rural areas where the disease burden is higher and access to healthcare services limited.

He said warning signs should be taught to caregivers and health workers to enable them identify severe infection that would require hospitalisation.

Adegboro said hand hygiene should be emphasised to limit spread of the virus and although there are vaccine candidates and monoclonal antibody candidates at advanced stages of clinical trials, none has been approved for use.

The immunologist said learning from the COVID-19 pandemic, research should be intensified to have a treatment drug and prevention vaccine available in the shortest possible time so as to reduce morbidity and mortality as a result of RSV infections and co-infections with other viruses in children under-five years.

DPH Interim Director, Dr. Rick Hong, said: “We are managing the response to three serious respiratory viruses at once – the flu, RSV, and COVID-19 – and are significantly concerned about the impact increasing cases could have on an already strained hospital system.

“Our primary message is stay home if you are sick. Fortunately, a vaccine is available for flu and COVID-19, and now is the time to ensure all eligible Delawareans have received these critically important immunisations, including the new COVID bivalent booster to provide them with the most updated protection against circulating variants. Unfortunately, a vaccine is not available for RSV and the current increase in cases throughout Delaware and the country emphasise the need to carefully follow prevention measures for these seasonal viruses.”