Meningitis outbreak exposes FG’s unpreparedness for epidemics

The ongoing Cerebrospinal meningitis (CSM) epidemic has continued to spread like wild fire in Hartmattan, with over 1,966 cases and 324 deaths, across more than 17 states. The question on the lips of concerned Nigerians is why was an infection that was expected and should have been prepared for, allowed to cause this level of devastation?

Despite excuses by agencies of the Federal Government (FG) such as the Federal Ministry of Health (FMoH), the Nigeria Centre for Disease Control (NCDC), and the National Primary Health Care Development Agency (NPHCDA) that the epidemic is due to a new strain of meningitis, The Guardian investigation revealed that the country has recorded cases of the new strain, Meningitis type C, since 2013.

The growing epidemic of CSM has been blamed on the scarcity of the needed vaccines. The new outbreaks are caused by new strains of CSM, Neisseria meningitidis serogroup C (NmC), the vaccines for which are not commercially available and need to be acquired through a special process managed by the World Health Organisation (WHO).

As the country does not have enough vaccine doses to deal with the deadly meningitis outbreak, and the drugs are too expensive at the cost of $50 (N18,000) per dose, more Nigerians may die from the disease. This is especially so since the means of livelihood of the majority of the citizens have been eroded by the current economic recession and the $50, which is the cost of the meningitis drugs per dose is the national minimum wage.

The Chief Executive Officer (CEO) of Nigeria Centre for Disease Control (NCDC), Dr. Chikwe Ihekweazu, told The Guardian that the country urgently needed 1.3 million doses to meet its immediate targets, but had taken delivery of only 500,000. Ihekweazu, however, said the country was expecting another batch of 800,000 doses last week.

This means that the country needs to spend not less than $65 million (N23.4 billion) to meet its needs.Also, various epidemiological studies have been conducted in the past on the trend of CSM in Nigeria and type C strain of Neisseria meningitides was involved in the epidemics in the past.

It was also shown that the country has a pattern of climate change and governments should have emergency medical preparedness plans that should be activated routinely to avert disasters.

Doctors under the umbrella of the Nigerian Medical Association (NMA) blamed the situation on delayed immunization of the citizens against an infection that is already established, which is ineffective based on the epidemiology of the disease.

President, NMA, Prof. Mike Ogirima, said for immunization to be effective it must have been administered around three months before the period of clinical manifestation due to the latent period.

The NMA also blamed late release of budgetary provisions for various health programmes for the ongoing epidemic.Also, pharmacists under the aegis of the Pharmaceutical Society of Nigeria (PSN) blame the meningitis epidemic to restriction on importation of essential medicines and vaccines, which the local pharmaceutical industry has not shown proven capacity to produce; and restriction on immunisation procedures by not allowing community pharmacists to conduct routine immunisation against all killer childhood diseases in public interest.

What went wrong?
Immediate Past President of PSN, Olumide Akintayo, told The Guardian: “You may need to ask the appropriate authorities in health at both Federal and State levels this question. For a very long time we have counselled the powers that be at the Federal Ministry of Health and State Ministries as well as (NPHCDA) plus its equivalent at state levels on the need to shun duplicitous politics of expediency in their unfortunate deft machinations to protect narrow professional interests or outright pecuniary accruals. It is the shame of a nation that we wait for thousands of people to be killed in a perennial cycle of delinquency annually because we do not want to be equitable, just and fair to all concerned.

“Healthcare is a global practice and for reasons of commonsense the Universal approach is to embrace primary care. Immunization is a cardinal part of primary care which we have woefully failed to implement properly.

“The logical questions include how does immunization work in other climes? Who are the personnel who make it happen? The answers are simple. Routine immunization against killer childhood diseases is the norm everywhere as opposed to designating immunization days, which we celebrate around here. The other leg is the involvement of all relevant and competent healthcare workers especially those who are close to the grassroots.

“80 per cent of immunization endeavours are conducted in Community Pharmacies in the United States (US). In the United Kingdom (UK) community pharmacists are involved in primary healthcare services, including immunization and they are remunerated for these services.

“It is sad that every year we wait for a new generation of people to die, even when the concerned authorities know that the period between November and April, which is the hot Harmattan season is the period our children and others are vulnerable to meningitis, especially in Northern Nigeria.”

Was there neglect somewhere? Akintayo said: “You know as much as I know that this borders on neglect in high places. The management of medicines in Nigeria and associated protocols is in shambles.

“Let me humbly submit my surprise at the quality and version of the change philosophy of the present administration. I am an admirer of President Buhari because of his seeming passion for discipline, transparency and accountability. Unfortunately, his approach to governance continues to take a toll on overall output. It is unimaginable that two whole years or thereabout into the life of this administration, major political appointments are yet to be made. It is as ridiculous as having key Jonathan players in some sensitive apparatus of the incumbent administration.

“Our sector in particular is very badly hit. Even when there were new appointments for fresh thinking in the medical sector through the National Primary Care Development Agency, National Health Insurance Scheme (NHIS), Nigerian Institute for Medical Research (NIMR) and Centre for Disease Control, nothing has happened in the pharmaceutical sector. An acting management has held sway at the National Agency for Food and Drug Administration and Control (NAFDAC) for over one year now. With due respect to the Acting management, some vital areas will continue to suffer without a substantive appointment of a Director General/Chief Executive Officer and the governing council of NAFADC.

“For instance, the DG NAFDAC who should ideally navigate trends in medicine protocol at the level of West African Postgraduate College of Pharmacists (WAPCP) and West African Health Organisation (WAHO) has not been appointed for over one year. It is the same complication at Pharmacists Council of Nigeria (PCN) where so many statutory processes have been stalled.

“Perhaps if you had some of these golden voices on board to qualitatively advise the Federal and State Governments on medicine matters, we might just be on the right track.”

Chief Consultant Family Physician; Vice President, Commonwealth Medical Association; and Past President, NMA, Dr. Osahon Enabulele, said: “It is really another sad and embarrassing reflection of our country’s state of affairs. It clearly shows a dearth of forecasting, as well as, apparent lack of proactive and effective strategic planning and response mechanisms. It is a known fact that meningitis outbreaks occur almost on an annual basis, particularly with the dry Harmattan wind. With the impact of climate change, our authorities ought to have been proactive by instituting anticipatory mechanisms on ground, backed by effective weather forecast, using readily available 21st century technologies.

“Again, there ought to have been consistent and aggressive health education and social mobilization based on feedback from geo-surveillance and past experiences. For the record, the devastating meningitis serotype C is not new in Nigeria. Available information from the World Health Organisation shows that the epidemic caused by meningitis serotype C when it occurred in Nigeria in 1975 caused the death of over 108, 000 lives in Northern Nigeria. So, we really shouldn’t have been caught napping if our leaders had learnt any lessons from past experiences backed with good institutional memory. Surely, the impact could have been minimized if our leaders were more proactive.”

Was there neglect somewhere?
Enabulele said: “Surely, as occurs in most other aspects of our national life, there would have been some neglect somewhere, particularly the need to socially mobilize and properly educate the people on a consistent basis, along with the proactive provision of enough year round preventive vaccines.

“The recent careless, primitive and most unfortunate talk on the possible cause of the recent Meningitis outbreak by the Governor of Zamfara State, tells a lot about the approach to major public health issues by some state actors. Rather than address the evidence based requirements for managing such public health issues, such state actors resort to their insular propensities and unfounded logic, while the people are left to suffer the dire consequences.”

What were the states involved doing? The medical doctor said: “Well, from information available to me, there seems to be ongoing collaboration between the Federal Government and Governments of affected states, with the support of some foreign agencies, including the World Health Organisation, to tackle the emergency and halt the tidal wave of meningitis outbreak in Nigeria.”

On what went wrong, National President, Association of Medical Laboratory Scientists of Nigeria (AMLSN), Toyosi Y. Raheem, said it is unfortunate that Nigeria is again experiencing another health calamity after a recent attack of Lassa fever and Ebola Viral Disease. These, Raheem said, are in addition to many other numerous infectious diseases like tuberculosis, malaria and tuberculosis (TB) that are daily causing morbidity and mortality.

Raheem further explained: “Unfortunately again, Nigeria has a culture of planning and always exhibiting fire brigade approach in all matters. The truth is that Nigeria is more highly endowed in both human and material resources that we do not need to suffer this way. It will be recalled that in October 2015, one of the issues raised by our association during our scientific conference in Port Harcourt, was on the need to strengthen local production of vaccines. Participants decried the moribund nature of human vaccine production laboratories in Nigeria, amidst a disturbing rise in emerging and re-emerging infectious diseases and hereby called upon the Nigerian government to quickly look into resuscitating these laboratories since Medical Laboratory Scientists are well trained in vaccine production technology as seen by their productive input in the National Veterinary Research Institute, Vom.

“When this is done, it will go a long way in combating healthcare challenges in Nigeria. Rather than the leadership of the FMoH, NCDC invited stake holders and brainstormed on the way forward, our call was ignored! It is unfortunate that innocent lives are lost for a vaccine preventable disease such as bacterial meningitis. This is what lack of plan usually breeds.”

Was there neglect somewhere?
The medical laboratory scientist said: “Yes. Need for local vaccine production was neglected, the vaccine lab production in NVRI was not encouraged. The Vaccine production laboratory in Yaba , Lagos, was allowed to rot away and the hitherto bubbling laboratory is now taken over by bush and rodents in the heart of Lagos. Rather, importation of vaccines prepared from foreign strains of bacteria species are emphasized. Usually, vaccines prepared from foreign strains of causative organisms could offer limited protection to indigenous people.

“We take pleasure in developing the potentials of foreign markets while neglecting our scientific potentials. In the past, when the Vaccine Laboratory, Yaba, Lagos, was performing optimally, Nigeria was producing several doses of bacterial vaccines for local needs and for export. It is sad that today, the leadership of the FMoH is thinking of importing 800,000 doses of meningitis vaccine in a country of 170 million people. What an under estimation!”

To address the situation, Ogirima demands immediate resuscitation of local vaccine production (LVP) at Yaba and expansion of the scope of LVP at National veterinary research institute, Vom. Ogirima said researches as far back as 1975 showed the various epidemics of CSM as to the type of strains involved and it is embarrassing again to note that this epidemic has taken the country unaware.

The NMA President said pharmaceutical industries should be challenged and supported to produce the country’s consumables and this should be the new order instead of budgeting huge sums of money for importation of vaccines and other consumables.

Ogirima said there is lack of awareness programme on the epidemic and called on the government to ensure massive public enlightenment programmes to the populace, which will go a long way to prevent the spread of all communicable diseases.

He said the working environment of all health workers must be safe as they risk being infected if the working tools are not optimal and up to date, and the doctors await better management of their welfare.

Yakasai said the approach for prevention and control of meningococcal epidemics is based on early detection, followed by massive vaccination of the vulnerable population with vaccines. Though has shown some effectiveness especially in young people, but is still perceived as a model for product development partnership in resource limited settings. “This is the norm in Nigeria and most African nations.”

The PSN President appealled to the Federal Government to follow the dictates and spirit of the Society’s position paper on the implementation of the recent 20 per cent Import Adjustment Tax (IAT).

Yakasai said a 20 per cent IAT on medicines and vaccines, which are life saving only exposes consumers of medicines to avoidable death sentence. “Our resolve as responsible health providers who embrace a connectivity of empathy seriously forbids jostling along this less than noble route,” he said.

Enabulele said Nigerians should equip themselves with health information on meningitis, particularly its symptoms like high grade fever, severe headache, neck stiffness, nausea and vomiting, and in the case of children less than one year, they should look out for symptoms such as fever or low temperature, poor feeding, as well as signs such as bulging fontanelle, especially while crying. They should thus have a high index of suspicion and anyone suspected to have meningitis should immediately report to the nearest health facility, rather than resort to self-medication.

He said Nigerians should also adopt good personal and community hygienic practices, including regular hand washing and proper disposal of respiratory secretions when sneezing or coughing. They should also avoid overcrowding and stay in well ventilated environments.

At the cost of $50 per dose, do you think that the government can afford to vaccinate up to 22 million people that need to be vaccinated to protect the country? Enabulele said: “Why not? If the political will and commitment is there, it can be achieved. Look at all the money we hear flying around! If a little of all that is sincerely and transparently invested in this venture, it will go a long way in achieving Nigeria’s vaccination target.

“Indeed, this situation again calls for accelerated operationalization of the 2014 National Health Act, particularly with respect to the provision of the Basic Health Care Provision Fund meant to assist in providing additional resources for the purchase of vaccines and consumables. So, government should give concrete expression to section 11 of the 2014 National Health Act, instead of relying heavily on donor support.”

Enabulele said the solution lies in electing health conscious political leaders who appreciate the place of health investments in the prosperity and well-being of the country’s citizens. “We need leaders with the right political will and commitment to the health of the people and the strengthening of Nigeria’s health system. So, the people should only vote in people who are patently committed to their health. The people must always demand accountability from their leaders, including accountability for investments made into vaccine purchase and provision,” he said.

The medical doctor added: “Again, the Federal Government should provide for the statutory Basic Health Care Provision Fund as prescribed in the 2014 National Health Act.
“I pray the emergency is effectively managed to prevent further mortalities and spread of the infection. Every death from meningitis has a negative knock-on effect on the image, development and fortunes of Nigeria.

“Nigerians should regularly equip and update themselves with appropriate and relevant health information. They should have a high index of suspicion and once they develop any of the symptoms and signs of meningitis, they should report to the nearest health facility. They should also adopt good hygienic and sanitary practices.

“I make the point again that Nigerians should always call to account government and leaders at all levels. Nigerians should only vote in people who are patently committed to their health. Finally, Nigerians and private institutions who have the means should invest in vaccine production and research.”

On local capacity to develop vaccines, Akintayo said: “Only May & Baker was in partnership with the Federal Government to produce vaccines at some point at the vaccine Laboratory, Yaba. I am not too sure funding has allowed sustainability of the project. My attitude to government funding of our sector is that the Federal Government and National Assembly which appropriates less than five per cent to the health sector when the Abuja declaration suggests a minimum of 15 per cent tells you the premium our leaders place on the health sector.

“Unfortunately, these are extremely capital intensive ventures for private players to touch, given the social welfare considerations/dimensions linked to healthcare. It is a tall order, but government must re-order its priorities, so that we can have a vaccine manufacturing centre for peculiar disease which afflicts our people.”

Akintayo said apart from canvassing routine immunization by community pharmacists and other competent health workers, the general public should keep faith with the reflected tips to prevent meningitis.

Akintayo said government must rely genuinely on its Public Private Partnerships (PPP) models to sustain initiatives in primary healthcare. The private sector is reputed to excel in service delivery, so I expect government to identify some private pharmacy facilities, clinics and other competent facilities, which will boost primary healthcare endeavours in Nigeria.

Raheem urged Nigerians to make their leaders accountable. “We must ask questions when things happen. We must not resign to faith and accept defeats in every situation. To do this is to exhibit laziness. We must all hold our leaders accountable for any life lost or incapacitated,” the medical laboratory scientist said.