The Nigeria Centre for Disease Control and Prevention (NCDC), recently recorded cases of diphtheria outbreak in the Federal Capital Territory (FCT), Abuja and other parts of the country.

Diphtheria is caused by a toxin produced by the bacteria Corynebacterium diphtheria. It is is a vaccine-preventable disease covered by one of the vaccines provided routinely through Nigeria’s childhood immunisation schedule.

Director General (DG), NCDC, Dr. Ifedayo Adetifa, said since December 2022, the organisation has reported multiple diphtheria outbreaks in different states across the country. As of June 30, 2023, there have been 798 confirmed diphtheria cases from 33 local councils in eight states including the FCT.

The DG stated that most of the cases 782 were recorded in Kano State. Other States with cases are Lagos, Yobe, Katsina, Cross River, Kaduna, and Osun.

“The majority (71.7 per cent) of the 798 confirmed cases occurred among children aged two to 14 years. So far, a total of 80 deaths have been recorded among all confirmed cases (case fatality rate of 10.0 per cent),” he said.
Despite the availability of a safe and cost-effective vaccine in the country, the majority, 82 per cent of the 798 confirmed diphtheria cases in the ongoing outbreak were unvaccinated, the NCDC said.

“Unfortunately, this also includes this recently announced FCT case. 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.

“Just like in other States reporting cases, we are working with the FCT Health and Human Services Department to implement control measures and avert the further spread of the disease,” the agency noted.

Adetifa urged the members of the public to remain vigilant and ensure persons with symptoms of diphtheria present early to health facilities for prompt diagnosis and treatment.

He stressed that early diagnosis and institution of effective treatment are key predictors of a favourable outcome. “Healthcare workers are urged to immediately notify local councils’ disease surveillance officers once they see a suspected case.”

The DG said the FCT Health and Human Services Secretariat has activated the diphtheria incident management system (IMS) to coordinate outbreak response activities. The key activities are not limited to active case finding in health facilities and communities, and risk communication and community engagement (RCCE) activities to raise awareness about diphtheria. Sample collection is also ongoing among suspected cases of diphtheria.

He said NCDC has activated a multi-sectoral national diphtheria technical working group as a mechanism for coordinating surveillance and response activities across the country.

“The response activities include coordination, surveillance, laboratory investigation, risk communication, case management and immunisation activities.”

Adetifa noted that NCDC has established multisectoral National Diphtheria Technical Working Group (TWG), bringing together relevant stakeholders to regularly meet and monitor the disease trend and coordinate response activities in the country.

He said the organisation also deployed Rapid Response Teams (RRT) to some of the affected states Kano, Katsina, Lagos, Osun, Yobe to support response activities in the states. “We supported the establishment of a diphtheria IMS in the affected states.

“There is also development and dissemination of surveillance tools across the country, case definition, case investigation form (CIF), line listing template among others. Including development of draft diphtheria surveillance and response guidelines.
“Sensitization/training of clinical and surveillance officers on the presentation, prevention, and surveillance of diphtheria.”

He said NCDC is building capacity of state-owned public health laboratories for diphtheria diagnosis. “This would strengthen the capacity of states for sample collection, transportation, and laboratory confirmation for diphtheria with the support of the United Kingdom Health Security Agency through the following. Training of laboratory physicians and scientists from selected states across the country at the National Reference Laboratory (NRL), Abuja, on laboratory methods for diphtheria confirmation.”

The DG stated that NCDC encouraged supply of diphtheria laboratory and sample collection consumables (transport media, reagents, sample collection materials etc.) to states across the country.

“Including supply of biosafety cabinets to some of the affected states. Supporting the States in confirming cultures and toxin production testing on specimens sent in from States. Performing drug susceptibility testing (DST) at NRL on isolates sent in from States.”

Adetifa said for the first time in over two decades, the country through NCDC and with support from World Health Organization (WHO), procured and prepositioned diphtheria antitoxin (DAT) in the country and distributed it to the affected states.

“Including development and dissemination of Standard Operating Procedures for DAT use. With support from Medecins Sans Frontiere (MSF) and the Kano State Ministry of Health, we established two isolation wards with a total capacity of over 80 beds at Murtala Mohammad Specialist Hospital (MMSH), Kano State.”

He said NCDC has encouraged development and dissemination of public health advisories on diphtheria. Including media appearances/engagement on diphtheria with media stakeholders to create awareness, inform the public and bridge knowledge gaps.

He said there was also development and dissemination of diphtheria posters, flyers, to affect states. Including coordinated the diphtheria risk communication and community engagement (RCCE) stakeholders’ coordination meetings both at the national and sub-national levels. We also had webinar series to share knowledge and raise awareness of response activities in the country.

Adetifa noted that NCDC encouraged intensification of routine diphtheria immunisation and some catch-up vaccination campaigns by the sister agency, the National Primary Health Care Development Agency (NPHCDA), in states with high numbers of children who had not received any childhood vaccination.

He said parents should ensure that their children are fully vaccinated against diphtheria with the three doses of diphtheria antitoxin-containing pentavalent vaccine given as part of Nigeria’s childhood immunisation schedule.

“Individuals with signs and symptoms suggestive of diphtheria should isolate themselves and notify their local government or state disease surveillance officer (DSNO), their state ministry of health helpline, or the NCDC through our toll-free line on 6232.”

He stated that individuals who had come in close contact with a confirmed case of diphtheria should be closely monitored, given antibiotics prophylaxis, and started on diphtheria treatment when indicated.

“Healthcare workers should practice standard infection prevention and control precautions while handling patients and body fluids.
“All healthcare workers, doctors, nurses, laboratory scientists, support staff among others with a high level of exposure to cases of diphtheria should be vaccinated against diphtheria.”

The DG said the major challenge NCDC face in eradicating diphtheria is lack of immunisation coverage among Nigerians. He advised parents to ensurethat their children are available for immunization in order to eradicate diphtheria.

Given the risk level the disease poses, health experts and stakeholders also stressed the importance of practicing good hygiene as it could help to reduce the risk of diphtheria transmission. They listed some of the good hygiene practices to include frequent hand washing with soap and water, especially before meals and after using the restroom, among other preventive measures.

Public Health physician and founder, MakeOurHospitalWork Campaign, Dr. LazUdeEze, said diphtheria is a serious bacterial infection of the nose and throat. He noted that itcan be prevented through vaccination.

He said children under five years who are not immunised and adults above 60 years of age are most likely to be affected by diphtheria due to low immunity.

Eze explained that government, especially at the state level, should ensure that all children are fully immunised. “All barriers to childhood routine immunization should be removed. The current outbreak can be controlled through effective health promotion in communities.”

He said Nigerians should imbibe appropriate health-seeking behaviours. “All pregnant women should attend antenatal clinic and deliver their children in a health facility. All children should be fully immunised in order to prevent further outbreak. Persons who are ill should avoid self-medication and seek quality treatment from trained health care providers.”

Consultant Public Health Physician and the National Director/Chief Executive Officer (CEO), Sickle Cell Foundation Nigeria, Idi-Araba, Lagos, Dr. Annette Akinsete listed some signs and symptoms of diphtheria, which could be picked up early, to include fever, swollen glands around the neck, sore throat, hoarse voice, difficulty in breathing, nasal discharge, and weakness/fatigue. She identified the possible treatment for diphtheria as antibiotics, analgesics, antitoxin, and rest, among others.

Akinsete, however, said the disease could be prevented through vaccination with diptheria vaccine and prophylactic antibiotics. She also noted that immunisation remains key in preventing diphtheria. “About 75 per cent of cases are due to poor vaccination coverage and this mostly affects children between two to 14 years.”

Abuja-based Public Health Physician and health promotion specialist, Dr. ObinnaEbirim, on his part, observed that though the disease primarily affects the respiratory system, including the throat and tonsils, the infection can spread to other parts of the body, leading to severe complications. He added that diphtheria could be life threatening, particularly in young children and individuals with compromised immune systems.

He said the disease is primarily spread through respiratory droplets, which are released when an infected individual coughs or sneezes. “These droplets contain the bacteria, and when inhaled by others, they can cause infection. Diphtheria can also spread by direct contact with open sores or wounds of an infected person,” he said.

He noted that covering the mouth and nose with a tissue or elbow while coughing or sneezing can also prevent the spread of respiratory droplets.“Avoiding close contact, limiting close contact with infected individuals, especially those showing symptoms such as a severe sore throat or a grayish membrane in the throat, is important. Individuals suspected to have diphtheria should seek medical attention promptly to prevent further transmission,” he added.

Ebirim noted that ensuring clean and hygienic environment couldalso ontribute to preventing the spread of diphtheria.
“Regular cleaning and disinfection of frequently touched surfaces, such as doorknobs and toys, can help eliminate the bacteria.

“Early diagnosis and treatment, prompt recognition and treatment of diphtheria are essential in preventing complications and reducing the spread of the infection,” he said.

He urged health authorities and relevant organisationsto undertake public health education campaigns to raise awareness about diphtheria, its transmission, prevention, and the importance of vaccination. “This can be done through various channels, such as media, community outreach programmes, and educational materials.

He said government bodies and healthcare organisations must also work towards strengthening healthcare systems, including ensuring the availability of vaccines, adequate diagnostic capabilities, and trained healthcare professionals. “Timely access to medical care plays a vital role in managing diphtheria outbreaks effectively,” he added.