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Bracing for meningitis, yellow fever, cholera, others that peak this season

By Guardian Nigeria
22 January 2022   |   2:41 am
A number of diseases peak during the dry season – usually between October and May– because the season comes with high temperatures and low humidity

Spinal fluid being taken from a patient’s spinal cord (lumbar puncture) for examination

A number of diseases peak during the dry season – usually between October and May– because the season comes with high temperatures and low humidity. CHIJIOKE IREMEKA reports that diseases such as Cerebrospinal Meningitis (CSM), cholera, measles, chickenpox, Lassa fever and Yellow fever may be rampant in the current season, hence the need to be cautious.

Cerebrospinal Meningitis (CSM), a priority epidemic-prone disease with cases reported all year round in Nigeria, is one of those that peak in this season – the end and beginning of a new year.

With its highest burden occurring in the part of sub-Saharan Africa (Meningitis Belt), including the 19 northern states and the Federal Capital Territory (FCT), there is a need for the country and its citizens to be conscious and cautious of the cyclical nature of the diseases.
 
Apart from meningitis Lassa fever, Yellow fever, chickenpox and cholera also hit their highest point this season, even as the government has raised the alarm over the re-emergence of Ebola in other African countries.
 
Meningitis is a deadly disease that kills within a few hours if immediate treatment is not administered, experts have said.

 
The case of Anya Desmond comes to mind when meningitis is being mentioned. It was a true picture of what the disease can do to the human body within a few hours. In some cases, it can be fatal.

Anya, with high body temperature, started that Saturday with hope, preparing for a wedding, not knowing what was lurking around for him. His health condition took a dangerous twist in spite of the medicine his mother administered on him after he had complained to the parents.

The innocent boy and his mother didn’t suspect anything deadlier than fever as they dispensed anti-malarial medicine on Sunday morning when he woke up with a high body temperature and was vomiting.
Later, he complained of neck stiffening, which made the parents seek the professional advice of a family physician, who suspected meningitis, but nothing was done about it.

Early Monday morning, he woke up, went to the bathroom to have his bath. He picked up his toothbrush to wash his teeth but midway, he noticed he couldn’t stand or walk anymore.

He managed to sit and shortly after, his mother came calling, but his hearing ability had gone. He couldn’t hear his mum’s call and couldn’t speak either. The situation threw his mother into confusion that made her call another doctor.

Again, the doctor suspected meningitis and this prompted the parents to take the boy to the Federal Medical Centre, Ebutte Metta, where he was rejected on the excuse that there was no bed space.

While this was happening, his nervous system collapsed. He urinated and defecated uncontrollably.

His parents immediately moved him to the Military Hospital, Yaba where drugs were administered and spinal fluid is taken from his spinal cord – lumbar puncture as it’s medically called – for examination. 

But this procedure couldn’t be completed at the military hospital as the facility lacked the requisite equipment to do so.

As a sequel to this, he was referred to the Lagos University Teaching Hospital (LUTH), Idi-Araba, Lagos, where he spent close to a month battling with meningitis. 

At LUTH, it was discovered that the 15-year-old Anya was battling Acute Bacterial Meningitis, a disease widely believed to be endemic in northern Nigeria before now.

Traumatised by this sickness, his father became apprehensive and prayed that his son wouldn’t end up in a wheelchair.

“It’s even better for my son to wear a hearing aid than to be confined in a wheelchair, crippled after 15 years,” he said.

“I never knew that meningitis is such a vicious disease, killing faster than AIDS. I have spent a fortune in the hospital. Hearing aid for one ear costs N500, 000. There is another one for N750, 000 for one ear, and for two years, you have to pay N1.5 million and so on. 

“I watched my son’s system, within 48 hours, I slumped. It was a traumatic experience. My son started learning how to re-walk after 15 years of age. He had renal failure; he couldn’t control his urine anymore and he wore a catheter at 15,” the father lamented.

This is one of the things that victims of meningitis go through. In some cases, the victims do not live to tell the story. Hence, meningitis is one of the diseases that should be prevented this season.

Its symptoms include drowsiness or difficulty waking, sudden high fever, sensitivity to light, severe headache, difficulty concentrating, seizures, stiff neck and vomiting.

According to a surgeon with Epe General Hospital, Epe, Lagos, Dr. Cynthia Okafor, each type of meningitis has a slightly different cause, but each ultimately acts in the same way.

“A bacterium, fungus, virus, or parasite spreads through the bloodstream until it reaches the brain or spinal cord. There, it sets up in the lining or fluids around these vital body parts and starts developing into a more advanced infection. Again, there is a case of non-infectious meningitis. It’s the result of a physical injury or other condition which doesn’t involve an infection,” she said.

On the incubation period, she said: “The average incubation period is four days, but can range between two and 10 days.” 

Okafor, who is a consultant at Havana Hospital, Lagos said that in infants, bulging fontanelle and ragdoll appearance are commonly found as symptoms of the disease. 

“A less common but even more severe, often fatal, form of meningococcal disease is meningococcal septicaemia, which is characterised by a haemorrhagic rash and rapid circulatory collapse. Even when the disease is diagnosed early and adequate treatment is started, eight per cent to 15 per cent of patients die, often within 24 to 48 hours after the onset of symptoms. 

“If untreated, meningococcal meningitis is fatal in 50 per cent of cases and may result in brain damage, hearing loss or disability in 10 per cent to 20 per cent of survivors.”

Also, the World Health Organisation (WHO) said meningococcal disease is potentially fatal and should always be viewed as a medical emergency. 

According to WHO, admission to a hospital or health centre is necessary but the isolation of the patient is not needed, BUT treatment with an appropriate antibiotic must be started as soon as possible.

“If treatment is started prior to the lumbar puncture, it may be difficult to grow the bacteria from the spinal fluid and confirm the diagnosis. However, confirmation of the diagnosis should not delay treatment.

“A range of antibiotics can treat the infection, including penicillin, ampicillin and ceftriaxone. Under epidemic conditions in Africa in areas with limited health infrastructure and resources, ceftriaxone is the drug of choice,” WHO said.

On why the disease peaks this season, Flourish Chukwuka said it was due to the low humidity and dusty conditions, usually at the end of the dry season, as the rainy season approaches.

“Meningitis is a tough disease, especially during this period, and it is associated with overcrowding. Understanding the living conditions in the country, people must keep their building ventilated,” he added.

Yellow fever, an acute viral haemorrhagic disease transmitted by infected mosquitoes, is another ailment that peaks during this season. The ‘yellow’ in the name refers to jaundice that affects some patients. The yellow fever virus is an arbovirus of the flavivirus genus, transmitted by mosquitoes belonging to the Aedes and Haemogogus species.

According to the WHO, Nigeria is a high-risk country for yellow fever and is recognised as a high priority country to the global Eliminate Yellow Fever Epidemics (EYE) Strategy.
 
The Guardian gathered that different mosquito species live in different habitats – some breed around houses (domestic), others in the jungle (wild), and some in both habitats (semi-domestic).

The WHO noted that there are three types of transmission cycles of yellow fever. In tropical rainforests, wild mosquitoes of the Aedes and Haemogogus species, which are the primary reservoirs of yellow fever, pass the virus on to monkeys.

The world body noted that humans working or travelling in the forest are bitten by infected mosquitoes and develop yellow fever. WHO stated that intermediate yellow fever occurs when semi-domestic mosquitoes infect both monkeys and humans.

According to WHO, increased contact between people and infected mosquitoes leads to increased transmission and many separate villages in an area can develop outbreaks at the same time.

“This is the most common type of outbreak in Africa. Large epidemics occur when infected people introduce the virus into heavily populated areas with a high density of Aedes aegypti mosquitoes and where most people have little or no immunity due to lack of vaccination or prior exposure to yellow fever. In these conditions, infected mosquitoes transmit the virus from person to person,” WHO added.

On the symptoms of yellow fever, Dr. Robert Saleko mentioned fever, headache, jaundice, muscle pain, nausea, vomiting and fatigue, among others. According to him, a small proportion of patients, who contract the virus develop severe symptoms and approximately half of those die within seven to 10 days.

“The virus is endemic in tropical areas of Africa and Central and South America. An extremely effective vaccine prevents yellow fever, which is safe and affordable. A single dose of yellow fever vaccine is sufficient to grant sustained immunity and life-long protection against yellow fever disease.
 
“A booster dose of the vaccine is not needed. The vaccine provides effective immunity within 10 days for 80-100 per cent of people vaccinated, and within 30 days for more than 99 per cent of people vaccinated,” Saleko said.

An Australia-based Nigerian medical doctor, Mike Okon, explained that once contracted, the yellow fever virus incubates in the body for three to six days. According to him, many people do not experience symptoms, but when these do occur, the most common are fever, muscle pain with prominent backache, headache, loss of appetite, and nausea or vomiting. In most cases, symptoms disappear after three to four days.

Okon further explained that a small percentage of patients enters a second and more toxic phase within 24 hours of recovering from initial symptoms, and at that point, high fever returns and several body systems are affected, usually the liver and the kidney.

He said: “In this phase, people are likely to develop jaundice (yellowing of the skin and eyes, hence the name ‘yellow fever’), dark urine and abdominal pain with vomiting. Bleeding can occur from the mouth, nose, eyes or stomach. Half of the patients who enter the toxic phase die within 7 to 10 days.”

On the diagnosis, he said: “Yellow fever is difficult to diagnose, especially during the early stages. A more severe case can be confused with severe malaria, leptospirosis, viral hepatitis, other haemorrhagic fevers, infection with other flaviviruses and poisoning.

“Polymerase chain reaction (PCR) testing in blood and urine can sometimes detect the virus in early stages of the disease. In later stages, testing to identify antibodies is needed (ELISA and PRNT).”

Occasionally, travellers who visit yellow fever endemic countries may bring the disease to countries that are free from yellow fever.

“To prevent such importation of the disease, many countries require proof of vaccination against yellow fever before they will issue a visa, particularly if travellers come from, or have visited yellow fever endemic areas,” he added.

Chickenpox, also called varicella, is characterised by itchy red blisters that appear all over the body. It often affects children, and is so common that it is considered a childhood rite of passage.

It’s very rare to have chickenpox infection more than once. And since the chickenpox vaccine was introduced in the mid-1990s, cases have declined.

An itchy rash is the most common symptom. The infection will have to be in your body for around seven to 21 days before the rash and other symptoms develop.

You start to be contagious to those around you up to 48 hours before the skin rash starts to occur. The non-rash symptoms, which may last a few days, include fever, headache and loss of appetite

“One or two days after you experience these symptoms, the classic rash will begin to develop. The rash goes through three phases before you recover, including red or pink bumps all over one’s body. The bumps become blisters filled with fluid that leaks. The bumps become crusty, scab over, and begin to heal,” said Dr. Pat Oloide.

The expert noted that the bumps in the body would not all be in the same phase at the same time. “New bumps will continuously appear throughout your infection period. The rash may be very itchy, especially before it scabs over with a crust.

“You are still contagious until all the blisters on your body have scabbed over. The crusty scabbed areas eventually fall off. It takes seven to 14 days to disappear completely,” he said.

The Guardian learnt that Varicella-zoster virus (VZV) causes chickenpox infection. Most cases occur through contact with an infected person. The virus is contagious to those around you for one to two days before your blisters appear. VZV remains contagious until all blisters have crusted over. The virus can spread through saliva, coughing, sneezing and contact with fluid from the blisters.

Oloide said: “Exposure to the virus through previous active infection or vaccination reduces risk. Immunity from the virus can be passed on from a mother to her newborn. Immunity lasts about three months from birth.

“Anyone who has not been exposed may contract the virus. Risk increases under any of these conditions: you have had recent contact with an infected person; you are under 12 years of age; you are an adult living with children; you have spent time in a school or childcare facility; your immune system is compromised due to illness or medications.

“Most people diagnosed with chickenpox will be advised to manage their symptoms while they wait for the virus to pass through their system. Parents will be told to keep children out of school and daycare to prevent the spread of the virus. Infected adults will also need to stay at home.

“Your doctor may prescribe antihistamine medications or topical ointments, or you may purchase these over the counter to help relieve itching. You can also soothe itching skin by taking lukewarm baths, applying unscented lotion, wearing lightweight and soft clothing

“Your doctor may prescribe antiviral drugs if you experience complications from the virus or are at risk of adverse effects. People at high risk are usually young, older adults, or those who have underlying medical issues.

“These antiviral drugs do not cure chickenpox. They make the symptoms less severe by slowing down viral activity. This will allow your body’s immune system to heal faster.

“The chickenpox vaccine prevents chickenpox in 98 per cent of people who receive the two recommended doses. Your child should get the shot when they are between 12 and 15 months of age. Children get a booster between 4 and 6 years of age.

“Older children and adults who haven’t been vaccinated or exposed may receive catch-up doses of the vaccine. As chickenpox tends to be more severe in older adults, people who haven’t been vaccinated may opt to get the shots later.”

MEASLES is viral infection that starts from the respiratory system. It remains a significant cause of death worldwide despite the availability of a safe and effective vaccine.

There were about 110, 000 global deaths related to measles in 2017, most of them in children under the age of five, according to WHO. Measles cases have also been increasing in the United States in recent years.

Symptoms of measles generally first appear within 10 to 12 days of exposure to the virus. They include cough, fever, runny nose, red eyes, sore throat and white spots inside the mouth.

A widespread skin rash is a classic sign of measles. This rash can last up to seven days and generally appears within 14 days of exposure to the virus. It commonly develops on the head and slowly spreads to other parts of the body.

Measles is caused by infection with a virus from the paramyxovirus family. Viruses are tiny parasitic microbes. Once you’ve been infected, the virus invades host cells and uses cellular components to complete its life cycle.

The measles virus infects the respiratory tract first. However, it eventually spreads to other parts of the body through the bloodstream. It occurs in humans and not in other animals. There are 24 known genetic types of measles, although only six are currently circulating.

Measles is highly contagious. A susceptible person that’s exposed to the measles virus has a 90 per cent chance of becoming infected. Additionally, an infected person can go on to spread the virus to anywhere between 9 and 18 susceptible individuals.

The main risk factor for catching measles is being unvaccinated. Also, some groups are at a higher risk of developing complications from measles infection, including young children, people with a weakened immune system, and pregnant women.

There is no specific treatment for measles. Unlike bacterial infections, viral infections aren’t sensitive to antibiotic. The virus and symptoms typically disappear in about two or three weeks.

The incubation period of an infectious disease is the time that passes between exposure and when symptoms develop. The incubation period for measles is between 10 and 14 days.

After the initial incubation period, you may begin to experience nonspecific symptoms such as fever, cough and runny nose. The rash will begin to develop several days later.

If you think you’ve been exposed to measles and haven’t been vaccinated, you should contact your doctor as soon as possible. Getting vaccinated is the best way to prevent measles.

Cholera is a waterborne disease with a high risk of transmission. It’s higher when there is poor sanitation and disruption of clean water supply. The practices such as improper disposal of refuse and open defecation endanger the safety of water used for drinking.

With a total of 72, 910 suspected cases and 2, 404 deaths with a Case Fatality Rate (CFR) of 3.3 per cent in 27 states and FCT, figures for the 2021 outbreak surpassed those for the peak record of 1991, where a total of 59,478 cases were recorded with 7, 654 deaths as well as CFR of 12.9 per cent.

Though the 1991 outbreak recorded more deaths (7,654) as against 2, 404 deaths recorded currently, medical experts and others are worried that the current outbreak may beat the record set by the 1991 outbreak earlier if the government continues with its laissez faire attitude.

According to the Nigeria Centre for Disease Control (NCDC) Cholera outbreak cumulative epidemiological summary as of September 12, 2021 (Week 36), of the suspected cases since the beginning of the year, age group 5 to 14 years, is the most affected for male and female.

The report reads: “Of all suspected cases, 50 per cent are males and 50 per cent are females. So far, 27 states and FCT have reported suspected cholera cases in 2021.

“They are Abia, Adamawa, Bauchi, Bayelsa, Benue, Borno, Cross River, Delta, Ekiti, Enugu, FCT, Gombe, Jigawa, Kaduna, Kano, Katsina, Kebbi, Kogi, Kwara, Nasarawa, Niger, Ogun, Osun, Plateau, Sokoto, Taraba, Yobe, and Zamfara.

“In the reporting week, 13 states reported 1,182 suspected cases – Bauchi (472), Katsina (194), Borno (106), Jigawa (95), Yobe (80), Kaduna (68), Adamawa (63), Sokoto (38), Gombe (34), Abia (13), Taraba (10), Ogun (8) and Niger (1).

“There was a 58 per cent decrease in the number of new suspected cases in week 36 (1,182) compared with week 35 (1, 677). Bauchi (472), Katsina (194) and Borno (106) accounted for 65.3 per cent of the 1,182 suspected cases reported in week 36.

“During the reporting week, 48 Cholera Rapid Diagnostic Tests (RDT) were conducted. RDT tests conducted were from Gombe (30), Adamawa (11), Katsina (3), Kaduna (2) and Abia (2). Of this, a total of 18 (38 per cent) were positive by RDT.

“A total of 10 culture tests were conducted: Katsina (6), Adamawa (3) and Kaduna (1). Of this, 2 (20 per cent) were positive.

“Of the cases reported, there were 23 deaths: Kaduna (6), Adamawa (5), Katsina (4), Gombe (2), Jigawa (2), Bauchi (1), Borno (1), Ogun (1) and Taraba (1) with a weekly CFR of 1.9 per cent.

“Two new states (Abia and Ogun) reported cases in week 36. The national multi-sectoral EOC activated at level 02 continues to coordinate the national response.

“Three states of Bauchi (18,822 cases), Kano (10,187 cases) and Jigawa (9,300 cases) account for 53 per cent of all cumulative cases, while 10 local councils across 5 states–Bauchi (4), Jigawa (2), Zamfara (2), Kano (1) and Katsina (1)– have reported more than 1,000 cases each this year.”

To address the underlying issues in the long term, the agency said there was a need for access to safe drinking water and maintenance of proper sanitation and hygiene, while the NCDC continues to advocate for states’ prioritisation of actions that ensure access to and use of safe water, basic sanitation and good hygiene practices in communities.

In its report, the NCDC advised Nigerians to visit a health facility immediately they experience a sudden onset of profuse watery diarrhoea, nausea, vomiting and weakness, saying that cholera is preventable and treatable but can be deadly when the infected does not access immediate care.

Lassa fever
With the confirmation of Lassa fever cases in Nasarawa State and FCT, the NCDC has intensified the activities of the national multi-sectoral and multi-disciplinary Lassa fever Technical Working Group (TWG) for surveillance and adequate response in the country.

Lassa fever is an acute viral hemorrhagic illness that is transmitted to humans through contact with food or household items contaminated by infected rodents (rats, others).

Person-to-person transmission can also occur, particularly in healthcare settings, when there is absence of or inadequate infection control measures.

Lassa fever presents initially like any other febrile illness such as malaria, and so, a high index of suspicion is required, especially for the attending healthcare workers.

Its symptoms include fever, headache, sore throat, general body weakness, cough, nausea, vomiting, diarrhoea, muscle pains, chest pain, and in severe cases, unexplainable bleeding from ears, eyes, nose, mouth, and other body openings.

Benjamin Oruene, a medical doctor, said the time between infection and appearance of symptoms of the disease is three to 21 days, adding that early treatment and diagnosis increase the chances of survival.

“The disease is endemic in Nigeria like in several other countries in West Africa, and most cases are seen during the dry season, often between November and May.”

The Guardian gathered that since January 2021, a total of 434 confirmed cases, with 80 deaths, have been reported from 17 states and 63 local government areas in Nigeria.

Responses
It was learnt also that since 2016, NCDC has worked towards improving diagnostic capacity for the disease. Currently, seven laboratories have the capacity to test for Lassa fever in Nigeria while the NCDC National Reference Laboratory (NRL) coordinates their operations.

This development is said to have improved active case detection and care for affected individuals.

Nigeria, through NCDC, is participating in the largest-ever Lassa fever study supported by the Coalition for Epidemic Preparedness and Innovations (CEPI) to provide an accurate assessment of the incidence of the disease in West Africa.

This is also geared towards the development of vaccines and therapeutics for Lassa fever. The NCDC continues to provide support to states through the provision of emergency medical and laboratory supplies and by the deployment of Rapid Response Teams (RRT).

Following the recommended One Health approach, the NCDC is working with relevant ministries, departments and agencies as well as other partners to strengthen the capacity of states to effectively manage outbreaks alongside COVID-19 and other diseases of public health relevance.

The Guardian learnt that risk communication activities are ongoing through radio, posters, flyers, and social media. The Federal Ministry of Environment is also implementing a Lassa fever environmental response campaign in high burden states.

To reduce the risk of the spread of Lassa fever, NCDC advises Nigerians to ensure proper environmental sanitation – keeping the environment clean at all times, blocking all holes in the house to prevent rats from entry, covering dustbins and disposing of refuse properly.

The agency urged communities to set up dumps very far from their homes to reduce the chances of having rodents within homes. It advised the masses to store foodstuff like rice, garri, beans, corn/maize and their likes in containers that are well covered with tight-fitting lids

“Practice good personal hygiene by frequent washing of hands with soap under running water /or use of hand sanitisers when appropriate. Visit the nearest health facility if you notice any of the signs and symptoms of Lassa fever as mentioned earlier, avoid self-medication,” NCDC said.

Reason For Peaking During Dry Season
On the mysteries behind these diseases peaking between November and May, the Managing Director, Chidicon Medical Center, and Institute of Space Medicine and Neurocybernetic Flow Laboratory, Prof. Philip Njemanze, listed two major factors – humidity and temperature that determine the cyclical nature of a disease.

“The major factors that determine the spread of diseases, virus and bacteria, are humidity and temperature. Some of these diseases cannot survive in a high-temperature belt and that is why you see them come during this period, end of the year, before the beginning of the rain when the humidity is low.

“Sometimes, the temperature may be high but the humidity is low. So, it takes such low humidity for them to survive. And that is why we talk about COVID-19, what we need in the banks are humidifiers and not air conditioners because the air conditioner is giving it the natural habitat to survive and procreate,” he explained.

 
According to Dr. Auda Fares of Department of Internal Medicine, Johannes Hospital, Bedburg, Germany, many infectious diseases flourish when the weather is cold and when people live in closed houses. It decreases in warmer weather. “Understanding of the reasons for seasonality of infectious diseases may offer possibilities for preventive measures.”

On the factors influencing the seasonal pattern of infectious diseases, he said it could be population, susceptibility and behavior. According to Fares, environmental influences are also important considerations.

“The knowledge of the role of environmental factors (infection, cold, etc.) or other triggers (indoor activity, vitamin D intake) could be used to improve prevention measures and educational strategies, especially in people with a risk of infection.

“People should be informed about the importance of proper housing ventilation and the potential benefits of increased outdoor activity in natural UV light. Furthermore, adequate vitamin D status may be required particularly in winter to decrease infection rates. Future population-based studies to evaluate broad effects of vitamin D supplementation on infection rates may be warranted,” Fares said.