Diphtheria remains a significant threat to individuals and families in Nigeria, particularly affecting unvaccinated children. The current outbreak starkly highlights past failures. The question looms: will the leadership of the Federal Ministry of Health and Social Welfare rise to the challenge, or will they engage in meetings, talks, and interventions with limited impact? ALAO ABIODUNdelves into the issues
Why should anyone succumb to diphtheria? Why should children fall victim to a disease entirely preventable with vaccines? These questions echo the frustration faced in Nigeria, a country equipped with both vaccines and diphtheria antitoxin (DAT) either procured or donated by development partners. As of October 3, 2023, a staggering 8,604 individuals have been afflicted by diphtheria, and 453 lives have been lost, as outlined in a joint report by the Federal Ministry of Health, the National Primary Health Care Development Agency (NPHCDA), and the Nigeria Centre for Disease Control and Prevention (NCDC). Shockingly, these infections and fatalities have spread across 114 Local Government Areas (LGAs) in 19 states, including the Federal Capital Territory (FCT).
Kano State emerges as the epicentre of this outbreak, representing 86 per cent (7,188 cases) of the total 8,604 confirmed cases in Nigeria. Other affected states include Yobe (775 cases), Katsina (232 cases), Borno (118 cases), Jigawa (23 cases), Bauchi (20 cases), Kaduna (17 cases), Lagos (8 cases), FCT (6 cases), Gombe (5 cases), Osun (3 cases), Sokoto (3 cases), Niger (2 cases), Cross River (1 case), Enugu (1 case), Imo (1 case), Nasarawa (1 case), Zamfara (1 case), and Kebbi (1 case).
Tragically, the most impacted by diphtheria are children aged 1 to 14, with 80 percent of confirmed cases in this age group being unvaccinated. This grim reality stems from historical failures, manifested in Nigeria’s vaccination coverage gap, currently standing at 43 percent. This means that only 5 out of every ten children in the country have received all three pentavalent vaccines, which protect against five life-threatening diseases: Diphtheria, Pertussis, Tetanus, Hepatitis B, and Hib.
Behind these harrowing statistics lie real human beings—Nigerians with families who cherish them, individuals with dreams and potential that could have benefited the nation. Their lives have been tragically cut short due to various preventable reasons, including parental ignorance or the government’s failure to fulfill its crucial role in ensuring that every child receives the full spectrum of vaccines they need to thrive.
Diphtheria, as described by the World Health Organisation (WHO), is a highly contagious disease preventable through vaccination. It is primarily caused by Corynebacterium diphtheria, with Corynebacterium ulcerans also identified as a source. The disease spreads through direct contact or respiratory droplets in the air, posing a significant risk to unimmunised children. Symptoms typically start with a gradual onset, including a sore throat and fever. In severe cases, the bacteria produce a toxin that forms a thick grey or white patch at the back of the throat, potentially obstructing airways, leading to breathing and swallowing difficulties, accompanied by a barking cough. Swelling in the neck, caused by enlarged lymph nodes, is also a common symptom.
Nigeria has experienced diphtheria outbreaks in the past, notably in 2011 and 2022. In the current year, an initial outbreak occurred between January and April, affecting 21 of the 36 states and the Federal Capital Territory (FCT). However, the WHO recently sounded an alarm, declaring that Nigeria is facing a second wave of the diphtheria outbreak. The first wave occurred from January 1, 2023, to May 22, 2023. The WHO reported an increase in affected population, with a rise in confirmed cases and related deaths during epidemiological weeks 31 to 33, which span from the end of July to mid-August this year. Additionally, there is an elevated risk of transmission, with clusters and outbreaks reported in newly affected Local Government Areas (LGAs).
Nigeria’s vaccination figures betray the true narrative
The Coordinating Minister of Health and Social Welfare, Prof Muhammad Ali Pate, has his work cut out for him, as the health indices and wellbeing optics in the country are not looking good at all. Maternal and infant death is on the rise, communicable and non-communicable diseases are taking the lives of millions, COVID-19 and its attendant mortality and morbidity is not yet over, the health sector is poorly funded, out-of-pocket expenses for health are outrageous and catastrophic, and now, diphtheria disease that countries of the world have long left in the annals of their distant history is still a regular guest in Nigeria.
In all this, one must acknowledge some of the efforts of the government to curb the escalation of diphtheria, particularly in taming the community spread of the disease. Few weeks ago, Prof. Pate constituted an emergency Taskforce to curb diphtheria outbreak in the country. The taskforce which is being co-chaired by the Executive Director and Chief Executive Officer of the NPHCDA, Dr. Faisal Shuaib and the Director-General of the NCDC, Dr. Ifedayo Adetifa, will also have the Director of Public Health in the Federal Ministry of Health and Social Welfare, Dr. Anyaike Chukwuma, representatives from the WHO, UNICEF, Federal Ministry of Information, and the Northern Traditional Leaders Committee on Primary Healthcare Delivery (NTLC) as members.
The taskforce team has the responsibility to liaise with the governors of states affected by diphtheria for their counterpart funding, ownership and mass mobilisation. Pate stressed that there is an urgent need for massive mobilisation and sensitisation. “Our people should be aware about the disease, the dangers inherent in it, and what they need to do,” he said.
The Federal Government has urged state governors of affected states to institute face-covering requirements such as facemasks in public gatherings in order to slow down the progress of the diphtheria outbreak. The Executive Director and Chief Executive Officer (CEO) of the NPHCDA, Dr. Faisal Shuaib, during a briefing on diphtheria, said, “I would like to call on governors of affected states to institute face-covering requirements such as facemasks in public gatherings. By so doing, we can add another intervention to slow the progress of the outbreak.”
The WHO, in its diphtheria situation report for Nigeria, disclosed that diphtheria outbreaks are underreported in Nigeria. According to the 2021 Nigeria Multiple Indicator Cluster Survey and National Immunisation Coverage Survey, the third dose of pentavalent vaccine (Penta3) coverage was 57 per cent in 2021. Also, WHO second Rapid Risk Assessment for diphtheria in Nigeria reassessed and maintained the risk as high at the national level and low at the regional and global levels. “The low national coverage (57 per cent) of the Pentavalent vaccine (Penta 3) administered in routine immunisation, and the suboptimal vaccination coverage in the paediatric population—with 43 per cent of the target population unvaccinated—underscores the risk of further spread and the accumulation of a critical mass of susceptible population in the country with sub-optimal herd or population immunity,” it said.
The WHO recommends that vaccine coverage of 80 to 85 per cent must be maintained to ensure community protection. This is a task that all government agencies saddled with the sacred responsibility of public health safety and security, including the Federal Ministry of Health, NPHCDA, NCDC, among others, must do. UNICEF Nigeria has called for an urgent ramping-up of vaccination efforts across the country amidst the most severe diphtheria outbreak in recent times. In a statement, the agency stated that the devastating impact of the diphtheria outbreak across the country is not only a grim reminder of the importance of vaccination, but also that Nigeria is home to a staggering 2.2 million zero-dose children, that is, children who haven’t received even a single dose of vaccine – the second largest of such cohort in the world. “We must collectively take urgent actions to drastically reduce this number. Every child deserves protection from preventable diseases. This is not negotiable,” said Dr. Rownak Khan, UNICEF Representative.
It also called on all local and international partners to rally together to ensure that every child is reached with life-saving vaccines. It emphasised the importance of strengthening routine immunisation, community engagement, and health systems strengthening to avoid similar outbreaks in the future.
No excuses for low vaccination coverage
It is diphtheria today. Tomorrow, it may be hepatitis, tetanus, circulating variant poliovirus (cVPV2), and others. Although ensuring that children are immunised against vaccine-preventable diseases is the collective responsibility of all, especially parents, the government has a major responsibility to provide qualitative, affordable and accessible healthcare services to the people.
With over 30,000 primary health care centres (PHCs) scattered across the country, only about 4,000 of them are actually functional at any given time. Although under the Nigerian federal system, building and maintaining of PHCs is the responsibility of states and local governments, the Federal Government still plays a very big role in its funding and equipping, especially through the Basic Health Care Provision Fund (BHCPF), which is a Federal Government initiative through which one per cent of Nigeria’s consolidated annual revenue and partner resources is deployed to guarantee a defined package of care; provide operational budgets for PHCs, and support accident victims across selected highway belts around the country. While national and sub-national leaders hold meetings and conferences about how to increase routine immunisation in the country, hundreds of thousands of Nigerian children are losing their precious lives. Experts in the immunization space have continued to maintain that the health sector needs less talk and more action.
Stakeholders give practicable solutions
Stakeholders in the health sector have urged the government to do more in terms of advocacy, community engagement, and most important of all, ramping-up routine immunization for children. Stressing that it is much cheaper to spend resources carrying out public enlightenment and community engagement than to treat a lot of people, they noted that the historically low vaccination coverage in the country has come back to haunt the country, affecting children.
Nigeria’s foremost virologist, Prof Oyewale Tomori, has urged the government to stop giving excuses and tackle the issue head-on by vaccinating as many children as possible, especially those in the hard-to-reach areas. Speaking with The Nation, Prof. Tomori said, “We should be ashamed. Close to 80 per cent of cases are partially vaccinated or not vaccinated at all. Children, from new-born to 14 years old, are affected. This shows you how far back our immunisation coverage has been hopeless. More cases between July and September 2023 than from May 2022 to June 2023, shows that we have been waiting for over a year and not declared this a national emergency. How callous and uncaring.
“We spent all our energy on a traumatic election while our children are dying of ordinary diphtheria that the world has forgotten. Every child born in Nigeria must receive their childhood vaccination.”
In a chat with The Nation, Dr. Ejike Orji, a public health advocate and the immediate senior special adviser to the FCT Minister on Health and Hospital Management said, “Once there is a breakdown in the vaccination process, there could be a flare-up and some of these diseases flare up around the world from time to time. The most important thing here is to have surveillance bio-vigilance and a surveillance system to be able to detect it early enough and start acting before it spreads like a wildfire. The government has been doing a lot to contain it, but for me, especially in the public health space, it is human behaviour that is the critical component in most of these. This is because science has made it possible and there are scientific steps to contain or treat the disease.
“However, the most important thing that increases the spread of all these diseases is the human behaviour component. The key thing is to vaccinate children. In Abuja, there is a vaccination program, especially in high risk areas. The FCT Disease Surveillance and Vaccination unit is going round vaccinating children. But will people bring their children out to be vaccinated is another thing. Also, will people keep their environment clean enough?
“On the government side, the government is doing what it is supposed to do, but often, we say the room of improvement is in public education and community engagement. There should be massive public education and community engagement on the matter so that people will know about the disease – how it spreads and how it can be prevented and treated. When people are armed with this information, you have done almost 90 per cent of the work.
“Governments need to use the media, community media, play groups, town cries and others to engage the major stakeholders in the community. It is much cheaper to spend resources doing public enlightenment and community engagement than to treat a lot of people. Traditional and religious leaders are the bridge between the government and the people. They are closer to the people, they know their nuances, and the people believe in them.”
Also speaking with The Nation, Dr. Patrick Ezie, the Chief Medical Director of Silver Cross Hospital in Abuja said, “The important thing to really note on why WHO is raising the alert level for diphtheria currently is because diseases have different spans of spread. For instance, if you have one case of diphtheria in a year, it is not something to be worried about, but when you start having 10, 15, 20 or more cases, you start reaching epidemic levels. At the epidemic level, it means that the illness has spread to such a degree that it now becomes a public health emergency.
“What the government can do is to recognise that it needs to ramp up the public health concern about it, and be on the same page as WHO and realise that this is a disease that can become an epidemic for the country. This way, you can become more aggressive by setting up different public health interventions. Having diphtheria spreading to this level means that there is a failure in the current immunisation programme. It means that the immunisation is not getting to enough babies or you have a pool of babies who are not able to access this vaccine or the vaccine storage system is faulty; this means you have vaccines that have lost their potency by the time they are getting to the end users. As a result, you have people who are supposed to be immunized, but in reality, they are not immunised.
“The government also needs to introduce booster doses and start vaccinating the population of citizens that may be at risk or do not have access to health facilities, so that diphtheria antibodies increase. I don’t think there has been enough adverts on radio, TV, print, and others to alert the populace on the spread of diphtheria, the nature of illness, and the way to prevent it. Government also needs Public-Private Partnerships (PPP). It is okay to have the vaccines in public institutions, but are the private ones carried along? There is an increasing proportion of people who use private facilities, as against the public facilities, especially with the frequent strikes and breakdown of services in the public sector.
“The current way the diphtheria vaccine is given is in combination with three or four other vaccines for babies. But there is a combination of tetanus and diphtheria that can be done. So, when you are giving a tetanus shot, diphtheria can be given alongside. If we have such vaccines in-country, there needs to be more advocacy such that health workers can know that the vaccine is available and push it for the population. The government can also ensure that when people have the exposure or are identified to have diphtheria, that there is public health surveillance to check if the people in contact with the infected individual are suffering the symptoms. Contact tracing is very important.”
