Image Source: Science Direct
Lara Adejoro
Diphtheria, a contagious and potentially fatal bacterial infection, has been eradicated from most countries after routine childhood vaccination drives. Yet in Nigeria, low vaccination coverage, ignorance and apathy awakened the once-forgotten disease. LARA ADEJORO writes
At about 5:30 p.m., 17-year-old Madina Samalla was wheeled into the Intensive Care Unit of the Diphtheria Treatment Centre in the Murtala Mohammed Specialist Hospital, Kano.
Immediately, a doctor and two nurses lifted her to the bed and fixed on her left hand a monitor to track her vitals.
With her hands clasped and head bowed, her agitated mother, Zuwara Masaudu, sat by the bedside.
Samalla urgently needed dialysis, and so an international medical humanitarian organisation, Médecins Sans Frontières, also known as Doctors Without Borders, stepped in, took up the matter and settled her medical bills.
The sick girl was subsequently referred to the Aminu Kano Teaching Hospital in Kano.
That would be the fourth place Samalla would be taken to for medical intervention.
When she developed a fever and splitting headache, her mother first took her to a nearby patent store in the Badawa, Nasarawa Local Government Area, where she was given some intravenous fluid but there was no improvement.
A few days later, she was taken to a government-owned hospital, given IV fluids and later taken home, but the fever did not subside.
“It was during our third visit to another hospital that a doctor checked her throat and found a thick coating there and referred us to this place,” her mother explained in Hausa.
Not knowing what the disease was, the woman did not hesitate to take her to the MMSH for diagnosis, and treatment.
On the 26 days of her tiny frame being ravaged by diphtheria, Samalla could no longer speak or walk, and her right hand and leg were partially paralysed.
It was then that an ambulance took her to the DTC, where she was then being fed through a flexible tube inserted through her nose.
Hers was a typical case of severe diphtheria and it led to acute kidney injury and polyneuropathy (the simultaneous malfunction of many peripheral nerves throughout the body).
Samalla and her mother live with a family member in Badawa in the densely populated Nasarawa Local Government Area, where houses are sandwiched together, making cross ventilation very difficult.
Sometimes families of six live in one very small room, a living condition that provides an ideal environment for disease incubation and outbreaks.
Nasarawa Local Government Area is one of the places with the highest incidence of diphtheria cases in Kano state.
Samalla’s case was one of those caused by lack of immunisation and late detection, worsened by low awareness about the disease.
She was not vaccinated at birth and her family had never heard of diphtheria.
Worsening her case was the fact that local doctors did not immediately suspect the disease, despite the infection having affected thousands of people and killed hundreds in the state.
One of the doctors in the ICU, Dr Aminu Liman, feared Medina may develop a heart disease.
“It has not started manifesting but she may start manifesting with symptoms of myocarditis. The thing with diphtheria is that the earlier you begin treatment, the better for the patient. She is responding positively to treatment and has received diphtheria antitoxin and is being well managed,” he added.
The MMSH is one of the two MSF-supported DTCs treating patients with moderate to severe cases of the disease.
The second DTC is the Infectious Disease Hospital in Kano, where patients with mild cases are treated. The two centres have a total of 146-bed capacity.
Diphtheria, a fatal infection
According to the Nigeria Centre for Disease Control and Prevention, diphtheria is a serious bacterial infection that affects the nose, throat, and sometimes, the skin of an individual.
It is caused by the bacterium Corynebacterium species, mainly by toxin-producing Corynebacterium diphtheriae and rarely by toxin-producing strains of C. ulcerans and C. pseudotuberculosis.
“It manifests as laryngitis, pharyngitis, or tonsillitis and is associated with the presence of an adherent membrane covering the tonsils, pharynx, and/or nose. Beyond the respiratory symptoms, approximately a quarter of cases may develop heart problems (myocarditis),” NCDC stated.
The nation’s public health institute stated that a historical gap in vaccination coverage is a driver of the outbreak.
Diphtheria affects mostly children aged one to 14 years with those aged five to 14 years bearing major brunt of the disease.
According to the former Executive Director and Chief Executive Officer of the National Primary Health Care Development Agency, Dr Faisal Shuaib, over 80 per cent of children who died of diphtheria or were admitted to hospitals never received routine childhood immunisations.
“People living in crowded or unclean conditions and those who are not well nourished can also be affected. Diphtheria affects all age groups. The age group commonly affected the most is children under five years. Adults over 60 years are also at high risk of being infected,” Faisal said.
MSF emergency medical doctor in Nigeria, Dr Hashim Juma Omar emphasised that low national vaccination coverage and a worldwide shortage of lifesaving antitoxin worsened the outbreak.
“Children under the age of five and women are the most affected in Kano state, and they really need help. The number of suspected cases in other countries in the region adds to the urgency of increasing access to antitoxin drugs and vaccination initiatives,” he added.
Omar urged international organisations to scale up improved surveillance and contact tracing, and measures to strengthen the local health system.
A report by the United Nations Children’s Fund revealed that 67 million children across the world missed out on either some or all routine vaccinations between 2019 and 2021, and that 48 million children did not receive a single dose during this period.
The report showed that as of the end of 2021, India and Nigeria – with very large birth cohorts, had the largest numbers of zero-dose children but increases in the numbers of zero-dose children were especially notable in Myanmar and the Philippines.
India leads the world with the largest number of 2.7 million children with zero doses, followed by Nigeria with 2.2 million unvaccinated children.
A disease of the past posing a new threat
An ICU nurse, Maria Fix who travelled from Germany to support the severe cases of diphtheria at the ICU stated that outside Nigeria, there are not lots of people specialising in diphtheria cases.
She noted that though some of the complications recorded are not new, diphtheria is a disease that has not been researched in the last years, adding, “Because there are not plenty of cases and what we have learnt right now about diphtheria is huge and managing the disease better because there was not much about diphtheria.
“I never knew diphtheria was severe before I came here, even in my home country, you hardly learn about it anymore. It is not really a topic that I have some knowledge about but we need to learn more, especially about how fatal the disease is and how critical it can get.”
Fix said most of the complications recorded at the unit are acute kidney injury, thrombocytopenia, airway obstruction, myocarditis, and neuropathy.
“The complications are coming from the bacteria, which produces an endotoxin that finds its way to the organs. When the endotoxin is in a specific organ, it is very difficult to treat. This is important to prevent because the antitoxin is difficult to get.
Ignorance and lack of awareness thrive
Aisha Bello did not know what she was up against when she noticed white patches on her daughter’s throat, which was accompanied by an uncontrollable dry cough.
For four days, she took her ailing 18-month-old daughter, Fatima Abubakar, to a patent shop and a health facility to ascertain what could have caused her persistent fever.
“They gave me two bottles of syrup and four different injections,” the troubled mother said.
But the illness refused to clear, making her travel to another locality, where she was administered another set of injections.
Not long after, the already severely malnourished baby developed a bull’s neck and could not eat again.
“It was a Fulani friend who told me her kind of condition is being treated at the MMSH. I travelled from Dogorawa to Dawaki Tofar,” the 27-year-old- mother said.
Where and how did she get it, the mother of four did not know, just like many other parents whose children were admitted to the ICU.
However, one obvious fact she never knew was if her daughter was vaccinated against the deadly disease
“I don’t know anyone with the disease in my neighbourhood, she only goes to an Islamic school and never missed her immunisation schedule,” she quipped.
Background of diphtheria in Nigeria
In Nigeria, there was a diphtheria outbreak in Borno, north-eastern Nigeria in 2011 with a total of 98 cases, and 21 deaths (case fatality ratio was 21.4 per cent), according to the NCDC.
“This outbreak and the associated high case fatality were due to a combination of low vaccination coverage, delayed clinical recognition and laboratory confirmation, and the absence of antitoxin and antibiotics for treatment,” the centre said.
On December 1, 2022, the NCDC was notified of suspected diphtheria outbreaks in Kano and Lagos states.
In response to the notification, Rapid Response Teams were deployed to both states to confirm the outbreak and support response activities.
Diphtheria outbreaks were confirmed in both States and NCDC has been supporting response activities in both states.
As of the third week in January 2023, the disease had spread to two more states – Yobe, and Osun, with total confirmed cases hitting 111 with 22 deaths.
However, by the fifth week, it had spread to Katsina, and the dead among the 216 confirmed cases increased to 40.
By week nine, a total of 389 confirmed cases were reported from six states, including Kaduna, with 62 deaths.
As of May 31, Cross River recorded a case and the number moved to 672 with 73 deaths.
By October 19, the country had recorded about 9,478 confirmed cases from 15,060 suspected cases of diphtheria infections from 137 LGAs across 20 states, including the Federal Capital Territory.
As of December 3, the NCDC confirmed 12,086 cases of diphtheria across 148 LGAs in 20 States.
The NCDC also reported a total of 554 deaths among confirmed cases.
“A total of 20,684 suspected cases were reported from 33 States across 280 LGAs. Kano (13461), Yobe (2234), Katsina (1509), Bauchi (1139), Borno (968), Kaduna (486) & Jigawa (256) accounted for 96.9 per cent of suspected cases reported.
“Of the 20,684 suspected cases reported, 12086 (58.4 per cent) were confirmed cases (320 lab-confirmed; 0 epid linked; 11,766 clinically compatible), 4,509 (21.8 per cent) were discarded, 1,844 (8.9 per cent) are pending classification & 1,827 (8.8 per cent) were unknown.
“The confirmed cases were distributed across 148 LGAs in 20 States. Kano (9613), Yobe (966), Bauchi (614), Katsina (440), Borno (348) & Jigawa (44), and Kaduna (24) accounted for 99.7 per cent of confirmed cases reported.
“Majority [8,393 (69.4 per cent)] of the confirmed cases were among children aged 1 – 14 years. Only 3,202 (26.5 per cent) out of the 12086 confirmed cases were fully vaccinated with a diphtheria toxoid-containing vaccine,” the NCDC stated on its website.
The centre said the case fatality rate of 4.6 per cent was recorded among confirmed cases.
Diphtheria and vaccination
The diphtheria outbreak reawakened the vaccination drive as many in states and across the country submitted to vaccination.
At the MMSH and the IDH, all the parents and guardians of infected patients were vaccinated within 24 hours to prevent the risk of further spread.
A Consultant Paediatrician and Kano State Manager for diphtheria outbreak response, Salma Ali-Suwaid said there is an increase in the vaccination rates but agrees that there is still vaccine hesitancy due to recent unfounded claims of some individuals.
The expert, who has been one of the front liners since the outbreak of the disease explained, “At the beginning of the outbreak, there was that enthusiasm of people coming (for vaccination) but there was a big blow recently where a local radio aired some claims that some children developed complications after taking the diphtheria vaccines. This affected the acceptability of the vaccine and we are trying to catch up.”
The Paediatrician said the state Ministry of Health partners with MSF and others for capacity building, surveillance, and response at various levels.
“It has partnered with MSF in ensuring the availability of beds, and supply of DAT, the NCDC is supporting the centre with the supply of DAT and helping with other partnerships to give the booster doses to all the close contacts and other individuals.
“MSF has been wonderful with their support; they feed the patients and give all the other management services including drugs, and investigations. In those that developed complications, MSF sees to it that the services are given to the children free of charge,” she added.
Ali-Suwaid agreed that the challenge has been the naivety of people towards accepting vaccination.
As of mid-October, Dr Shuaib said 1,692,762 children, between six months and four years of age, had been administered the Pentavalent vaccine, and that 3,166,419 children aged four to 14 years had received the Tetanus-Diphtheria vaccine.
He disclosed that 1,111,310 children in Kano had been immunised with the TD vaccines and 544,737 children with the Pentavalent vaccine.
Katsina had vaccinated 403,252 children with TD vaccines and 255,075 children with Pentavalent vaccines.
Low funding for vaccine-preventable diseases
PUNCH Healthwise checks through the budgetary allocations in the health sector from 2020 to 2023 showed that there were no specific allocations to disease outbreaks in the country.
The only places where diseases are mentioned are to conduct research, surveillance, capacity development, and campaigns for diseases of public health importance.
The Director General of NCDC, Dr Ifedayo Adetifa told our correspondent that “This outbreak (diphtheria) response has been funded with government funds through appropriation, through the World Bank Regional Disease Surveillance Systems Enhancement project before it closed in August 2023, and also through support in kind by development partners – the UK Health Security Agency, the World Health Organisation, the United Nations Children’s Fund; and for outbreak deployments (GAVI through WHO).”
Also, the Chief Executive Officer of the Vaccine Network for Disease Control, Chika Offor, said the Federal Government did not release any substantial funds from the appropriated immunisation budget for 2023.
He noted that the total amount that has been appropriated, cash-planned, and not released is about N60bn, which is over 80 per cent of the budgeted sum.
“We urgently advocate to the Accountant General of the Federation for the swift release of the cash-planned N60bn immunisation funds.
“The timely release of these funds is paramount to sustaining the momentum in our nation’s immunisation efforts, which directly impact the health and well-being of our citizens,” she said at a recent press briefing in Abuja.
According to her, the failure to release funds for immunisation purposes has left Nigeria vulnerable to the resurgence of vaccine-preventable diseases such as diphtheria, and polio.
Prompt response to outbreak key – Expert
A public health expert, Dr Obinna Ebirim, however, did not foresee a future outbreak due to a drop in the effectiveness of the Nigerian vaccination programme.
“Outbreaks are highly likely when we have a new disease or drop the ball on preventive measures like vaccination. I have huge confidence in the new leadership at the NPHCDA,” he said.
Based on the coordinated response by NPHCDA and NCDC, he believed Nigeria would ensure that measures reach diverse populations, especially those in rural and underserved communities in terms of language and geography.
“Our response to these outbreaks is key. Based on the coordinated response by NPHCDA and NCDC, I am hopeful. We must ensure that measures are reaching our diverse populations, especially those in rural and underserved communities in terms of language and geography.
“Climate pattern modelling can be used to predict some seasonal diseases. While predicting future outbreaks or pandemics is not an easy task, we can do something now to be better prepared and respond better,” Ebirim said.
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