In Abuja, the Federal Capital Territory, where the grandeur of the nation’s capital shines, an insidious threat of diphtheria silently spreads.
This long-forgotten disease has resurfaced, fuelled by a deadly nexus of ignorance, lack of access to healthcare, and deeply ingrained religious beliefs.
The bacterial infection, often forgotten amidst the world’s pressing health challenges, has recently reemerged in Nigeria, leaving healthcare professionals, communities, and families on high alert.
Diphtheria is a respiratory infection caused by the bacterium Corynebacterium diphtheriae, which can be fatal if left untreated. It is primarily transmitted through respiratory droplets and close contact with an infected individual.
According to the Nigeria Center for Disease Control and Prevention(NCDC), Lead Diphtheria Technical Working Group, Dr. Bola Lawal, diphtheria is a vaccine-preventable disease, highly infectious, caused by bacteria diphtheria.
It is actually a germ, in layman’s words. While coughing or sneezing, symptoms actually start at about two to five days after a susceptible individual is actually exposed to these bacteria, which could be as mild as fever or sore throat.
Dr Lawal further said in severe cases, there are toxins being produced by some bacteria, and these toxins actually lead to some form of greyish-white patches on the back of the throat.
“When accumulated in high quantity or volume, will actually lead to obstruction of the throat as well as the passage, thereby leading to difficulty in breathing as well as in severe cases as well.
“This toxin can equally be clinically passed into the bloodstream, affecting the nerves, muscles, and even the heart, and can even cause some form of bleeding disorder abnormalities, and in very severe cases, it could result in death. It’s been reported that one in every ten individuals infected with diphtheria will actually die.
The Nigeria Centre for Disease Control and Prevention says as of June 30th, 2023, there have been 798 confirmed diphtheria in eight (8) States, including the FCT, with a total of 80 deaths accounting for a case fatality rate of 10 percent.
Tungan Wakili, a rural community in the Federal Capital Territory, Abuja, has been devastated by a recent diphtheria outbreak.
The Director of FCT Public Health, Dr Saddiq Abdulrahan, announced the outbreak in the FCT, with one death recorded and one confirmed case.
“The outbreak in the FCT, we had one four-year-old that died out of the eight cases, for that we took the sample to NCDC NLR lab and out of that eight, it is only one that came out positive, and one also died.” He said.
Tribune visited the family which lost the four-year-old recorded by the FCT Public Health Department, revealed that they had actually lost five children in the space of two weeks.
Reaching out to the FCT Public Health department, Tribune learnt that only the 5th case was reported as the other four children had died before the Disease Surveillance Notification officer was alerted.
Diphtheria which is associated with crowded environments, poor hygiene, and lack of immunization, leaves no one to wonder that the disease bacteria can spread and kill 5 children in a short period of two weeks.
The mother of those children lost to diphtheria in FCT who did not want her name in print is the eldest wife in the family. She said when they first noticed the fever in the children, they thought it was normal fever due to the change in season.
While speaking in Hausa, a colleague translated her words as she narrated her experience.
She said: “It started as fever, then they started throwing up, and after some time, their throat ached. After two weeks, one side of their neck started swollen, and after two days, both sides of the neck swole up to the face.”
“It did not stop after this, the neck and face kept swelling up, but after some time, it subsided. Initially, two of them were taken to the hospital, and they were placed on drip, but after that, it seemed the situation got worse than the other.”
“We decided not to take any of the children to the hospital anymore. After nine days, the first child died. One week later, the second child, and a day later, another one died. A day later, another one died, and between 12 days, the other child also died.”
How Ignorance and religious beliefs drive diphtheria transmission
In the community, a lack of knowledge about diphtheria and its transmission and the religious belief that it is God’s will played a significant role in the escalation of the disease.
The mother of children lost to diphtheria said the family left what happened to them with God because God has a plan for everything.
“God decided what happened to us. If God has planned that this is your fate, nobody can change it.” She added.
Also, a community member, who was identified as Nurse Confidence, said when the parent was asked if those children were taken to the hospital, they replied that sometimes it’s not a hospital issue.
Lack of healthcare services
Alhaji Mohammed Daudu the Dakachi of Tungan Wakili, believed that lack of access to a Primary Healthcare Facility in the community also contributed to the rapid spread of the disease.
He said due to the location of the community, the residents cannot access healthcare services because of the highways that lead to the healthcare center nearby
He, therefore, appealed to the government to bring at least one healthcare facility to his community.
Government action to contain diphtheria
With more cases of diphtheria recorded in the country, the House of Representatives has asked the Nigeria Centre for Disease Control and Prevention and the Federal Ministry of Health to effectively contain the outbreak of diphtheria and reduce the fatality ratio in confirmed cases.
A Federal House of Representatives member, Hon. Muktar Shagaya, who mentioned the worrisome situation of diphtheria at a plenary, said there has been a sporadic increase in the number of diphtheria cases in Nigeria since the beginning of the year 2023.
“The house further urges the Federal Ministry of Health and the Nigeria Centre for Disease Control to intensify sensitization and a multiple campaign to prevent and eradicate the scourge of diphtheria and other related diseases in Nigeria.
Authority says vaccination has been the cornerstone of diphtheria prevention efforts, and with recent outbreaks, the FCT Administration is upscaling its vaccination status to protect all children from diphtheria.
The Director General of the NCDC, Dr Ifedayo Adetifa said, anything from 2 to 14 years ago, parents did not make use of opportunities to get vaccinated.
“Because if you are vaccinated according to our immunization schedule, and you receive your three doses of the pentavalent vaccine, which contains anti-diphtheria toxin at 6, 10, and 14 weeks, then you are protected against diphtheria.
The DG further disclosed that over 82 percent of confirmed diphtheria cases are unvaccinated, as he added that it doesn’t mean that because people were not vaccinated when they were younger, they are now being ignored.
NPHCDA is conducting a vaccination campaign including diphtheria antitoxin in the communities at the state hotspots where these cases were found.
Adetifa also appealed to parents and caregivers to take their children to health facilities for routine immunization
“Please take all the children Infant to the health centre; if they’ve not been vaccinated, let them start to catch up with vaccination, and that is the only thing to do to end current and future diphtheria outbreaks.”
WHO risk assessment on diphtheria?
Diphtheria cases are under-reported in Nigeria, with few reports of outbreaks in the past. The last outbreak was reported between February and November 2011 in the village of Kimba and its surrounding settlements in Borno State, north-eastern Nigeria, where 98 cases were reported.
The diphtheria toxoid-containing vaccine third dose coverage in Nigeria is suboptimal. According to the 2021 Nigeria Multiple Indicator Cluster Survey (MICS) and National Immunization Coverage Survey (NICS), the third dose of pentavalent vaccine coverage was 57% in 2021.
The country is currently faced with several public health emergencies such as Lassa fever, cholera, pox, meningitis, and a humanitarian emergency in the northeast of the country. Due to insecurity, especially in northeastern Nigeria, vaccination coverage remains suboptimal, especially in the areas controlled by non-state armed groups.
Therefore, the diphtheria outbreak further complicates and strains the already overstretched resources. The global supply of diphtheria antitoxin (DAT) is limited, which may affect the availability of the required doses in a timely manner.
The overall risk of diphtheria in Nigeria was assessed as high at the national level, low at the regional level, and low at the global level.
WHO advice on diphtheria
WHO recommends epidemiological surveillance ensuring early detection of diphtheria outbreaks should be in place in all countries, and all countries should have access to laboratory facilities that allow for the reliable identification of toxigenic C. diphtheriae. For the adequate medical management of cases, sufficient quantities of diphtheria antitoxin should be available nationally or regionally.
WHO also recommends early reporting and management of suspected diphtheria cases to initiate timely treatment of cases and follow-up of contacts and ensure the supply of diphtheria antitoxin. Case management should be carried out following the WHO guideline and involve administering antitoxin to neutralize the toxin and antibiotics to kill the bacteria, reducing complications and mortality.
As vaccination is key to preventing cases and outbreaks, high-risk populations such as children under five years of age, schoolchildren, close contact with diphtheria cases, and healthcare workers should be vaccinated with diphtheria-containing vaccines on a priority basis. A coordinated response and community engagement can support control of the ongoing outbreak.
Although travellers do not have a special risk of diphtheria infection, it is recommended that national authorities remind travellers going to areas with diphtheria outbreaks to be appropriately vaccinated in accordance with their national vaccination scheme. A booster dose is recommended if more than five years have passed since the last dose.
WHO does not recommend any travel and/or trade restrictions to Nigeria based on the information available for this event.
Non- vaccination strategy prevention of diphtheria
Health workers and public health officials have emphasized the importance of non-vaccination measures in tandem with immunization.
One crucial aspect of this strategy is raising awareness among the general public about the signs, symptoms, and risks associated with diphtheria.
While progress has undoubtedly been made, the battle against diphtheria in Nigeria is far from over.
It is important that Health officials remain vigilant and the healthcare infrastructure is strengthened to improve access to healthcare and maintain high vaccination coverage to eradicate diphtheria.
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