VICTOR AYENI writes on how the combination of decrepit healthcare and vaccine hesitancy have contributed to tragic deaths from diphtheria in Nigeria
When Zakariya Shehu woke up with a strep throat in the second week of January, he thought it was simply one of the effects of the harmattan haze.
Shehu resides in Kano State, and climate-data.org described January as the “the driest and coldest month in the state.”
Within a few days, the 25-year-old, who resides in Fagge Local Government Area of the state, noticed his sore throat worsened as he also began to experience cough and swelling in his neck.
Describing his ordeal to Saturday PUNCH, Shehu said, “It first started as a sore throat. I know I usually have strep throat when I am about to have a catarrh, which is understandable because of the harmattan.
“But this time round, the sore throat lasted for days and it soon got to a point that I wasn’t able to swallow food or water without pain. I took medicines used in treating strep throat, but they didn’t work. Then I began to cough and noticed a swelling in my neck shortly after then.
“I was scared because I knew I was no longer dealing with mere catarrh. My voice had changed, I began to feel feverish and saliva would frequently fill my mouth. It was then I went to a hospital on France Road.”
According to Shehu’s hospital card, which was seen by our correspondent, he was referred to a laboratory for a throat swab and four broad-spectrum antibiotics were prescribed for him.
Shehu said he felt some relief when he began to take the medicines prescribed for him, stressing that he believed he must have had diphtheria because its outbreak in his state was noted by health agencies.
On December 1, 2022, the Nigeria Centre for Disease Control and Prevention was first notified of suspected diphtheria cases in Kano and Lagos states. But since the first week of 2023, the outbreak of the deadly disease has been heavily concentrated in Kano State.
Raising awareness of the disease on Twitter, an epidemiologist in the state, Dr Abdulrahman Sabo, advised residents to seek medical attention and limit physical contact.
“It is airborne; therefore it spreads by coughing, sneezing or coming in contact with droplets of an infected person. Prevention vaccination for unimmunised, diphtheria toxin booster for the immunised and limit contact with an infected person,” he wrote.
Contagious yet preventable disease
Diphtheria is a highly contagious vaccine-preventable disease caused by the bacterium Corynebacterium diphtheria.
The severe disease is mainly spread through direct contact with an infected person or exposure to airborne droplets. It could infect the respiratory tract and the skin.
It is often associated with the presence of an adherent membrane covering the tonsils, pharynx and nose and approximately a quarter of the patients might also develop heart problems (myocarditis).
The United States Centres for Disease Control and Prevention listed diphtheria’s primary symptoms, which often show up between two to five days, as weakness, sore throat, mild fever, and swollen glands in the neck.
The pathogen involved produces a toxin that kills healthy tissues in the respiratory system. The dead tissue, notes the CDC, forms a thick, grey coating (pseudomembrane) that can build up in the throat or nose.
According to experts, this coating makes it difficult for patients to breathe and swallow and if the toxin gets into the bloodstream, it can cause heart, nerve and kidney damage.
Saturday PUNCH gathered that the incidence of diphtheria has reduced dramatically globally over the past five decades due to widespread immunisation using a diphtheria toxoid-containing vaccine.
For instance, the number of diphtheria cases reported to the World Health Organisation declined from about 100,000 cases in 1980 to less than 10,000 cases in 2021.
However, in recent years, there has been a gradual rise in cases with over 20,000 cases of the deadly disease recorded in 2019.
Diphtheria can be prevented with the use of a vaccine, known as DTP vaccine, which is a combined vaccine, Diphtheria-Tetanus-Pertussis, given to children.
There are other types of vaccines which are effective too. Adults can get booster vaccines, usually every 10 years, especially when visiting endemic regions.
In 2011, there was an outbreak of diphtheria in Borno State with a total of 98 cases and 21 deaths. The NCDC pointed out that the outbreak and the high case fatality associated with it could be attributed to “low vaccination coverage, delayed clinical recognition and laboratory confirmation, and the absence of antitoxin and antibiotics for treatment.”
Diphtheria vaccination is one of the primary vaccines given to children in Nigeria. The WHO recommended a three-dose primary vaccination series with a diphtheria-containing vaccine followed by three booster doses.
Many deaths across 27 states
Since 2022 when diphtheria outbreak was reported in Nigeria, it has sent tens of citizens, including children, to an early grave.
A few days ago, the NCDC released its latest Diphtheria Situation Report, revealing that between May 2022 and July 2023, there have been 1,534 confirmed cases of diphtheria with a total of 137 deaths in the country.
The report added that 1,257 out of the 1,534 confirmed cases were patients who were not fully vaccinated against the bacterial disease.
It said, “A total of 4,160 suspected cases have been reported from 27 states across 139 LGAs in the country. Kano (3,233), Yobe (477), Katsina (132), Kaduna (101), Bauchi (54), FCT (41), and Lagos (30) account for 97.8 per cent of suspected cases.”
Other states with suspected cases are Niger (two); Gombe (two); Osun (one); Jigawa (one); and Cross River (one).
It added, “Of the 4,160 suspected cases reported, 1,534 (36.9 per cent) were confirmed (87 lab-confirmed; 158 rapid linked; 1,289 clinically compatible), 1,700 (40.9 per cent) were discarded, 639(15.4 per cent) are pending classification and 287 (6.9 per cent) unknown.
“The confirmed cases were distributed across 56 LGAs in 11 states. The majority (1,018) of the confirmed cases occurred in children aged one to 14 years. A total of 137 deaths were recorded among all confirmed cases (CFR: 8.9 per cent). Out of the 1,534 confirmed cases reported, 1,257 (81.9 per cent) were not fully vaccinated against diphtheria.”
During a media briefing in Abuja in July, the Executive Director of the National Primary Health Care Development Agency, Dr Faisal Shuaib, noted that vaccination against diphtheria was important.
He had said, “There is concern over the outbreak of diphtheria cases across the country. From May to July, 2023, an estimated 2,455 suspected cases have been reported in 26 states.
“As of July 27, 2023, 836 of these cases have been confirmed in 33 LGAs across eight states: Cross River, Kano, Katsina, Kaduna, Lagos, Osun, Yobe, and FCT.
“Tragically, 83 deaths have been reported from these confirmed cases, making vaccination against this deadly disease critically important, especially for our children.”
In Kano State, which has been most hit by the outbreak, the government recently disclosed that it had activated contact tracing as the disease had spread to 31 out of the 44 LGAs.
The state epidemiologist, Dr Abdullahi Karaunmata, noted that the resurgence of diphtheria might be linked to the aftermath of the Covid-19 pandemic, which resulted in a lockdown and disruption of routine immunisation of children.
Karaunmata said, “Currently, we have more than 100 cases on admission. We have treated and discharged over 2,000. Diphtheria has been reported in 31 out of the 44 LGAs in the state.”
Yobe, the second worst-hit state, has recorded a death toll of 26 while 289 people have been discharged from the isolation centres where many patients were quarantined.
The Senior Special Assistant to the governor on Health, Dr Muhammad Gana, was quoted to have said, “With regard to diphtheria, we have 21 active cases, 26 deaths while 289 have been discharged as of July 17, 2023. We have 336 cumulative numbers from 2022 to 2023.”
Commenting on the high mortality rate of diphtheria in Nigeria, the General Secretary, Association of Resident Doctors, Federal Medical Centre, Abeokuta, Dr Adewumi Babatunde, told Saturday PUNCH the several factors that contribute to the high rate.
Babatunde noted, “There is limited access to healthcare in the country. In areas with limited access to healthcare services, people may not receive timely medical attention or appropriate treatment for diphtheria. This can lead to the infection progressing to a severe stage, increasing the risk of death.
“Access is not limited to location but also to the finance to access the healthcare people require. There is a lack of public awareness about diphtheria, its symptoms and the importance of seeking medical care to avoid delayed treatment.
“Overcrowded living conditions and poor hygiene practices can also facilitate the spread of diphtheria and other contagious diseases because close proximity to infected individuals increases its chances of transmission.”
He further identified limited resources and brain drain in the health sector as other challenges.
He added, “Diphtheria can be effectively treated with antitoxin and antibiotics, but the availability of these treatments is limited in some areas in Nigeria, especially the antitoxin which needs special storage. Without proper medical intervention, the infection can progress and become more life-threatening.
“It’s important to note that the situation regarding diphtheria can change over time, and improvements in healthcare infrastructure, vaccination coverage, and public health awareness can lead to a reduction in mortality rates.”
He stressed that preventive measures such as vaccination campaigns, improved access to healthcare and health education can play a crucial role in reducing the impact of diphtheria and other infectious diseases.
He advised the government to expand healthcare infrastructure by investing in and upgrading facilities, especially in underserved regions.
He added, “Government needs to develop a skilled health workforce through training programmes, incentives like scholarships and competitive salaries. Diagnostic and laboratory capacity with investments and training for accurate disease detection should be enhanced.
“They need to strengthen disease surveillance systems for quick outbreak detection and reporting and improve vaccine distribution and coverage, addressing hesitancy with education campaigns.”
Vaccine hesitancy
Earlier in August, the United Nations Children’s Fund in a statement titled, ‘Diphtheria outbreak in Nigeria: UNICEF intensifies response,’ decried the spread of the disease in 27 states, although it gave the figure of confirmed cases lower than that of the NCDC.
The statement quoted the UNICEF Representative in Nigeria, Cristian Munduate, who stated that most of the children who were killed by diphtheria had not received a single dose of a childhood vaccine.
She stated “It’s heartbreaking to note that only 22 per cent of the confirmed cases received their routine childhood immunisation vaccinations.
“Most of these affected children, especially those who unfortunately passed away, had not received a single dose of the vaccine. The need to reach the unreached has never been more critical.
“Many children did not receive their vaccines during the Covid-19 lockdown. We now urgently need to catch-up. These ‘zero-dose’ children; those who haven’t received a single dose of vaccine are a primary concern.”
On his part, the UNICEF Chief of Health in Nigeria, Eduardo Celades, described Nigeria as home to the second-largest number of zero-dose children in the world.
He added that so far, Nigeria had been able to reach about 150,000 children with vaccination, yet more needed to be done.
This prevalence of zero-dose children has been linked to what the WHO defined as vaccine hesitancy which is “the reluctance or refusal to vaccinate despite the availability of vaccines” noting that it is “a threat that seeks to reverse progress made in tackling vaccine-preventable diseases.”
The WHO added, “The reasons why people choose not to vaccinate are complex; complacency, inconvenience in accessing vaccines and lack of confidence are key reasons underlying hesitancy.”
A study published in the Journal of Infectious Diseases and Epidemiology in 2021 attributed vaccine hesitancy to “fear of possible adverse events, misconceptions about the safety and efficacy of vaccines, concerns over a possible ‘immune system over-exposure,’ past negative experiences with vaccines, mistrust of the seriousness of the vaccine industry and the healthcare system, heuristic thinking, and philosophical and religious issues.”
Findings by Saturday PUNCH revealed that vaccine hesitancy based on extreme religious views had been prevalent in northern Nigeria, even before Covid-19.
The WHO representative in Nigeria, Dr Walter Mulumbo, had disclosed plans to deliver 1,800 vials of diphtheria antitoxin to the country on August 2, 2023.
He noted that Nigeria would receive erythromycin after two weeks, pending government’s authorisation as the health commodities would save lives and reduce complications in affected patients.
But according to Abdullahi Auwal, a Kano resident, such an effort might not be effective in some circles.
He told our correspondent, “There are people here who will not allow any vaccine to be given to their children because they believe it could make them impotent when they grow up. The people who produce these vaccines know what they are doing. We know they want to depopulate and kill us slowly like Pfizer did in Kano. These vaccines can have side effects and people are now awake.”
To curb the belief, an infectious diseases expert, Dr Iorhen Akase, stressed the need for more awareness and vaccination campaigns across the board.
He stated, “The community should be aware. The efforts to reduce and stop the spread of diphtheria can be divided into government, community and individual.
“At the community level, they should be aware of the outbreak and know the symptoms so they can act quickly when they see it. At the family level, those who are not vaccinated should be vaccinated.
“It is not something that should cause panic because this is not an organism that is not already in the environment. What differentiates people is whether they have immunity or not.”
Nigeria compared to others
According to the CDC, diphtheria is endemic in many regions, including Haiti and the Dominican Republic; Asia and the South Pacific; Eastern Europe and the Middle East.
Since 2016, respiratory diphtheria outbreaks have occurred in Bangladesh, Burma (Myanmar), Indonesia, South Africa, Ukraine, Venezuela, Vietnam and Yemen.
Based on the online Knoema Database, India tops countries on diphtheria. As of 2022, it recorded 3,286 cases which accounts for 56.11 per cent of the world’s diphtheria cases.
The other countries said to have high prevalence of the disease were Indonesia, Pakistan and Nepal which account for 85.52 per cent of it.
However, checks by our correspondent showed that India had stepped up its immunisation coverage from 82 per cent in 2021 to 91 per cent, according to the WHO South-East Asia region.
Data submitted by the Union Ministry of Health and Family Welfare (Government of India) shows that a total of 24.6 million citizens received a combination of three doses of diphtheria, pertussis and tetanus.
In South Africa, following an alarm raised by the National Institute for Communicable Diseases on two laboratory-confirmed cases of diphtheria in April, all parents were urged to make sure that their children were up to date on routine vaccines.
Children who were not up to date on vaccination were mandated to be taken to the nearest clinic for vaccination. Laboratories were also mandated to screen all throat swabs for diphtheria and that all confirmed cases should be sent to the Centre for Respiratory Diseases.
Experts seek solutions
The NPHCDA Executive Director had promised that there would be two phases of response to the diphtheria outbreak.
He said the first phase would encompass 25 LGAs across Bauchi, Katsina, Yobe, and Kaduna states; phase two would cover 171 LGAs in Kano, Katsina, FCT, Yobe, Kaduna, and Bauchi states, while there would be targeted responses in LGAs across Jigawa (eight LGAs), Borno (four), Osun (four), Lagos (three), Zamfara (three), Gombe (three), Plateau (one), and Nasarawa (one ).
Meanwhile, experts have pointed out that government needs to bridge the existing gaps in the health sector to effectively tackle diphtheria.
A forensic physician/clinical officer with the Women at Risk International Foundation, Dr Oluwatosin Babalola, in an interview with Saturday PUNCH commended the government for the provision of antibiotics and vaccines but noted that more needed to be done to combat diphtheria.
She added, “One can prevent diphtheria by covering one’s nose and mouth when sneezing, avoiding touching wounds of others, and hand-washing. Its treatment should commence once detected, by giving antibiotics, and anyone who has been in contact with someone with diphtheria may also need to take antibiotics too.”
She said in spite of providing vaccines, antibiotics and other health commodities to combat diphtheria, government should do more by ensuring more test centres and equipment, which were insufficient at the moment.
She added, “Another factor is the need for training staff as many staff have not received adequate training on how to test for diphtheria. Before an outbreak, there should be frequent training on epidemic control to increase level of preparedness for emergency response. National immunisation has also been found not to reach some populations in hard-to-reach communities.”
She listed the solutions to include the need to combat food insecurity because a malnourished child is at a higher risk of diphtheria.
Also, the Chief Research Officer, Department of Biotechnology, Federal Institute of Industrial Research, Lagos, Dr Frank Orji, called on stakeholders to increase public awareness about disease prevention and address socioeconomic factors.
He added, “There are also socioeconomic factors such as poverty, malnutrition and inadequate sanitation that should be looked into. These factors can weaken individuals’ immune systems and make them more susceptible to infections. They can also lead to the rapid spread of diseases in overcrowded and unsanitary conditions.”
Also, a microbiology researcher and doctoral candidate at Bowling Green State University, United States, Jeremiah Adesanya, in a telephone interview with our correspondent advised that laboratory capacity and vaccine distribution should be stepped up nationwide.
He added, “The limited access to diagnostic tools and laboratory facilities can lead to delays in identifying the causative agent of diphtheria outbreak, which in turn will delay the implementation of appropriate control measures. This needs to be properly addressed.
“Vaccines are available to prevent diphtheria infection in children and adults and these vaccines are given from time to time to prepare the immune system for exposure to the infection. So, it’s important for the government to ensure that local hospitals have access and good storage equipment for the vaccines to ensure easy distribution.”
Adesanya added that personal protective equipment and training should be provided for nurses, doctors and other individuals involved in treating and working in high-risk areas.
He added, “Adequate testing should be carried out since most bacterial infections share common symptoms. Testing is important to differentiate between diphtheria and other infections.
“A proven way to prevent the disease is to practice good hygiene by washing your hands as often as possible and avoid contact with anyone showing potential symptoms of the disease, including fever, shortness of breath and body weakness.
“It is also important for people to wear nose masks when visiting the hospital and locations where the disease is prevalent and they should avoid touching open wounds and blisters.”
