Ongoing Diphtheria outbreak in Nigeria appears to be worsening.

Since the week ending 2 July 2023, Nigeria has recorded an unusual increase in cases of Diphtheria across several states, according to a press release issued by the World Health Organization on 13 September 2023. From 30 June to 31 August 2023, a total of 5898 suspected cases were reported from 59 Local Government Areas in 11 states. In week 34 (ending 27 August 2023), 234 suspected cases have been reported from 20 Local Government Areas in five states, with one laboratory confirmed case from the 22 samples collected. Eighteen of these cases were epidemiologically linked and 141 were classified as clinically compatible.

Diphtheria is a highly contagious vaccine-preventable disease caused mainly by the Bacterium Corynebacterium diphtheriae, a form of Mycobacterium, which can be fatal in 5-10% of cases, with a higher mortality rate in young children.

The World Health Organization's most recent risk assessment of the Diphtheria outbreak in Nigeria has maintained the risk as high at the national level, and low at the regional and global levels. Public health measures such as vaccination response, enhanced surveillance for early case detection, case management and risk communication coordinated by the Nigeria Centre for Disease Control, in collaboration with the World Health Organization and other partners, are being implemented in response to the outbreak.

Since 27 April 2023, Nigeria has reported suspected cases of Diphtheria weekly to the World Health Organization. However, between 30 June and 31 August 2023, the country recorded an unusual increase in the number of confirmed Diphtheria cases. From 30 June to 31 August 2023, a total of 5898 suspected cases were reported from 59 Local Government Areas in 11 states across the country. The majority (99.4%) of suspected cases were reported from Kano (1816), Katsina (234), Yobe (158), Bauchi (79), Kaduna (45) and Borno (33). 

Diphtheria cases by year/epidemic-week in Nigeria, 1 May 2022 – 27 August 2023. World Health Organization.

Of the cumulative 8353 suspected cases reported since the outbreak was first reported in 2022, 4717 (56.5%) cases were confirmed (lab confirmed (169; 3.6%), epidemiologically linked (117; 2.5%) and clinical compatibility (4431; 93.9%)). While 1857 (22.2%) were discarded as not compatible with Diphtheria, 1048 (12.5%) cases are pending classification and 731 (8.8%) cases had unknown diagnosis. The case fatality ratio dropped slightly from 6.7% before April 2023 to 6.1%. Of the 4717 confirmed cases, 3466 (73.5%) were aged 1 – 14 years, of these 699 were aged 0-4 years, 1505 aged 5-9 years, 1262 (aged 10 – 14 years. More than half of the cases (2656; 56.3%) were females. Only 1074 (22.8%) of the confirmed cases were fully vaccinated against diphtheria, 299 (6.3%) were partially vaccinated. More than half of the cases (2801; 59.4%) were unvaccinated.      

Definitive diagnosis through laboratory molecular testing identified Corynebacterium diphtheriae and Corynebacterium ulcerans isolates as the species driving this outbreak, particularly Corynebacterium diphtheriae as the major etiologic pathogen. Antibiotic susceptibility tests for 62 isolates of Corynebacterium diphtheriae have been carried out and the findings revealed that all isolates were resistant to penicillin, and most were resistant to trimethoprim-sulfathiazole and ciprofloxacin, while being susceptible to erythromycin. Thus, erythromycin became the drug of choice in the management of this outbreak.

Drug sensitivity results of toxigenic Corynebacterium diphtheriae isolated in Nigeria, May 2022 – July 2023. Nigeria Centre for Disease Control and Prevention/World Health Organization.

Diphtheria is a highly contagious vaccine-preventable disease caused mainly by Corynebacterium diphtheria but also by Corynebacterium ulcerans. It spreads between people mainly by direct contact or through the air via respiratory droplets. The disease can affect all age groups; however, unimmunized children are most at risk.

Symptoms often come on gradually, beginning with a sore throat and fever. In severe cases, the Bacteria produce a poison (toxin) that causes a thick grey or white patch at the back of throat. This can block the airways, making it hard to breathe or swallow, and also creates a barking cough. The neck may swell in part due to enlarged lymph nodes.

Treatment involves administering Diphtheria antitoxin as well as antibiotics. Vaccination against Diphtheria has been effective in reducing the mortality and morbidity from Diphtheria dramatically. Diphtheria is fatal in 5-10% of cases, with a higher mortality rate in young children. However, in settings with poor access to Diphtheria antitoxin, the case fatality ratio can be as high as 40%.

Nigeria has recorded Diphtheria outbreaks in the past, notably in 2011 and 2022. In 2023, a previous outbreak of Diphtheria was recorded between January and April 2023 affecting 21 of the 36 states and the Federal Capitol Territory.

Nigeria is currently facing a second wave of a Diphtheria outbreak after a first wave of the outbreak was recorded between epidemiological week 52, 2022 (1 January 2023) and week 20, 2023 (22 May 2023). There is an increase in the affected population with a rise in the number of confirmed cases and related deaths reported in epidemiological weeks 31-33. There is an increased risk of transmission, with clusters and outbreaks reported in newly affected Local Government Areas, with currently 27 Local Government Areas reporting one clinically compatible case in the last three reporting weeks relative to 15 Local Government Areas that had active case in the preceding three weeks.

The low national coverage (57%) of the Pentavalent vaccine administered in routine immunization, and the suboptimal vaccination coverage in the paediatric population, with 43% 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. Vaccine coverage of 80–85% must be maintained to ensure community protection.

This emphasizes the urgent need to strengthen Diphtheria vaccination coverage nationwide, especially in the most affected states, such as Kano. Additionally, particular attention is necessary for regions experiencing insecurity challenges, like the Northwest, as it hampers vaccine accessibility. Due to insecurity, especially in Northeast Nigeria, vaccination coverage remains suboptimal.

Diphtheria antitoxin supply is currently very constrained and insufficient to respond to current demands, as there is only a limited number of manufacturers and large outbreaks are being reported in different regions of the world.  The Nigeria Centre for Disease Control and Prevention, with support from World Health Organization and other partners have procured 10 050 Diphtheria antitoxin vials for case management in response to the outbreak.

Diphtheria outbreaks are underreported in Nigeria. According to the 2021 Nigeria Multiple Indicator Cluster Survey and National Immunization Coverage Survey, the third dose of pentavalent vaccine coverage was 57% in 2021.

The control of Diphtheria is based on primary prevention of disease by ensuring high population immunity through vaccination, and secondary prevention of spread by the rapid investigation of close contacts to ensure prompt treatment of those infected.

Epidemiological surveillance ensuring early detection of Diphtheria outbreaks should be in place in all countries, and all countries should have access to laboratory facilities for reliable identification of toxigenic Corynebacterium diphtheria. Adequate quantities of Diphtheria antitoxin should be available nationally or regionally for the medical management of cases.

Vaccination is key to preventing cases and outbreaks, and adequate clinical management involves administering Diphtheria anti-toxin to neutralize the toxin and antibiotics reducing complications and mortality.

The World Health Organization recommends early reporting and case management of suspected diphtheria cases to initiate the timely treatment of cases, and follow-up of contacts, and ensuring a supply of Dihphtheria antitoxin.

The World Health Organization also advises that healthcare settings where Diptheria cases are likely to be encountered apply standard precautions, with focus on hand hygiene, personal protective equipment and equipment and environmental cleaning and disinfection droplet and contact precautions (at all times). That during screening/triage, medical personnel immediately place patients with symptoms of Upper Respiratory Tract Infection in a separate area until examined, and, if multiple cases are suspected, these should be cohorted with patients with the same diagnosis. Isolation areas should be kept segregated from other patient-care areas. Hospitals and medical centres should one meter between patients, and keep patient care areas well ventilated. Where possible, medical personnel should avoid patient movement or transport out of isolation area. If movement is necessary out of isolation area, have patient use a medical mask and cover any wounds/lesions on patient’s body.

Case management should be carried out following the World Heath Organization guidelines. In addition, high-risk populations such as young children under five years of age, school children, the elderly, close contact with diphtheria cases, and healthcare workers should be vaccinated on a priority basis. A coordinated response and community engagement can support further transmission and control of the ongoing outbreak.

Prophylactic antibiotics (penicillin or erythromycin, dependent on drug sensitivity) are indicated for close contacts of confirmed cases for seven days. If the culture is positive for toxigenic Corynebacterium spp., then the contact should be treated as a case with an antibiotic course for two weeks (Diphtheria antitoxin is not needed for asymptomatic cases or cases without a pseudomembrane).

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 the national vaccination scheme established in each country prior to travel. A booster dose is recommended if more than five years have passed since their last dose.

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Unexpectedly large herd of Elephants sighted in Borno State, Nigeria.

A large herd comprising around 250 African Bush Elephants, Loxodonta africana, has been spotted close to the town of Rann in Borno State, northeastern Nigeria. The sighting was made from a helicopter operated by the United Nations Humanitarian Air Service that was delivering supplies in the area on 19 December 2019. Northeastern Nigeria was known to be home to several hundred Elephants until about ten years ago, when Boko Haram insurgents set up camps in the Sambisa Forest Game Reserve, a key environment and part of the annual migration route of the Elephants. In the decade since that time the area has been a subjected to repeated fighting between the insurgents and the Nigerian military, including aerial bombardments and extensive use of artillery, things generally thought to be adverse to Elephant survival. However the discovery of a large Elephant herd in Borno suggests that Elephants have not just survived in the area but flourished, with the discovery roughly doubling the known Elephant population of Nigeria, according to Tunde Marokinyo of Africa Nature Investors.

A large herd of African Bush Elephants, Loxodonta africana, spotted in Borno State, Nigeria, on 19 December 2019. United Nations Humanitarian Air Service

Elephants are considered to be threatened across Africa, due to a combination of hunting, principally for the value of their tusks, and habitat loss, with the population across the continent thought to have dropped from 3-5 million in 1900 to about 415 000 today, and about 50% of Elephant-suitable land having disappeared since 1970. The population of Elephants in Nigeria has not been surveyed properly in the last decade, due to the running civil war in the area, but is thought to have been subjected to heavy poaching, based upon seizures of ivory in other countries that is thought to have originated in Nigeria. 

On Tuesday 24 December authorities in Vietnam revealed that they had confiscated 330 kg of ivory being smuggled in three shipping containers from Nigeria, along with 1700 kg of Pangolin scales, another lucrative, but illegal, wildlife product.

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Seven cofirmed deaths from Yellow Fever in northern Nigeria.

Seven people have been confirmed dead in an outbreak of Yellow Fever in northeastern Nigeria, according to the Nigeria Centre for Disease Control. The first death occurred in late August 2019, when a father and son arrived at a health centre in Kano showing symptoms of the disease. Both were given immediate treatment, but the father died of the infection, and the illness was later confirmed to be Yellow Fever by the Kano State Epidemiology Team. Six further deaths form the disease were reported among students at the Waka College of Education in Borno. All of the deceased are reported to have visited the Yankari National Park in Bauchi State, where they are thought to have contracted the Mosquito-born disease, with the father and son having visited the park as part of a family excursion, and the students having been part of a group of 95 students from the college that took part in an educational trip to the park, eight of whom subsequently developed Yellow Fever symptoms. Two other people are reportedly being treated for the disease after visiting the Yankari National Park, one of whom is described as a foreign tourist.

A health worker administering Yellow Fever innoculations in Nigeria. WHO.

Yellow Fever is a Mosquito-born Flavivirus (the group of RNA Viruses that also includes the West Nile, Zika and Hepatitis C Viruses). The Virus causes a mild fever, accompanied loss of apatite, nausea and muscle pains, which passes within about 15 days. However, in about 15 % of cases a more severe infection attacks the liver and kidneys, which can lead to their failure, and therefore the death of the patient.  It originated in tropical Africa and but was carried to South America and the Caribbean during the trans-Atlantic slave trade. Outbreaks of the disease have also been recorded in parts of tropical Asia and the Pacific in recent years, and many countries in tropical regions require visitors to carry a certificate proving they have been vaccinated against the Virus.

 The Yellow Fever Virus. Erskine Palmer/Centers for Disease Control and Prevention/Wikipedia.

Yellow fever can be prevented through vaccination, but uptake of this is considered to be dangerously low in Nigeria.  To this end the Nigerian Federal Ministry of Health and World Health Organisation have initiated a program to encourage immunisation within the country, with 8.7 million adults and children vaccinated in 2018, and plans to vaccinate a further 39.5 million by the end of 2019.

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Almost 200 dead in Nigerian floods.

A total of 199 people have been reported dead in Nigeria after the Niger and Benue rivers burst their banks due to rains associated with an exceptionally severe rainy season, according to the National Emergency Management Agency. Ninety seven deaths have been reported in the states of Borno and Yobe in the northeast of the country, where a Cholera outbreak has infected over 3000 people. This outbreak has also hit the neighbouring nations of Niger, where 67 people have died and another 180 cases reported, as well as Cameroon and Chad. The flooding has made about 286 000 people homeless, mostly in southern Nigeria, as well as destroying large areas of crops and killing large amounts of livestock, raising the risk of future famine.

Flooding in Kara-Isheri, Ogun State, southwest Nigeria, on 20 Septmber 2018. Pius Utomi Ekpei/AFP.

West Africa has a distinct two season climatic cycle, with a cool dry season during the northern winter when prevalent winds blow from the Sahara to the northeast, and a warm rainy season during the northern summer when prevalent winds blow from the Atlantic Ocean to the southwest. These warm winds from the Atlantic are laden with moisture, which can be lost rapidly when the air encounters cooler conditions, such as when it is pushed up to higher altitudes by the Jos Plateau of central Nigeria and Shebshi Mountains on the border with Cameroon.

 Rainfall and prevalent winds during the West African dry and rainy seasons. Encyclopedia Britanica.

Cholera is caused by the Bacterium Vibrio cholerae, a Gram-negative, comma-shaped Gammaproteobacteria, related to other pathogenic Bacteria such as Yersinia pestis (Bubonic Plague), and Esherchia coli (food poisoning). The Bacteria produce proteins which can cause watery diarrhoea, which helps spread the disease, and can prove fatal in severe cases, as patients are killed by extreme dehydration.

 SEM image of Vibrio cholerae Bacteria. Kim et al. (2000).

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Cholera kills 44 in Borno State, Nigeria.

Forty four people are known to have died, and another 2300 possible cases have been reported, in an outbreak of Cholera in Borno State, Nigeria, since the first cases were reported on 16 August 2017. The UN Office for the Coordination of Humanitarian Affairs in Nigeria estimates that 3.7 million people are at immediate threat, particularly the large number of internally displaced people living in temporary camps in the state, due to the ongoing conflict between Nigerian Government troops and Boko Haram Islamic Militants, and is working to improve sanitation in these camps, in addition to setting up four specialist treatment centres for severe cases and seven rehydration centres for less severe cases.

A Cholera treatment centre in Borno State. Medecins Sans Frontieres.

Cholera is caused by the Bacterium Vibrio cholerae, a Gram-negative, comma-shaped Gammaproteobacteria, related to other pathogenic Bacteria such as Yersinia pestis (Bubonic Plague), and Esherchia coli (food poisoning). The Bacteria produce proteins which can cause watery diarrhoea, which helps spread the disease, and can prove fatal in severe cases, as patients are killed by extreme dehydration.

SEM image of Vibrio cholerae Bacteria. Kim et al. (2000).

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