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WEEKLY BULLETIN ON OUTBREAKS
AND OTHER EMERGENCIES
Week 7: 6 to 12 February 2023
Data as reported by: 17:00; 12 February 2023
...
Nigeria Diphteria Ungraded
Date notified to WCO 1-Dec-2022
Start of reporting period 1-Dec-2022
End of reporting period 5-Feb-2023
Total cases 480
Cases Confirmed 164
Deaths 66
CFR 13.8%
As of epi week 5, 2023, 480 suspected cases of diphtheria have been reported by eight states in Nigeria. One hundred sixty-four of these cases were confirmed (14 cases, laboratory-confirmed, 410 cases, clinically compatible). Sixty-six deaths (CFR 13.8%) have been reported from 4 of the eight states. The cases among the age group 1-14 constitute 90% of the total cases. Kano state has reported most of the suspected cases (71.7%), and majority of the laboratory-confirmed cases 78.6% (11/14), whereas 2 cases were reported in Lagos and 1 case in Osun state were infected by strains of C. diphtheriae for which toxin production was confirmed. The 480 suspected cases have so far been reported from Kano, Lagos, Osun, Katsina, Kaduna, Niger Yobe and Federal Capital Territory, of which Kano, Lagos and Osun have reported a cumulative 14 laboratory-confirmed cases.
"Safety and security don't just happen, they are the result of collective consensus and public investment. We owe our children, the most vulnerable citizens in our society, a life free of violence and fear." -Nelson Mandela
WEEKLY BULLETIN ON OUTBREAKS
AND OTHER EMERGENCIES
Week 8: 13 to 19 February 2023
Data as reported by: 17:00; 19 February 2023
...
Nigeria Diphtheria
724 Cases
89 Deaths
12.3% CFR
EVENT DESCRIPTION
There is an ongoing diphtheria outbreak in Nigeria. The
Nigeria Centers for Disease Control (NCDC) was notified
of suspected diphtheria outbreaks in Kano and Lagos
States on 1 December 2022. Since early January 2023,
the number of confirmed cases has gradually increased,
peaking at nearly 100 in week 3.
Between week 19 of 2022 and week 7 of 2023, 724
suspected cases of diphtheria were reported from 20
states in Nigeria, with the majority of cases reported
from Kano (533, 74%), Yobe (86, 12%), Katsina (45, 6%),
Sokoto (14, 2%), Enugu: (9, 1%), Osun: (7, 1%), Osun (7,
1%), Kaduna: (6, 1%), Lagos (5, 1%), and Zamfara (5,
1%) states. A total of 89 deaths were recorded among
all suspected cases, representing a case fatality rate of
12.3%. Of suspected cases, 313 cases were confirmed,
including 13 (4.2%) laboratory confirmed and 300
(95.8%) clinically compatible. Kano state accounts for
84.6% (11 cases) of the laboratory confirmed cases. Both
sexes are affected and children aged 2-14 years account
for the majority of confirmed cases (85.2%). Only 43.2%
of confirmed cases were fully vaccinated with a vaccine
containing diphtheria toxin.
The previous outbreak of diphtheria in Nigeria occurred
in Borno State, in the northeast of the country, in 2011.
A total of 98 cases and 21 deaths were reported (CFR
21.4%).
PUBLIC HEALTH ACTIONS
Coordinating and monitoring diphtheria surveillance
and response activities in the country through the
weekly diphtheria Technical Working Group meetings
Deployment of rapid response teams (RRTs) to
Katsina, Osun and Yobe State and re-deployment of
RRTs to Kano and Lagos States to support response
activities
Harmonization of surveillance and laboratory data
across states and laboratories is ongoing
Sensitization/training of clinical and surveillance
officers on the presentation, prevention, and
surveillance for diphtheria in States where RRTs were
deployed
Conducted cascarded training by some of the
laboratory scientists/physician trained at National
Reference Laboratory (NRL), Abuja in their respective
States
Procurement for reagents and sample collection and
transportation materials/media processes initiated
Released results of the first batch of drug sensitivity
test (DST) conducted at NRL on isolates sent in from
States
Distribution of 100 vials of diphtheria antitoxin (DAT)
to Kano State
Protocol for prioritization of diphtheria cases for DAT
use in situations where there is inadequate DAT
compared to number of cases in need of DAT have
been developed
Pre-testing and finalization of diphtheria IEC materials
Conduct of routine immunization intensification
among children < 2 years in Kano State
Ongoing development of the zero draft of a manuscript
on “Confirmation of Diphtheria Outbreak in Nigeria”.
SITUATION INTERPRETATION
The previous diphtheria outbreak in Nigeria in 2011 and
its associated high CFR were due to a combination of
low vaccination coverage, delayed clinical recognition
and laboratory confirmation, and lack of antitoxin and
antibiotics for treatment. The same reasons are at the root
of the current outbreak. Improving routine immunization
coverage (including 3-dose series of diphtheria toxoid
containing vaccines in the first year of life beginning
at six weeks of age) would prevent most cases and
complications resulting in death.
"Safety and security don't just happen, they are the result of collective consensus and public investment. We owe our children, the most vulnerable citizens in our society, a life free of violence and fear." -Nelson Mandela
Diphtheria infection kills 61 in Kano
March 6, 2023
A deadly infection called diphtheria has killed 61 people in Kano State.
Diphtheria is a serious bacterial infection caused by the bacterium called Corynebacterium species that affects the nose, throat, and sometimes, skin of an individual.
It spreads easily between people through direct contact with infected people droplets from coughing or sneezing, and contact with contaminated clothing and objects.
The Kano State Case Manager, Dr Salma Suwaid, disclosed the fatality numbers on Monday at a webinar organised by the Nigeria Centre for Disease Control and Prevention with the theme ‘Diphtheria outbreak in Nigeria: Vaccination Response.’
Dr Suwaid also said a total of 783 patients have been on admission so far. Of this number, 360 were females and 423 were males...
NCDC Diphtheria Situation Report Serial Number 02, Data as of Epi-week 05 2023
Format Situation Report
Source Govt. NigeriaPosted
16 Mar 2023
Originally published 11 Feb 2023
Origin View original
HIGHLIGHTS
▪ As of epi-week 04 – 05, 2023
‒ A total of 189 suspected cases were reported from 3 states across the country
– Kano: 172 (91.0%), Katsina: 9 (4.8%), Lagos: 8 (4.2%) ‒ Of the 189 suspected cases reported, 56 (29.6%) were confirmed (clinically compatible), 51 (27.0%) were discarded, 72 (38.1%) are pending classification & 10 (5.3%) are unknown
‒ Confirmed cases were all from 9 LGAs in Kano State
‒ Four (4) deaths were recorded from confirmed cases (CFR: 7.4%)
▪ Cumulatively: Epi-week 19 2022
– Epi-week 05 2023 ‒ A total of 523 suspected cases were reported – Kano: 396 (75.5%), Yobe: 78 (14.9%), Katsina: 34 (6.5%), Lagos: 14 (2.7%) and Osun: 1 (0.2%) States
‒ Of the 523 suspected cases reported, 216 (41.3%) were confirmed (14 lab confirmed & 202 clinically compatible), 80 (15.3%) were discarded, 106 (20.3%) are pending classification while 121 (23.2%) were unknown
‒ Majority (184 [85.2%]) of the confirmed cases occurred among cases aged 2 – 14 years.
‒ A total of 40 deaths were recorded among all confirmed cases (CFR: 18.5%)
‒ Only 27 (12.5%) out of 216 confirmed cases were fully vaccinated with a diphtheria toxin-containing vaccine
Since the beginning of 2023, 557 confirmed cases of diphtheria have been detected in Nigeria, affecting 21 of the 36 states and the Federal Capital Territory.
In December 2022, the Nigeria Centre for Disease Control and Prevention (NCDC) was notified of suspected diphtheria outbreaks in Kano and Lagos States. From 14 May 2022 to 9 April 2023, 1439 suspected cases have been reported, of which 557 (39%) have been confirmed, including 73 deaths among the confirmed cases (case fatality ratio of 13%). Nigeria has previously reported diphtheria outbreaks, with the most significant reported in 2011 affecting the rural areas of Borno State, in the northeast of the country. Diphtheria is a highly contagious vaccine-preventable disease which 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 particular at risk. It is potentially fatal.
The disease can be treated by administering diphtheria antitoxin as well as antibiotics. Vaccination against diphtheria has reduced the mortality and morbidity of diphtheria dramatically.
Description of the situation
The Nigeria Centre for Disease Control and Prevention (NCDC) was notified of suspected diphtheria outbreaks in Kano and Lagos States on 1 December 2022. In January 2023, the number of confirmed cases increased, peaking at over 150 cases in week 4 of 2023 (ending 28 January); since then, a weekly decreasing trend has been observed. From 14 May 2022 to 9 April 2023, 1439, suspected diphtheria cases were reported from 21 states in Nigeria, with the majority (83%) of cases reported from Kano (1188), Yobe (97), Katsina (61), Lagos (25), Sokoto (14) and Zamfara (13). Of the 1439 suspected cases, 557 (39%) were confirmed (51 laboratory-confirmed, 504 clinically compatible and two epidemiologically linked), 483 (34%) were discarded, and 399 (28%) are pending classification. Laboratory-confirmed cases were reported from Kano (45), Lagos (3), Kaduna (1), Katsina (1), and Osun (1) states. Among the 557 confirmed cases, 73 deaths were recorded, for a CFR of 13%. The CFR has dropped significantly since the beginning of the outbreak due to, among other factors, increased access to diphtheria antitoxin (DAT).
Nigeria had recorded diphtheria outbreaks in the past. The most significant outbreak reported was between February and November 2011 in the rural areas of Borno State, north-eastern Nigeria, where 98 cases were reported.
Figure 1: Epidemic curve of diphtheria cases by year/epi-week in Nigeria, epi-week 19 2022 – epi-week 14 2023
Figure 2: Distribution of Diphtheria cases by state in Nigeria from Epi week 19, 2022 to Epi week 14, 2023
Epidemiology of Diphtheria
Diphtheria is a highly contagious vaccine-preventable disease caused by exotoxin-producing Corynebacterium diphtheriae 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 particular at risk. It is potentially fatal. 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 reduced the mortality and morbidity of 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 CFR can be as high as 40%.
Public health response
Under the leadership of the Nigeria Centre for Disease Control and Prevention (NCDC), coordination and monitoring of diphtheria surveillance and response activities in the country are ongoing through the weekly diphtheria National Technical Working Group meetings.
Rapid Response Teams (RRTs) have been deployed to Katsina, Osun and Yobe States and re-deployed to Kano and Lagos States to support response activities.
Harmonization of surveillance and laboratory data across states and laboratories is ongoing.
Sensitization/training of clinical and surveillance officers has taken place in states where RRTs were deployed, on the presentation, prevention, and surveillance of diphtheria.
Cascaded trainings were conducted in their respective states by some of the laboratory scientists/physicians trained at the NCDC National Reference Laboratory (NRL), Abuja.
Procurement for reagents and sample collection and transportation materials/media processes has been initiated.
Drug sensitivity tests are ongoing at NCDC NRL on isolates sent in from states.
Distribution of DAT to the affected states has been ongoing since December 2022.
Strengthening of routine immunization activities across the country continues.
WHO risk assessment
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, mpox, meningitis and a humanitarian emergency in the northeast of the country. Due to insecurity, especially in north-eastern Nigeria, vaccination coverage remains suboptimal, especially in the areas controlled by non-state armed groups. Therefore, the outbreak of diphtheria further complicates and strains the already overstretched resources. The global supply of diphtheria antitoxin (DAT) is limited, and this 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
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 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 complication 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 of 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.
"Safety and security don't just happen, they are the result of collective consensus and public investment. We owe our children, the most vulnerable citizens in our society, a life free of violence and fear." -Nelson Mandela
Nigeria reports 557 diphtheria cases, 73 deaths
Abuja, May 3 (Prensa Latina) Nigeria has confirmed 557 cases of diphtheria across its states and 73 deaths since the beginning of 2023, the World Health Organization (WHO) reported Wednesday.
May 3, 2023
CDT16:47 (GMT) -0400
Published by: Pavel López Lazo
The death toll has also risen to 73 with a case-fatality ratio of 13%.
“From May 14, 2022, to April 9, 2023, 1,439 suspected diphtheria cases were reported from 21 states in Nigeria, with the majority (83 per cent) of cases reported from Kano (1,188), Yobe (97), Katsina (61), Lagos (25), Sokoto (14) and Zamfara (13). Of the 1,439 suspected cases, 557 (39%) were confirmed (51 laboratory-confirmed, 504 clinically compatible, and two epidemiologically linked), 483 (34%) were discarded, and 399 (28%) are pending classification...
Fresh outbreak worsens Nigeria’s effort at Diphtheria eradication
...as NCDC reports 160 confirmed cases in June
July 17, 2023
By Tumininu Ojelabi Hassan
The Nigeria Centre for Disease Control and Prevention (NCDC) has reported 836 confirmed diphtheria cases with 83 deaths in eight states across 33 Local Government Areas in the country this year. In June 2023, 160 cases of diphtheria were confirmed.
According to data from NCDC, 819 (37.7%) cases have been confirmed in Kano state, 3 (3.2%) cases were confirmed in Yobe, 2 (3.3%) cases in Katsina, 8 (27.6%) cases in Lagos, one case was confirmed in FCT, Osun, Kaduna and Cross river state respectively...
Diphtheria: Over 100 isolated as cases spread to 31 Kano Local Councils
By Murtala Adewale, Kano
30 July 2023 | 3:55 am
More than 100 confirmed patients of diphtheria infection are presently receiving treatment at two newly isolation centres in Kano, The Guardian was reliably informed.
Although an unconfirmed source said over 130 persons were currently on isolation in four treatment centres, official sources disclosed that the disease has now spread to 31 local councils of the state...
Diphtheria: Nigeria Records 83 Deaths In 7 States, FCT
Regina Otokpa 42 mins ago
Out of the 836 confirmed cases of diphtheria in 33 Local Government Areas (LGAs) across eight states: Cross River, Kano, Katsina, Kaduna, Lagos, Osun, Yobe, and FCT, no fewer than 83 persons have been reported to have died from the disease.
The Executive Director of the National Primary Health Care Development Agency (NPHCDA), Dr Faisal Shuaib who made the disclosure on Monday in Abuja at a press conference on the diphtheria outbreak in Nigeria, noted that as it stands, vaccination against diphtheria has become critically important, especially for children.
Shuaib lamented that despite efforts of the Federal Government to provide safe and cost-effective vaccines, a significant number of children in Nigeria still remain unvaccinated or partially vaccinated, thus compromising the country’s goal of achieving population immunity.
Shuaib added that suboptimal vaccination coverage has been the main factor contributing to these outbreaks, with the most affected age group being those between 2 to 14 years...
Diphtheria Killed 122 In Nigeria – UNICEF
Written by Leadership News...
4 seconds ago
United Nations Children’s Fund (UNICEF) has said that the Diphtheria outbreak has claimed 122 lives in Nigeria, with a case fatality rate (CFR) of 8.7%.
According to statement issued by UNICEF Nigeria Country Representative, Dr. Cristian Munduate, a copy of which was made available to journalists in Bauchi State on Friday, she said that the outbreak has affected children in 27 States, stating that as of July 2023, 3,850 suspected cases were reported with 1,387 confirmed as diphtheria.
“The outbreak has affected mainly Kano, Yobe, Katsina, Lagos, FCT, Sokoto, and Zamfara, which account for 98.0% of the suspected cases while most confirmed cases, approximately 71.5%, have occurred among children aged 2 – 14 years.”
According to her, it was heartbreaking to note that only 22% of the confirmed cases received their routine childhood immunization vaccinations with 78% unreached...
WHO Director-General's opening remarks at the media briefing – 6 Septmber 2023
6 September 2023
...
Finally to Nigeria, which is experiencing a severe outbreak of diphtheria.
So far, more than 9000 suspected cases have been reported across 17 states, with 307 deaths.
This is the second wave of diphtheria this year.
Diphtheria is a highly contagious but vaccine-preventable disease, caused by a bacterium which can be fatal in 5 to 10% of cases, with a higher mortality rate in young children.
In response, WHO is supporting the government to improve vaccination, surveillance, case management and risk communication.
We are also working with partners to increase access to vaccines and antitoxin.
This outbreak and others highlight the need to increase routine vaccination to stop these outbreaks before they start
...
"Safety and security don't just happen, they are the result of collective consensus and public investment. We owe our children, the most vulnerable citizens in our society, a life free of violence and fear." -Nelson Mandela
Situation at a glance
Since epidemiological week 26, ending 2 July 2023, Nigeria has recorded an unusual increase in cases of diphtheria across several states. From 30 June to 31 August 2023, a total of 5898 suspected cases were reported from 59 Local Government Areas (LGAs) in 11 states. In week 34 (ending 27 August 2023), 234 suspected cases have been reported from 20 LGAs in five states, with one Lab confirmed case1 from the 22 samples collected. Eighteen of these cases were epidemiologically linked 2 and 141 were classified as clinically compatible.
Diphtheria is a highly contagious vaccine-preventable diseasecaused mainly by the bacteria Corynebacterium diphtheriae which can be fatal in 5-10% of cases, with a higher mortality rate in young children.
WHOs 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 (NCDC), in collaboration with WHO and other partners, are being implemented in response to the outbreak. Description of the situation
Since the lastDisease Outbreak News on diphtheria in Nigeria was published on 27 April 2023, the country has reported suspected cases of diphtheria weekly to WHO. However, between 30 June and 31 August 2023, Nigeria recorded an unusual increase in the number of confirmed diphtheria cases4 (figure 1). From 30 June to 31 August 2023, a total of 5898 suspected cases were reported from 59 LGAs 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).
Of the cumulative 8353 suspected cases reported since the outbreak was first reported in 2022, 4717 (56.5%) cases were confirmed4 (lab confirmed1 (169; 3.6%), epidemiologically linked2 (117; 2.5%) and clinical compatibility3 (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% during the last update 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. Figure 1: Diphtheria cases by year/epi-week in Nigeria, 1 May 2022 – 27 August 2023
Definitive diagnosis through laboratory molecular testing identified Corynebacterium diphtheriae and Corynebacterium ulcerans isolates as the species driving this outbreak, particularly C. diphtheria as the major etiologic pathogen associated with the current outbreak. Antibiotic susceptibility tests for 62 isolates of C. 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 (Figure 2). Figure 2 Drug sensitivity results of toxigenic Corynebacterium diphtheriae isolated in Nigeria, May 2022 – July 2023 Source: Nigeria Centre for Disease Control and Prevention Epidemiology of diphtheria
Diphtheria is a highly contagious vaccine-preventable disease caused mainly by Corynebacterium diphtheria but also byCorynebacterium 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 (DAT) 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 CFR 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 FCT. Details of the outbreak have been published on Disease Outbreak News.
Public health response
Coordination: WHO Country Office Incident Management System revised, National Emergency Operation Centre (EOC) activated likewise state EOC in the diphtheria high burden Kaduna, Katsina, Borno; partners mapping ongoing.
Surveillance: Terms of reference for the pillar developed, regular follow up with the states to submit weekly situation report and line-list; WHO and other partners supported NCDC to develop contact tracking and harmonized line-list forms; database for states reporting on response activities p; dashboard for monitoring and evaluation of the response in development;
Laboratory: procurement of commodities; activation of Kano lab to perform testing and culture at state level, transportation of samples;
Risk Communication and Community Engagement: engagement with community leaders, community awareness, development Information Education and Communication material, monitoring rumors, airing jingles, etc.
Case management: supported development of national guideline for case management and surveillance; provided technical guidance on case management; deployed ear, nose and throat (ENT) specialists to treatment centers;
Infection Prevention Control: monitoring of treatment centers on IPC measures is being undertaken;
Operation Support and Logistics: procurement of 10 050 vials diphtheria antitoxin, 15 000 vial erythromycin ETA 28/08 and lab commodities; prepared delivery plan of Personal Protection Equipment to priority states;
Preventing and Responding to Sexual Exploitation, Abuse and Harassment: conducted PRSEAH risk assessment.
Staff health security and wellbeing: general security briefings, reporting template, FAQ on diphtheria
WHO risk assessment
Diphtheria is a vaccine-preventable disease caused mainly by exotoxin-producing Corynebacterium diphtheriae but also by Corynebacterium ulcerans. Diphtheria is fatal in 5 - 10% of cases, with a higher mortality rate in young children. Treatment involves administering DAT as well as antibiotics. Vaccination against diphtheria reduces the mortality and morbidity of diphtheria dramatically.
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 LGAs, with currently 27 LGAs reporting one clinically compatible case in the last three reporting weeks relative to 15 LGAs that had active case in the preceding three weeks.
The low national coverage (57%) of the Pentavalent vaccine (Penta 3) administered in routine immunization, and the suboptimal vaccination coverage in the pediatric 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.
DAT 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 NCDC, with support from WHO and other partners have procured 10 050 DAT 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 (Penta3) coverage was 57% in 2021.
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.
WHO advice
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 C. diphtheriae. 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.
WHO 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 diphtheria antitoxin.
WHO advises implementing the following Infection Prevention & Control measures in health care settings:
1) 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).
2) At screening/triage, immediately place patients with symptoms of Upper Respiratory Tract Infection in a separate area until examined, and, if a suspected case, cohorted with patients with the same diagnosis. Keep the isolation area segregated from other patient-care areas.
3) Maintain one meter between patients. Keep patient care areas well ventilated.
4) 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.
The case management should be carried out following the WHO 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 (DAT is not needed for asymptomatic cases or cases without a pseudomembrane).
Although travelers do not have a special risk of diphtheria infection, it is recommended that national authorities remind travelers 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.
---------------------------------------------------------------------------------------------------------------------------------- 1 Lab confirmed (LC): a person with Corynebacteriumspp. isolated by culture and positive for toxin
production, regardless of symptoms. 2 Epidemiologically linked (EL): a person that meets the definition of a suspected case and is linked
epidemiologically to a laboratory-confirmed case. 3 Clinical compatible (CC): a person that meets the definition of a suspected case and lacks both a
confirmatory laboratory test result and epidemiologic linkage to a laboratory confirmed case. 4 Confirmed case = Lab Confirmed + Epidemiologically Linked + Clinical Compatible (Nigeria Centre of Disease Control (NCDC): Diphtheria Situation report, Serial Number 03, Data as of Epi-week 31 2023: An Update on Diphtheria Outbreak in Nigeria) Citable reference: World Health Organization (13 September 2023). Disease Outbreak News; Diphtheria in Nigeria. Available at https://www.who.int/emergencies/dise...em/2023-DON485
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