17 July 2017

Nigeria: Red Alert for Cholera, Hepatitis E Outbreaks

Photo: Nancy Palus/IRIN
A man washes his hands during cholera prevention session (file photo).

The World Health Organisation (WHO) has raised red alert for acute outbreaks of cholera and hepatitis E in Nigeria. The WHO blamed the cholera outbreaks on lack of access to clean drinking water and poor hygiene conditions, and the hepatitis E epidemic on the ongoing humanitarian crisis in north-eastern Nigeria.

The WHO said it was notified of a cholera outbreak in Kwara State, where the event currently remains localised. The first cases of acute watery diarrhoea were reported during the last week of April 2017 and a sharp increase in the number of cases and deaths has been observed since May 1, 2017. However, the number of new cases reported has shown a decline over the last four reporting weeks.

According to the WHO, as of June 30, 2017, a total of 1558 suspected cases of cholera have been reported including 11 deaths (case fatality rate: 0.7 per cent). Thirteen of these cases were confirmed by culture in laboratory. 50 per cent of the suspected cases reported are male and 49 per cent are female (information for gender is missing for one per cent of the suspected cases). The disease is affecting all age groups.

WHO, in a statement, said between May 1 and June 30, 2017, suspected cholera cases in Kwara State were reported from five local government areas; Asa (18), Ilorin East (450), Ilorin South (215), Ilorin West (780), and Moro (50) (information for local government areas is missing for 45 of the suspected cases).

"Poor sanitation conditions observed in the affected communities are one of the predisposing factors for this cholera outbreak. An important risk factor is the lack of access to clean drinking water and poor hygiene conditions," the United Nation (UN) apex health body noted.

According to the WHO, the Nigerian Ministry of Health notified her of an outbreak of hepatitis E located in the north-east region of the country on June 18, 2017.

The first case was detected on May 3, 2017 in Damasak, a locality at the border with the Republic of the Niger. Samples were collected from the case and sent to laboratory for confirmation. Cases were later reported in Ngala, one of the local government areas in Borno State that borders Cameroon. As of July 2, 2017, 146 confirmed and suspected cases were reported including 21 confirmed cases.

According to WHO, in Ngala, 25 infected pregnant women (21 per cent) were reported, including two deaths (case fatality rate = eight per cent). Cases were reported from three local government areas: Ngala (112), Mobbar (19), and Monguno (14). The number of hepatitis E cases is highest in Ngala with 29 cases reported from June 19 to July 2, 2017. Twenty-seven samples were shipped to the virology laboratory in Lagos for further diagnosis. Among the samples collected and tested, 21 tested positive (10 in Ngala, seven in Mobbar, four in Monguno) and six tested negative. Twenty-three samples have been collected and are pending laboratory tests.

The apex UN body said the hepatitis E outbreak could propagate rapidly due to the ongoing humanitarian crisis in the region, which arises from the volatile security situation in north-eastern Nigeria and continues to persist.

It further explained: "This crisis in Nigeria has been ongoing for eight years and as a result 1.9 million people are internally displaced. The region has been facing intense movements of population coming from refugee camps or displaced populations in the areas bordering Chad and Niger.

"In addition, the fresh wave of returnees from neighbouring countries is overwhelming the current humanitarian capacity. Returnees began entering the town in January 2017 and so far the town has an estimated population of 90 000, according to International Committee of the Red Cross (ICRC) and immigration officials. The town has one unofficial camp hosting returnees considered as strangers or people not affiliated to any of the indigenous communities who have settled in the town. As a result there is overcrowding which is overwhelming the already weak systems in place. Lack of access to essential water, sanitation, hygiene, and health services may lead to propagation of this disease at a very rapid rate."

To address the cholera outbreaks, the Kwara State Ministry of Health has established an Emergency Operations Center to coordinate the outbreak response with support from the Nigeria Centers for Disease Control (NCDC), Nigeria Field Epidemiology and Laboratory Training Programme, National Primary Health Care Development Agency (NPHCDA), the University of Ilorin Teaching Hospital, WHO, and partners.

The following response measures are being carried out:

*National multidisciplinary teams were deployed to Kwara State to provide technical support.

*Cases are being managed in local health care facilities in Kwara State. Active case searching is ongoing in the affected and surrounding communities. These have been strengthened with the formation of surveillance teams made up of the above mentioned partners, and the deployment of local government area Disease Surveillance and Notification Officers (DSNOs).

*Collation and data entry of cases is currently ongoing.

*In order to improve laboratory investigations, cholera rapid diagnostic tests are being distributed to selected facilities and health care staff trained on their use.

According to the WHO, efforts to improve case management are ongoing. On 15 June 2017, clinicians from the three most affected local government areas were trained on cholera case management, and infection prevention and control (IPC). The current IPC capacity is not well developed and there is poor access to safe water, poor sanitation and hygiene conditions as well as severe challenges to adhere to IPC standards. Efforts are further impeded by limitations of supplies, and a general requirement for patients to pay for treatment.

Social mobilization activities continue with the use of Yoruba language radio 'jingles', and religious leaders had been sensitized in the affected state to create awareness and prompt early presentation to healthcare facilities. Communities have been mobilized through house-to-house sensitization on the use of Aquatab for household water treatment and safe water storage.

Also, environmental investigations are ongoing, and water samples (a local community well and household drinking water) have tested positive for Vibrio cholerae.

Laboratory response activities include the prepositioning and on-the-job training on use of rapid diagnostic tests in two health facilities. Sensitivity results of Vibrio cholerae show resistance to Tetracycline and Ampicillin. Also, additional rapid diagnostic kits are expected to arrive.

A multisectoral approach needs to be emphasized and participation encouraged. This would include ensuring proper medical waste management by the State Ministry of Health and access to clean portable water by the Ministry of water resources.

The WHO in its risk assessment of the situation noted: "The current outbreak occurs while the country is facing a serious humanitarian situation and is recovering from a large meningitis outbreak. At this stage, the overall risk is moderate at national level.

"Potential issues of concern for this outbreak include the ongoing rainy season, the capacity challenges at the State level to manage the outbreak and the sharing of borders with five other States as well as Republic of Benin. Although these issues can potentially lead to the worsening of the outbreak and its spread to other States and neighbouring countries, the country has capacities to quickly control the outbreak.

"The surveillance system should be strengthened in neighboring States to ease early detection of any potential spread of the outbreak."

WHO recommends enhanced surveillance for the detection of new cases and improvement of record keeping and data management at healthcare facility level. WHO recommends the urgent establishment of cholera treatment centres in the most affected areas, ensuring that adequate logistics are in place and that medical supplies are in stock. The establishment of a multisectoral approach is imperative to successfully addressing this outbreak.

WHO does not recommend any restriction on travel and trade to Nigeria on the basis of the information available on the current event.

Meanwhile, coordinating partners in the hepatitis E response include WHO, United Nations Children's Fund (UNICEF), Oxfam (representing the Water, Sanitation and Hygiene (WASH) sector), Médecins Sans Frontières (MSF), FHI 360, ICRC (working with Nigerian Red Cross) and North East Regional Initiative (NERI).

Response activities for this outbreak include the following:

*WHO and MSF are supporting case management at no cost to patients and this includes hospitalization of those in need, availability of drugs, and health personnel. Symptomatic case management is supported by MSF at the district level.

*Epidemiological surveillance system at health facilities exists with the support of local partners.

*Technical support is being provided from WHO and other partners.

*As of June 15, 2017, WASH assessed and mapped the current water sources and established contacts for a rapid response in the chlorination of water.

The WHO insists that a multisectoral approach needs to be emphasized and coordinated between the State Ministry of Health, Nigeria Centre for Disease Control, and Ministries of Water and Environment.

Public health awareness through sensitizations and announcements in mosques and other public places by local government area health educators is taking place. In addition, local health personnel are being sensitized, eight Volunteer Community Mobilizers (VCMs), the health care staff, MSF, UNICEF and FHI 360.

The WHO in its risk assessment of hepatitis outbreak in Nigeria noted: "Nigeria shares an international border with four countries, Chad and Cameroon in the east, Republic of the Niger to the north, and Republic of Benin on the west. The areas of insecurity are located in north-eastern Nigeria, bordering Republic of the Niger, Cameroon, and Chad. The hepatitis E outbreak is taking place in this same area.

"This area is characterized by a hepatitis E outbreak in neighbouring Chad and in Republic of the Niger. The ongoing humanitarian crisis and insecurity, high numbers of Internally Displaced Persons (IDP) and refugees, and poor access to safe water leads to the spread of disease. There are also an increasing number of displaced persons moving back to the region post occupation. In addition, the potential cross-border contamination and subsequent increased risk of spread from Republic of the Niger and other neighbouring countries should be considered. There are a number of refugee and IDP camps that are overcrowded and have poor sanitation conditions thereby increasing the risk of hepatitis E. Therefore the observed risk at the national level is high.

"The risk at regional level is moderate especially in the countries around the humanitarian crisis in north-eastern Nigeria. The risk at global level is low."

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