Nigeria has received 10,000 doses of the Mpox vaccine, but none for children under 18.
As Mpox cases surge in Africa, with 35,525 cases and 996 deaths reported as of 8 October in 14 countries, including Nigeria, PREMIUM TIMES sat down with Eduardo Celades, the Chief of Public Health for UNICEF Nigeria, to discuss the Mpox outbreak, its impact on children, vaccine hesitancy, other major health concerns, and the Nigerian health sector.
PT: There's a global outbreak of Mpox, particularly in Africa, and children are amongst the group most vulnerable to this disease. Nigeria has also recorded several suspected and confirmed cases. How vulnerable are children in Nigeria to this virus?
Celades: First, it's important to understand how Mpox is transmitted. Mpox is very easily transmitted with close contact. Close contact with fluids, sweat, changing linen, or taking care of the rash or sores that an infected person can have. When a person with Mpox is not isolated, it can easily transmit to close contacts. That's why we see a lot of transmission at the household level. If one person has Mpox, other members of the family are likely to be infected.
Globally, at UNICEF, we saw that 65 per cent of the total cases of this outbreak are children under five. Here in Nigeria, out of the 67 confirmed cases, at least 24 are for children under 10. This shows children are very vulnerable to Mpox. For us at UNICEF, children are a priority in the efforts to prevent the expansion of the outbreak. They are highly vulnerable, especially if they have underlying conditions. If they are malnourished, for example, they will have weak defences and, for this, face a bigger risk of death.
PT: In August, we received some doses of Mpox vaccines. How many doses for children are available?
Celades: Indeed, the country received 10,000 doses of Mpox vaccine in a couple of weeks. However, the received vaccine is not for children under 18. So, at this moment, Nigeria does not have a Mpox vaccine for children.
PT: Why is that?
Celades: At this moment, there are three main manufacturers: one in the US, one in Japan, and one in Denmark. Unfortunately, the vaccines manufactured in the US and Denmark are not approved for children. Only the Japanese vaccine is approved for children, but it is approved only for children in Japan and not for children outside of Japan. That's why we cannot use them for children.
Vaccines are a powerful tool. In Nigeria, what is approved by the government is that vaccines can be administered to close contacts within 42 days of exposure to the virus. This is because of the incubation period of 21 days. The government doubled the number of days and 21 days plus 21 days equals 42 days. So, anyone with close contact with a person with Mpox, excluding children below age 10, can benefit from the vaccine. But remember that the vaccine in Nigeria at this moment is very limited. It's only 10,000, and one person needs two doses. Hence, we are talking about 5,000 people or even less because of the wastage rate of the vaccine. Only about 5,000 people can benefit from the vaccine. It is very limited at this point, and that is why prevention, early diagnosis, and tracing of contacts are very important.
PT: What is responsible for the low availability of the Mpox vaccine?
Celades: The issue is that the global production of vaccines is not too big. The number of vaccines for Mpox is limited because it's a disease that is not so frequent. This is one of the main challenges. The appeal from African CDC, UNICEF, and WHO is that partners share vaccines with the country that needs them the most. Recently, the US government donated 10,000 vaccines to Nigeria. It was the first country in Africa to receive the Mpox vaccine. Shortly after, the DRC received an additional 100,000 vaccines.
We believe that the allocation of vaccines should be based on equity. They are to be deployed to the places where we need them more. The Mpox vaccines that we have are evolved vaccines from the vaccines used for smallpox. It is part of the same family of viruses as smallpox - a more severe disease that has been eradicated.
PT: How does Nigeria treat and protect children from the virus?
Celades: There is no specific treatment for Mpox. What is available is support treatment. For example, paracetamol if you have pain, calamine if you have a rash or lesions in your skin or fluids if you are getting dehydrated. The best thing for Mpox is prevention and isolation. Once a person has been confirmed infected, we need to do three things. First is the isolation of the person. Then, trace the contacts to be able to vaccinate them if they are adults or to observe them if they are children. And this is the best way of stopping the outbreak.
Nigeria has a very good track record of stopping outbreaks in time; for example, the Ebola outbreak came to Lagos in 2014, and for this, I'm confident that with the measures that the government is putting in place, the country is well-placed to control the pox outbreak within its borders.
PT: With the limited vaccine, what effort should the public make?
Celades: First, let's understand the epidemiology of Mpox. Mpox has two variants, called clades: Clade I and Clade II. Clade I is more prominent in Central Africa, while Clade II is in West Africa. The one that is endemic here in Nigeria is Clade II, and this is the less dangerous one, so to speak.
However, both the African CDC and WHO have declared a public health emergency of international concern and this is because the spread of Clade IB is already affecting six countries. But Nigeria is yet to detect Clade IB. We still have Clade II, which is, let's say, less dangerous in the sense that the case fatality rate is lower than the other one. But why is it a public health emergency of international concern? Because there is mobility of people, this disease by close contact is very easily transmitted. As a result, Nigeria may start to have cases of Clade 1 and Clade 1b. To prevent the spread of the virus, the first step when a person notices any symptom is to go to your closest health facility for medical advice. One of the efforts that UNICEF is making in collaboration with the government and partners is to train people on Mpox.
The second important step is isolation. If you don't isolate yourself, you will likely be spreading the disease to the people who care about you.
Mpox symptoms are very common. So, normally, when one has Mpox, you will have a fever, a headache, and pain in your joints, but as well, you will have a rash. The rash can be very painful. It starts in the face and goes to your hands and your legs. But many diseases trigger these symptoms, such as measles, scabies, chicken pox, and even bacterial skin infections. That's why it's so important that if you suspect you have a painful rash, you just go to your health facility to look for advice.
PT: Earlier, you spoke of Nigeria's ability and effort to curb the spread of Mpox, Also, the Africa CDC once mentioned that using the test alone might not always show an accurate result. Concerning this, how well is the country doing with detection?
Celades: The Nigerian CDC is leading the surveillance efforts, but the effort could be strengthened because the country has a limited number of tests. For example, as UNICEF, we shipped to the country a donation from the US government of 2,000 Rapid General Tests for Mpox. Surveillance efforts need to be strengthened. For example, surveillance at the community level and among vulnerable groups like the IDPs. In IDP camps, it's very frequent to see measles outbreaks, which are very similar to Mpox.
PT: Do you have data on reported Mpox cases from IDP camps?
Celades: I don't have the data at this moment, but what I can say is there's a need to have special attention and surveillance and a strong health system to be able to respond to a potential outbreak in IDP camps and prison facilities due to the high risk of transmission.
Vulnerable groups must be prioritised. There are three main groups. The frontline health workers are group number one because these are the ones who are going to be the patients. The close contact and then people living in crowded spaces or areas, like in IDP camps or prisons, are going to be the most difficult ones.
These are the three main groups that we need to pay attention to and out of that, of course, we have children. They are the most vulnerable, especially when they are malnourished or when they have weak immunity.
PT: An investigation recently showed an increasing prevalence of drug-resistant malaria infections in parts of Africa and Asia. What are the best strategies to prevent the spread of this disease in Nigeria, particularly in light of the country's high malaria burden?
Celades: Malaria is a big concern in Nigeria. One out of four cases of malaria in the world happen in Nigeria, and almost one out of three of the malaria deaths in the world are here in Nigeria. This affects mostly children and pregnant women.
This country has a high burden of malaria, and it cannot respond to this with one intervention. The country should have a package of interventions. The good news is the malaria vaccine will be introduced in the country this year. But, again, with vaccines, we are facing an issue of global constraints in the supply of vaccines because the global stockpile or supply of malaria vaccines is limited at this moment. However, there are other tools the country can use. For example, the regular distribution of mosquito nets, which is already happening, the seasonal chemoprophylaxis, the SCP, and the SCM, so that people have access to malaria prevention pills during the high season. There are also other strategies, such as water and sanitation, because this will reduce the breeding sites of the mosquitoes.
There is no magic bullet to end malaria. Instead, what we need is a package of interventions, and we need to look critically at all of them to see how we can combine them.
PT: Has there been any confirmed case of drug-resistant malaria infection in the country?
Celades: I cannot tell you that. I don't have evidence that the malaria parasites in Nigeria are resistant. I cannot tell you that at this moment, but I do know that some of the neighbouring countries are starting to report cases, and so, Nigeria needs to be prepared. This year, an anti-malarial drug produced in Nigeria was pre-qualified by the WHO. This is a huge milestone for Nigeria because it can help with the production of affordable malaria drugs here in Nigeria.
PT: Could you share what triggered this new strain of drug-resistant infections?
Celades: As you know, malaria is transmitted mostly by the female anopheles mosquito and there are four main subtypes of the parasite, the malaria parasite. Malaria plasmodium falciparum, plasmodium ovale, plasmodium vivax, and falciparum falciparum.
Plasmodium falciparum is endemic in Nigeria, and it has the highest fatality rate in most countries. Resistance normally starts because of the poor use of drugs. For example, self-medication is a widespread practice here in Nigeria. When people self-medicate, this can increase resistance. We are seeing that not only in malaria but also in other diseases. This is a big risk. To avoid that, what we need is an accurate diagnosis. Rapid diagnosis tests and treatment for malaria are available at the health facility level.
PT: How adequately prepared is Nigeria to handle an outbreak or a crisis of drug-resistant malaria infections?
Celades: The WHO leads the work to support countries to improve their capacities for antimicrobial resistance. As UNICEF, our role is to support the different actors, including the Nigerian CDC, the Federal Ministry of Health, and the NPHCDA, to strengthen the health system, for example, by training health workers and recruiting more human resources for health. So, I cannot really speak on this. For us at UNICEF, this is not our core focus. But I think, for antimicrobial resistance, what the country needs is a strong surveillance system and a good lab system in place.
I don't know of a case yet but when those cases begin to arise, if they haven't started, the first frontline centres would be primary healthcare centres, and that's our main focus.
Our main effort at UNICEF is to support the state governments and the federal government to strengthen primary healthcare. We are seeing that primary healthcare is still weak. There is not enough human resources for health. The quality of the data is poor. There is insufficient financing. Also, the logistic chain is inefficient; there are stock-outs of drugs.
PT: Compared to other African countries, Nigeria's maternal mortality rate has not been encouraging. The rate of 1,047 deaths per 100,000 births in 2020 is the third-highest in Africa, and according to major public health organisations, reducing the rate has been difficult. What is responsible for this?
Celades: Maternal mortality is a big concern in the country. We are happy to see that reducing maternal mortality is priority number one of the current Honorable Coordinating Minister of Health, using the sector-wide approach and what is called the strategic blueprint of the National Health Sector Renewable Investment Plan. The number one priority of the current government is to reduce maternal mortality.
I believe this is very good news. But I would like to mention that we have an issue with the quality of the data. According to different estimates, we can see that the ratio of maternal mortality ranges from 500 maternal deaths in every 100,000 live births up to 1,000 maternal deaths in every 100,000 deaths, according to who you are asking. We don't yet have a single source of truth for maternal mortality. That is one of the challenges that we have.
We hope, as well, that with these new investments in data and new surveys, we will be able to have that. A new survey is going to be published very soon that hopefully will have this information. Then, to be able to reduce maternal mortality, you need to do two things.
One is to have a strong health system. Maternal mortality is like a proxy indicator of how good your health system is. For example, what we are seeing is that in the country, 70 per cent of pregnant women go at least once to a health facility. This is according to data from MIGS 2021. Around 70 per cent of pregnant women go at least once to do an antenatal check-up at a health facility. Only 60 per cent of them go at least four times, and only 50 per cent of pregnant women will have a delivery attended by a skilled birth attendant.
You see, there is a cascade. It means that you are losing pregnant women during the different steps of the process. The services provided for pregnant women might be inadequate, and that is why we are losing them. This is compounded by a problem of access. About 30 per cent of pregnant women will never go to a health facility.
Poor access can be a result of distance to a public health facility, but also because of violence or insecurity, or maybe even because of poverty and opportunity costs. There are different factors that are behind this high mortality rate. Of course, there are cultural or socio-economic factors. For example, who makes the decision to look for treatment and care?
What we are happy to say is that we believe that the government is taking the appropriate steps to try to have a comprehensive plan to reduce maternal mortality in the country. We know that there are different interventions that work. For example, expanding the number of health facilities that can provide comprehensive obstetric and neonatal services, as well as, for example, micronutrient supplementation for pregnant women to reduce anaemia and training on how to conduct a safe delivery. We believe that we are on the right track. We hope that in the next three years, we will see a significant reduction in maternal mortality in Nigeria.
PT: Could you share insights on the current public health challenges that affect children, particularly those related to immunisation and nutrition?
Celades: I think there are three main challenges in Nigeria. For children, for women, and the most vulnerable in general. The first challenge is that our primary healthcare system is still very weak. I mentioned that before. 80 to 90 per cent of all the diseases can be treated at a primary healthcare facility. We also know that primary healthcare is the platform to deliver prevention measures like immunisation or vaccination, but unfortunately, the primary healthcare system is still very weak: we don't have enough doctors or nurses, the quality of the aid is poor; there is insufficient financing.
There's a need to ensure that our primary health care is strong enough to respond to the needs of children, women and the most vulnerable. For example, adequate health insurance. Also, we are happy to see that the government is taking firmer steps to move in that direction and to ensure that we have at least two fully functional primary healthcare facilities per ward. This will give us about 70,000 facilities.
The second challenge that we are seeing is a lack of access. We still see that a lot of people, especially children and women, don't have access to the services that they need. A good example is the high number of zero-dose children. A zero-dose child is a child that doesn't have any vaccines, and Nigeria has the highest number in the world. About 2.1 million children don't have any vaccine or at least the PentaOne vaccine. For us at UNICEF, this is a big priority. It is not only a health issue that they don't have any vaccines; it is also a proxy of multidimensional poverty.
Let's say if a child doesn't have any vaccine, it's unlikely as well that the child has access to water or to, sanitation or eventually to education or social protection programmes. Zero-dose children is an issue. The other challenge is how to expand the coverage of services. How to expand the coverage of maternal care, how to expand the coverage of immunisation, the coverage of nutrition programmes, et cetera.
There are three main challenges; weak parental care systems, lack of access, inequalities like zero-dose children, and low coverage of social services.
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PT: Can you discuss the best strategies for improving health outcomes for children in rural versus urban areas in Nigeria?
Celades: UNICEF is developing a new strategy to improve immunisation in urban areas because we are seeing a high number of zero-dose children here. Most times, people tend to assume that the high number of zero-dose children is only in very rural communities without access to vaccines, but we are seeing that there are some urban communities affected. Urban communities have residents that are actually close to the health facility, but they don't get vaccinated. For example, with polio, there are cases of non-compliance. Families are refusing polio vaccination. Some of them, because of religious beliefs. Vaccine hesitancy is not only among people in rural areas but among people from every social and economic background. We are seeing that this is increasing. It started to increase during COVID-19, and now we are seeing that it's happening more and more.
To address this, UNICEF monitors social media. We look at the conversation that is happening in social media, in X, Facebook, and Instagram, to know what is happening. Another thing that we are doing is targeting information and messages. To improve the level of vaccination, there's a need to target the audience. UNICEF also has a national immunisation and social behaviour change strategy tailored to fit different LGAs or even settlements. We have been doing lots of work to be able to identify and co-create with the communities the messages needed to enlighten the people and increase vaccination.
However, the issue of access still exists, and this is the case in many rural, semi-urban, and slum areas.
PT: How does UNICEF Nigeria collaborate with local governments and communities to enhance public health initiatives?
Celades: UNICEF believes in the role of communities in public health. At this moment, we have a network of more than 16,000 community mobilisers, most of them women working at community level to help with line listing of all the new births and help with messages about vaccination and about polio. We believe in the role of communities to lead in their own health, to make informed decisions, to do surveillance at the community level, and to discuss health issues. .
Working with communities is very important. As I said before, our main priority is to strengthen primary health care, and this is very clear. There is a new strategy of two primary health care centres per ward, fully functional 24-7, with services for women and children, with nurses living on-site. We are supporting the effort to expand that PHC, especially in our priority states in the north.
We are working mostly in 14 states in the north, and one in the south, and we are fully committed to that. We think community efforts and empowering communities should be the centre of our public health interventions.
PT: Lastly, how do you see the future of children's health in Nigeria, and what are the immediate and critical areas that need immediate attention?
Celades: I am an optimist, and I really believe that the health outcomes and indicators in Nigeria are going to improve over the next three years. On the one hand, we have very strong leadership from the government and the Minister of Health, which has a very clear agenda to reduce maternal mortality and improve health outcomes. This agenda has resulted in a reduction of the fragmentation of the partners as well as in mobilising additional resources for the health sector. More than one billion dollars have been mobilised for this ambitious agenda. So we, as partners, as UNICEF, as a technical and financial partner, believe that we are in the right direction and that we can contribute to improving these health outcomes.
The country has made a lot of efforts to introduce new vaccines to reduce child mortality. For example, the rotavirus vaccine was introduced last year, and now the country has the HPV vaccine to reduce cervical cancer among young girls and women. The PCV vaccine to prevent pneumonia was introduced two years ago. The country plans to introduce a new vaccine for measles next year.
It is not only about vaccines, but I know that if we strengthen primary health care, establish a strong referral mechanism for pregnant women to reduce maternal mortality, and get more tools available like vaccines, if Nigeria does the homework and we as partners and the government realign in a common objective, there'll be a huge change in the health indicators of Nigeria over the next three years.
