Why Nigeria may top cholera cases worldwide again — NCDC DG

Director-General of the Nigeria Centre for Disease Control and Prevention, Dr Ifedayo Adetifa, speaks with LARA ADEJORO on how the COVID-19 pandemic has strengthened the country’s disease surveillance system

What has been the most challenging aspect of your role since you assumed office?

I was appointed from outside the country, which involved the challenges of moving back, adapting to the public service sector and the operating environment, which are substantially different from what I was used to, and also adjusting to the different governance structure.

While doing that, we still had to respond to COVID-19. Six weeks after I resumed, we had to contend with Omicron, Lassa fever, and cholera.

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It was challenging; you seem to be always at war, and you’re expected to do that with the required quality and coverage to satisfy the citizens that we serve and establish a sterling reputation. It also raises expectations from people on what the NCDC is supposed to be doing.

And of course, you do not want slippage that will be attributed to the fact that there is a new person in charge. Also, there’s a bit of worry around the time that we’re losing the previous DG, and maybe this would lead to some intermission. So, it was important that I also focus on steadying the ship and maintaining the confidence that citizens have in the agency.

What have been the gains and gaps comparing COVID-19 and other diseases?

We respond to communicable diseases that are public health threats, and they are either caused by viruses, bacteria, or parasites, but in this case, mostly viruses and bacteria. The agency became a household name in the context of COVID-19.

We have had to previously respond to matters of monkeypox, the 2019 Lassa fever outbreak, the 2017 large meningitis outbreak, and cholera.

Overall, the profile shows that the agency has been informed by the experience of dealing with many of those challenges. Nigeria is considered a pioneer in rolling out a national digital surveillance system, so we don’t do paper-based reporting anymore, which contributed to our being able to report COVID-19 cases the way that they were reported: daily, weekly, in a transparent manner.

The real momentum to have a digital surveillance system was stimulated by the monkeypox reemergence. It began in a few high-burden states, but it was boosted by Lassa fever, which was then boosted by meningitis, and COVID-19 ensured that we now have nationwide coverage.

We’re going beyond that to also meet our target to roll out in every health facility and laboratory, and this is the impact of the impetus that was provided by COVID-19. I don’t necessarily see gaps because, because of COVID-19, we are in a better place than we were before COVID-19, and because of monkeypox, we are in a better place than we were before monkeypox. So COVID-19 helped us to strengthen the surveillance system, both with the platform that is used and in the relationships that were established with partners in the states, including state epidemiologists, disease surveillance and notification officers, senior surveillance officers, and commissioners and ministries of health.

Because of COVID-19, we now have molecular labs—at least one in every state in the country. Of course, that comes with another challenge, but it means that should we have another COVID-19-like outbreak, we are not going to be at the point where we are starting with only three labs. We are in a better place now in terms of any molecular diagnosis of any condition.

When monkeypox emerged in 2017, we couldn’t diagnose it ourselves, let alone talk of sequencing. The diagnosis was made within a few months, and I believe the sequencing will be finished by the following year. However, in the context of COVID-19, we now have significantly more investments in sequencing because everyone suddenly knows about variants.

People didn’t know monkeypox had clades. Everyone is aware that there are two COVID-19 variants: Delta and Omicron. But that’s the power of genomics, which we cannot go back on. The next area of expansion is to ensure that we have very strong, nationally representative sequencing—not just sequencing but genomic surveillance—that is not limited to COVID-19 but is multi-pathogen, that includes all pathogens that are likely to threaten us, both those we know and those that will reemerge or are new.

We now know that we need to decentralise our lab system. We are currently implementing a plan to have regional labs, so we’ll have labs in the six geopolitical zones that will decentralise or bring services a bit closer so that not everything has to go to Abuja or Lagos. The next growth area is figuring out how to coordinate all of that, keep it going, and also ensure that the gains from COVID-19 and previous outbreaks are sustained.

Why are yellow fever samples still sent to Dakar for confirmation?

There are two ways of diagnosing yellow fever. There’s PCR, and there are special antibody tests, which is what’s called the “yellow fever neutralising antibody test.” For serological diagnosis, that’s what we send to Dakar because that’s the World Health Organisation reference centre for testing. Our reference lab is also a WHO-certified centre for diagnosing yellow fever by PCR, but for the ones that need antibody tests, we will test them, but until the samples are retested in Dakar, we cannot call them confirmed cases. We are working on making sure that we get that status. The IPD in Dakar manufactures yellow fever vaccine and has standardised yellow fever neutralising antibodies for which we can currently seek certification.That means we can count those cases not as presumptive but as confirmed cases, as the case may be.

With Ebola in Uganda, what is the NCDC doing to prevent it in Nigeria?

We have a Technical Working Group at the NCDC that is responsible for everything that has to do with preparedness and response to these diseases, including Ebola, so they have been working in the background in terms of preparedness, and since the start of this outbreak in Uganda, we’ve now moved into an alert mode. We are now actively taking steps to prepare for the eventualities of having to deal with an imported case, and we’ve strengthened the surveillance at the points of entry.

We generate lists of passengers who return from Uganda, and they are followed up with phone calls for symptoms for 21 days. We’ve also added some more measures in the advisory that you shouldn’t travel domestically, locally, or internationally till the end of that period, and we will work with port health authorities to enforce that, at least for international travel, so that people that are on the list will not be allowed to get on planes if they’re trying to travel before the follow-up period is complete.

We have made the recommendation that if it is not essential, don’t travel to Uganda. We are conducting assessments of potential treatment and isolation centres; we have distributed diagnostics, and we are trying to increase capacity to make diagnoses in case there are a large number of cases.

Currently, we can make diagnoses here; we can also make diagnoses in Lagos. We need special PPE for Ebola, not the normal PPE that people may have gotten used to during COVID-19. So we have mobilised stocks of that to make it available. We are in the process of buying more and mobilising supplies to make sure that they are available for people at the port health services and the centres where they may be looked after. We’re working closely with the states, which are following up with the contacts from Uganda.

There’s training for Port Health Services officers and training for healthcare workers in the designated hospitals, centres, and laboratories, including ramping up all the IPC training that we’ve been doing.

We’ve prepared an incident action plan that looks at the first 72 hours to two weeks after a case arrives with a view of the coordination efforts that need to be done, what additional surveillance things, what additional things in the lab, risk communication and community engagement, what needs to be done for research, what needs to be done at the point of entry, and of course now you have to mobilise the resources to make sure that they are available and you’re not just looking for money when the case arrives. So those are some of the things that have been happening in the background since September, when the outbreak in Uganda was announced.

The cases of cholera, Lassa fever, and other diseases have been high this year compared to last year. What are the factors responsible for this?

Last year, we had the unenviable position of recording the highest number of cholera cases worldwide. This year appears to follow the same pattern.But perhaps it’s not surprising because if the circumstances that contributed to the case numbers last year have not been dealt with, then we should have the same number of cases this year. So, it tells us that the necessary interventions that needed to have been put in place were not done at the scale desired to make an impact on cholera cases.

In addition, we do realise now that we have had flooding, the security challenges have led people to be displaced, and all of those are additional risk factors for waterborne diseases like cholera, which we are trying to respond to, along with our colleagues in the National Emergency Management Authority and respective state governments. It’s a very challenging situation.

At the moment, we have rapid response teams to help with cholera response, and we have been providing commodities and supplies according to requests that we get to help with cholera response. We are keeping an eye on the situation, and we will continue to offer assistance and help states respond to the various challenges within their borders.

For cholera, outside of a situation where you have a natural disaster with the flooding, we need significant investments in water, sanitation, and hygiene. People require clean and safe water supplies, as well as safe sewage disposal.

At the moment, there are no clean and safe water sources. There is indiscriminate open defecation in communities, and when the rainy season comes, all of the openly defecated materials are washed into the water sources, contaminating the rivers, ponds, and wells. People get their water from there and get cholera.

What we need to do is make sure that at the local and state levels, authorities put in place water supply systems, boreholes, and pipes for water that will make sure that communities have access to safe water and discourage open defecation, which is what contaminates the water sources.