With COVID-19 pandemic taking a toll on Nigeria practically all through 2020, Martins Ifijeh reviews with timelines, the performance of the Nigeria Centre for Disease Control (NCDC); the agency responsible for the country’s health security through disease preparedness, detection and response
The year 2020 has been unprecedented. It has been dominated by the COVID-19 pandemic, with many countries now experiencing a second wave of the outbreak. Nigeria, in addition to the pandemic has recorded other outbreaks, including yellow fever, weekly cases of Lassa fever, monkeypox, cholera, measles and other epidemic prone diseases.
This has indeed been a critical year for health security with the Nigeria Centre for Disease Control (NCDC) leading the fight against the pandemic and other disease outbreaks experienced by the country since January.
Prior to the confirmation of Nigeria’s first case of COVID-19 on February27, NCDC announced that it was monitoring the COVID-19 outbreak in China and conducted a risk assessment of the threat to the country. The Director General of NCDC, Dr. Chikwe Ihekweazu was part of a team invited by the World Health Organisation (WHO) to carry out an exploratory visit to China. On January 22, a public health advisory was published and disseminated while NCDC established a multisectoral Coronavirus Preparedness Group on January 26 to prepare the country for the impending outbreak.
The group identified laboratories to establish capacity for COVID-19 testing, with the agency partnering with states and tertiary hospitals to map out treatment/isolation centres for case management, as well as training health workers across all states on case management, infection prevention control, surveillance, risk communications and other areas. It also prepositioned medical supplies such as personal protective equipment to all states, while developing preparedness guidelines and plans by adapting global regulations to Nigeria’s context. This summed the beginning of preparation before the pandemic arrived in the country.
Nigeria’s Public Health Laboratory Services
At the beginning of the COVID-19 pandemic, Nigeria had only four laboratories with the capacity to confirm the SARS-CoV-2 virus. Three of the laboratories in Lagos, Irrua, Edo State and Ede, Osun State were part of the NCDC molecular laboratory network for other diseases; the fourth was the NCDC National Reference Laboratory (NRL).
The public health laboratory service in Nigeria has been a weak point for several years. Before the COVID-19 pandemic, NCDC had established a Lassa fever laboratory network with five laboratories, yellow fever/measles/rubella network with seven laboratories, cholera/meningitis laboratory network with 17 laboratories and a network for antimicrobial resistance (AMR) surveillance with 12 laboratories. However, most states in Nigeria did not have a public health laboratory.
Between February and October 2020, NCDC supported every state in Nigeria to establish at least one public health laboratory for COVID-19 diagnosis. These laboratories now have the required molecular diagnostic capacity that can be used for other epidemic prone diseases in Nigeria such as Lassa fever.
Additionally, the NCDC NRL was selected by the Africa CDC and WHO to provide genetic sequencing for COVID-19, to other countries in Africa. The NCDC NRL and the African Centre for Genomics of Infectious Diseases (ACEGID) at Redeemers University Ede, are the only two laboratories in Nigeria set up for this purpose.
There is still a lot of work to be done to strengthen Nigeria’s public health laboratory services. However, we have grown from about five public health molecular laboratories in Nigeria, to over 60 public health laboratories. It remains to be seen how the Government will scale up the capacity built for COVID-19, for other diseases.
Establishing Emergency Operations Centre in All States
The phrase “Public Health Emergency Operations Centres” or EOC for short, have become common in Nigeria. This is where the COVID-19 pandemic response has been coordinated across states and at the national level.
In April 2018, NCDC announced the establishment of Zamfara State Public Health EOC, following the meningitis outbreak in 2019. This was the first State Public Health EOC in Nigeria. NCDC has now established 28 Public Health EOCs in states and the FCT as at December 2020. About seven of these public health EOCs were established this year, as the country responded to the COVID-19 pandemic.
Seven states in Nigeria already have polio EOCs. Following the eradication of the disease in Nigeria, it is expected that these EOCs continue polio surveillance but also integrate other public health functions. Currently, only two states in Nigeria do not have a polio nor Public Health EOC- Jigawa and Ogun.
The establishment of these EOCs before the COVID-19 pandemic gave many states the upper hand, in terms of outbreak coordination. Some states such as Edo State had activated their EOC multiple times for Lassa fever and yellow fever prior to the COVID-19 pandemic.
However, some of these Public Health EOCs are still poorly funded with intermittent power supply and shortage of human resources affecting capacity. We rank the establishment of Public Health EOCs as a major milestone, but more work needs to be done in strengthening the activities of these critical institutions.
Digitalising Surveillance for Epidemic Prone Disease
During the 2014 Ebola outbreak, Nigeria still had a surveillance system that depended on paper-based reporting and use of Excel sheets. This was a major challenge as it caused delay in reporting from LGA to states, and from states to the national level. As part of lessons from the Ebola response, NCDC said it has worked with partners in Germany to develop a tool called SORMASthrough which cases of diseases are reported using a tablet from health facilities or LGAs.
At the beginning of 2020, only 17 states had SORMAS deployed partially (not covering all LGAs). However, by the end of November 2020, all states in Nigeria and the FCT, plus all LGAs have begun to use SORMAS for disease reporting. This has also enabled rapid analysis of cases, contact tracing and other disease surveillance functions.
Currently, SORMAS is used for epidemic prone diseases which are within the mandate of NCDC e.g. Lassa fever. However, major infectious diseases like HIV and Tuberculosis still use separate systems for surveillance.
If Nigeria wants to strengthen its surveillance system, it must move to an integrated digital system, owned and led on by government institutions such as NCDC which has the mandate for infectious diseases.
The COVID-19 pandemic has stretched health systems and health workers. Organisations like NCDC have continued to work extremely hard since the beginning of the year with no signs of stopping, as the second wave begins. In addition to the areas mentioned above, NCDC has continued its routine functions.
This year, the Nigerian Integrated Disease Surveillance and Response (IDSR) guideline was reviewed after over ten years, taking into consideration changes in the health field such as event-based surveillance. NCDC has scaled up its communications strategies and become a household name, with over 2 million followers on its social media accounts. The agency has also established new training programmes such as the online IPC programme for health workers and trained over 40,000 health workers physically using this curriculum.
In 2021, Nigeria needs to build on its progress with the COVID-19 response and extend this to other areas of health security. The NCDC needs to expand its capacity and achievements but requires the funding and political commitment for this.
Response to Yellow Fever
In November 2020, as Nigeria was responding to the COVID-19 pandemic, news of “strange illness” in towns in Enugu and Delta States were shared widely. In a swift response, NCDC released a holding statement to inform the public of ongoing laboratory investigation in collaboration with the reporting states. Within five days of receiving reports of the first case, NCDC confirmed that the reported clusters of cases and deaths were caused by yellow fever. This was confirmed at the NCDC National Reference Laboratory in Abuja.
Prior to 2017, Nigeria relied completely on sending samples to the Institute Pasteur Dakar, for yellow fever diagnosis. However, the NCDC National Reference Laboratory which was operationalised in May 2017 now leads the diagnosis of epidemic prone diseases including yellow fever confirmation.
Following the confirmation of the outbreak, NCDC activated a Yellow fever Emergency Operations Centre (EOC) to provide a command-and-control response to the affected states. Rapid Response Teams were deployed to affected states and surveillance activities were heightened.
The swiftness in confirming the yellow fever outbreak and activating response activities is indicative of the agency’s improved capacity over the last four years. Nigeria no longer has to rely on other countries, to confirm its outbreaks.
Response to Lassa Fever
In spite of the COVID-19 pandemic, Nigeria continued to record cases of other epidemic prone diseases. In fact, at the beginning of the COVID-19 response in February, NCDC had declared an emergency phase for Lassa fever. The country was responding to two outbreaks simultaneously.
Despite the pressures of concurrent outbreaks, this year’s Lassa fever outbreak had improved outcomes according to the agency. According to its situation report published weekly since the beginning of the year, more Lassa fever cases were detected this year. This, it said may be attributed to improved surveillance system, laboratory testing and risk communications. Weekly reports show that there was also less number of health workers affected.
According to a statement issued by the Coalition for Epidemic Preparedness Innovations (CEPI), the organisation is working with NCDC and institutions in Benin Republic, Guinea, Liberia and Sierra Leone to carry out the largest-ever Lassa fever research programme in West Africa. This has been a long-awaited programme as NCDC had announced plans for this project in 2019 at the Lassa fever International Conference.
The data from this study will be used for public health decisions, according to the NCDC DG, but also for the design of future late-stage efficacy trials to evaluate potential Lassa vaccine candidates. Over 4800 participants have so far already enrolled in this study as at December 17, 2020.
It is remarkable that Nigeria is now leading research and development activities for Lassa fever, which has long been neglected despite its emergence over 50 years ago.