Diphtheria, A Disease Slowly Eating Into The Heart Of Nigeria

There has been an unusual spike in the cases of diphtheria across several states in Nigeria since the beginning of July.

Diphtheria is a highly contagious vaccine-preventable disease caused mainly by the bacteria Corynebacterium diphtheria, which can be fatal in 5-10% of cases, with a higher mortality rate in young children.

Years ago, diphtheria was one of the leading causes of death among children; however, it has become almost non-existent in developed countries with the vaccine’s introduction.

This is not the case in Nigeria, considering there has been an influx in the disease recently.

Risk factors for diphtheria include crowded environments, poor hygiene, and lack of immunization, and if left untreated, it can cause severe damage to the kidneys, nervous system, and heart. It’s fatal in about 3 percent of cases.

In some cases, these toxins can also damage other organs, including the heart, brain, and kidneys.

Symptoms Of Diphtheria

The most visible and common symptom of diphtheria is a thick, grey coating on the throat and tonsils. Other common symptoms include,

Fever and chills

Sore throat, hoarseness

Painful swallowing

Croup-like (barking) cough

Drooling (suggests airway blockage is about to occur)

Bluish colouration of the skin

Bloody, watery drainage from the nose

Breathing problems, including difficulty breathing, fast breathing, and high-pitched breathing sound (stridor)

Skin sores (usually seen in tropical areas).

Signs of diphtheria often appear within two to five days of the infection occurring. Some people don’t experience symptoms, while others have mild symptoms similar to the common cold.

The first case of diphtheria was recorded in Nigeria between February and November 2011 in the rural areas of Borno State, north-eastern Nigeria, where 98 cases were cited.

Nigeria is currently facing the second wave of diphtheria outbreak after a first wave was recorded between 1 January 2023 and 22 May 2023.

There has been an increase in the affected population with a rise in confirmed cases and related deaths involving 21 of the 36 states and the FCT.

World Health Organisation (WHO), in its most recent risk assessment of the diphtheria outbreak in Nigeria, said that the risk was 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.

Since the last Disease 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 confirmed diphtheria cases.

From 30 June to 31 August 2023, 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).

UNICEF Nigeria is amplifying its efforts to counter a growing outbreak of diphtheria that has affected children in 27 states. As of July 2023, 3,850 suspected cases were reported, with 1,387 confirmed as diphtheria. The disease has tragically claimed 122 lives, with a case fatality rate (CFR) of 8.7%.

The outbreak has affected mainly Kano, Yobe, Katsina, Lagos, FCT, Sokoto, and Zamfara, which account for 98.0% of the suspected cases. Most confirmed cases, approximately 71.5%, have occurred among children aged 2 – 14 years.

Treatment Of Diphtheria

Treatment involves administering diphtheria antitoxin (DAT) as well as antibiotics. Vaccination against diphtheria has effectively reduced the mortality and morbidity from diphtheria dramatically. Diphtheria is fatal in 5-10% of cases, with a higher mortality rate in young children. However, the CFR can be as high as 40% in settings with poor access to diphtheria antitoxin.

Why Has There Been An Influx In Diphtheria In Recent Times

Insecurity is one of the major challenges plaguing the northern part of Nigeria.

Distributing vaccines in regions with insecurity issues can be quite difficult.

Due to insecurity, especially in Northeast Nigeria, vaccination coverage remains suboptimal.

There are also issues of poor hygiene by those who have been displaced.

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. With support from WHO and other partners, the NCDC has procured 10 050 DAT vials for case management in response to the outbreak.

This emphasizes the urgent need to strengthen diphtheria vaccination coverage nationwide, especially in the most affected states, such as Kano.

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.

While addressing the dire situation, the UNICEF Representative in Nigeria, Cristian Munduate, lamented that only 22 percent of the confirmed cases could access the vaccine.

She said, “It’s heartbreaking to note that only 22 % of the confirmed cases received their routine childhood immunization vaccinations.

“Most of these affected children, especially those who unfortunately passed away, had not received a single dose of the vaccine. The need to reach the unreached has never been more critical.”

Medical Expert Opinion

While speaking to our correspondent, a Doctor of Pharmacy, Emmanuel Obukishie, stated that the major constraint with the disease is the lack of access to the vaccine.

He noted that due to the Northern population and the disease’s high contagiousness, there would naturally be an influx of those that contact it.

He said via a phone interview, “Diphtheria is not a disease that should be causing problems, for Nigeria. In developed countries where everyone is vaccinated, an outbreak cannot happen. But the problem with Nigeria is that we do not have access to the vaccine as we should.

“This is a situation that should be taken seriously. Diphtheria is primarily controlled by the prevention of infection through mass vaccination of a high population.

“Presently we can say the North is like ground zero for the disease because that is where it is widespread. Most people go to the North for business, especially traders, and can easily contract the disease and spread it to other states.

“You can even contract diphtheria from someone who is showing no symptoms and if you do not receive treatment, it can lead to the damage of your brain, kidney, heart, and eventually lead to death.

“All I can say is that the Federal government has to look into ways in making the vaccine accessible to those infected.”