Millions of Nigerians are at risk as the government ignores other diseases

2021-10-21
THE NATION newspaper

While the COVID-19 has infected millions and claimed more than 4.5 million lives, experts are warning that the consequence of the neglect of other diseases due to the pandemic may be critical in the months and years to come. Neglected tropical diseases which are a group of chronic, disabling, disfiguring conditions, occur most commonly among people living in extreme poverty in rural and urban areas.
Nigeria contributes 40 percent of the NTD burden globally and carries roughly 25 percent of Africa’s NTD burden.


The National Coordinator of NTDs, Dr. Nseobong Akpan says an estimated 122 million people, two out of every Nigerian, are at risk of one or more of the neglected tropical diseases such as Trachoma, River blindness Elephantiasis, helminthiasis (diseases caused by parasitic worms such as Hookworms), schistosomiasis, (Bilharzia), Leprosy, snakebite, Yaws, Rabies, Leishmaniasis, Sleeping Sickness among others which are endemic in the country.

“Of the number, 20 percent are pre-school age children, 28 per cent of school-age children between the ages of 5 to 14 years and 52 per cent are adults 15 years and above,” Dr Akpan said during a media forum on neglected diseases held at Port Harcourt last month.

He explained that an estimated 119 million people are at risk of getting elephantiasis, 51 million for River Blindness, 28.8 million school-age children and 20.5 million pre-school-age children were at risk of getting parasitic worm diseases, 26 million people risked going blind from trachoma while 23.8 million school age children were at risk of getting soil-transmitted hermits, 26.8 million people for trachoma and 23.8 million school-age children were at risk of getting infected with Bilharzia.

Approximately 85% of the NTD disease burden results from worm infections.
For example, hookworm infection occurs in almost half of the continent’s poorest people, including 40–50 million school-aged children and 7 million pregnant women in whom it is a leading cause of anaemia. Hookworm is a parasitic roundworm that causes types of infection known as helminthiasis. Hookworm infection is common in areas with poor access to adequate water, sanitation, and hygiene. Across sub-Saharan Africa, the prevalence of hookworm is approximately 29%, corresponding to nearly 200 million people being infected. The WHO recommends —albendazole (400 mg) and mebendazole (500 mg) tablets as an effective, inexpensive and easy way to deworm those at risk such as children.

Another drug which the WHO was this year expected to include Ivermectin (produced for human use) for use in the management of hookworm and other parasitic infestations. Ivermectin formulated for use in animals, has been abused during the COVID-19 pandemic by individuals under the mistaken and unfounded belief that it can manage or treat those infected with the coronavirus.

Schistosomiasis or Bilharzia as it is commonly known, is a water-borne parasitic worm disease that affects about 258 million people worldwide. Sub-Saharan African countries account for about 90% of the world’s total cases. In Nigeria, an estimated 20 million people need to be treated for the disease annually. One way of managing the disease is through mass drug administration programs —where everyone in a targeted region at risk of an endemic disease such as Bilharzia, receives treatment without individual diagnosis.

The Nigeria government has been running school-based deworming programs with Praziquantel (PZQ) as the main drug because of its cost, efficacy against all species of parasitic worms and ease of administration.

In 2001, WHO member states including Nigeria, endorsed the World Health Assembly Resolution resolution on schistosomiasis and soil-transmitted helminths committing to attaining at least 75% regular treatment benchmark of all school-aged children in endemic communities by 2010.
“While this resolution generated a greater political commitment in many member states, it took Nigeria more than a decade to come up with a national action plan for control of NTDs,” Dr Oyetunde Oyeyemi, a senior lecturer in the Department of Biological Sciences, University of Medical Sciences, Ondo state says in this research paper published in ScienceDirect, a database of multi-disciplinary, peer-reviewed journal articles.

A new roadmap set out by the WHO to address Neglected Tropical Diseases set three time-bound goals which envisaged the elimination of Bilharzia by 2020.

“Conflict might have contributed in part to the non-realisation of control of schistosomiasis in Nigeria. Although COVID-19 pandemic has been suggested to impede interventional programmes of many diseases, it is not certain that with the level of development in the schistosomiasis control implementation programmes in Nigeria that the WHO NTD 2020 target could have been realized in the absence of the current pandemic,” says Dr Oyeyemi who is a public health parasitologist whose research interests are epidemiology and control of transmission of parasitic disease.

The Nigeria National Malaria Elimination programme (NMEP) has confounded earlier predictions that it would not be able to maintain its seasonal malaria chemoprevention (SMC) campaigns. The NMEP, with the support of the MAlaria consortium was by August this year expected to have provided nine million children under five years with a combination of two safe and efficacious drugs – amodiaquine and sulfadoxine-pyrimethamine to protect them against Malaria. The drugs given to eligible children once a month over a four month period (July to October).
The NMEP has ramped up its distribution of long lasting insecticide nets, increased is malaria diagnostic testing, preventive treatment for pregnant women and is public campaigns aimed at social and behavioural change.

The public awareness campaigns have been gaining momentum since the COVID-19 pandemic reported last year to encourage people to visit health centres for diagnosis and treatment. Many people have been reluctant to visit hospitals for fear of being diagnosed with the coronavirus or ‘catching’ it there.
Nurse Rakiya of Nkangbe Primary Healthcare in Minna said the centre has been receiving fewer patients seeking treatment.

“During the lockdown period, we did not get a lot of patients for malaria and other diseases. People did not come for treatment or testing because they were scared that they would be referred to another clinic where they would be isolated.

” Even before the COVID-19, many people in this area did not come to the hospital for malaria treatment. They feel once they buy these drugs and take them, they will be okay. So the COVID-19 just gave them another reason to avoid coming to the clinic”, she said.
Isaiah Yisa has suffered two bouts of malaria over the last 18 months. Before the COVID-19 pandemic, Yisa would have gone to the hospital for proper diagnosis and treatment. But with the advent of the pandemic, Yisa has opted to self-medicate by buying over the counter anti-malarial drugs. His biggest fear? Running the risk of his symptoms being misdiagnosed as COVID-19 resulting in being ordered to self-quarantine or at worst, being forced to isolate in a health facility.

Antimalarial self-medication practice in Nigeria is very common. It is considered an alternative way for people who cannot afford the cost of healthcare services. While the initial treatment of malaria fever often takes place at home without consulting trained professionals, Yisa and others who self-medicate run the risk of developing resistance to the readily available anti-Malarial drugs making them ineffective.

A Clinical and Medical Microbiologist, Dr Adam Mustapha of the Department of Microbiology, University of Maiduguri said antimicrobial resistance is a big challenge in Nigeria driven by the overuse and misuse of antibiotics.

” In Africa excessive use of antibiotics has become the norm as these drugs are available from the unlicensed and unregistered ‘chemists’ who litter our neighbourhoods. There are more such outlets than registered pharmacies. In Nigeria, such outlets are not supposed to sell antibiotics without prescription but you find them selling them without any concern or knowledge of the impact this might have,” he says.
Dr Mustapha said the emergence of the COVID-19 has further aggravated the situation as people presenting symptoms similar to the virus have been self-medicating using antibiotics and other prescription-only medicines in the mistaken belief they would protect them from catching the virus.

Bolanle Ojo was four months pregnant when she went to the hospital for malaria treatment. Bolanle did not want to join the estimated 11% of pregnant women who die because of malaria. Malaria in pregnant women leads to several complications, ranging from anaemia, low birth weight, miscarriages, placental parasitemia, neonatal mortality and death.

Malaria is also responsible for 11 per cent of maternal mortality in Nigeria, with pregnant women being one of the groups most vulnerable to this. On average, one in four Nigerians or 53 million suffer from malaria annually. Every hour, 11 Nigerians die from Malaria contributing to 94,070 or 23 per cent of the 409,000 annual global deaths.

As a preventive measure, the Federal Ministry of Health recommended that pregnant women receive intermittent preventive treatment using two doses of sulfadoxine-pyrimethamine (SP/Fansidar) during the second and early in the third trimester of pregnancy.
Bolanle said she was prescribed artesunate which is usually given to pregnant women for free. But she was told she had to go and buy the drugs as the hospital did not have any and health personnel cited disruption in supply as the cause of the lack of drugs.”I had to take the prescription given to me to buy the malaria drugs outside the health centre which was not what usually happened. I brought the drugs for N800″, she says.

Malaria and COVID-19 are different diseases and have different ways of transmission and infection. Malaria is spread by mosquitoes, and humans become infected by mosquito bites. COVID-19 is spread by respiratory droplets that are inhaled through the nose or mouth. However, the two diseases share some common symptoms—fever, headache and fatigue— which have made people suffering from malaria reluctant to go to the hospital for treatment for fear they may be diagnosed with COVID-19.

The common symptoms shared by malaria and COVID-19 include but are not limited to: fever, breathing difficulties, tiredness and acute onset headache, which may lead to misdiagnosis of malaria for COVID-19 and vice versa, particularly when the clinician relies solely on these symptoms.

Public health entomologist and president of the Pan-African Mosquito Control Association (PAMCA), Professor Charles Mbogo said cases of people having malaria in Africa increased from March 2020 when most countries imposed lockdowns to November 2020 because all equipment and focus were redirected into combating the spread of the COVID-19 pandemic.

An analysis of the effect of the disruptions caused by COVID-19 indicated that 19,000 additional deaths among people of all ages were likely to occur if access to treatment was reduced by 10% and would go upto 100,000 additional deaths if access to treatment was reduced by 50%.

“In some countries, malaria cases have increased. This is because whenever one has a fever, people think you have COVID-19 and fever is one of the symptoms the virus shares with malaria. It is befuddling that when one needs to be tested for malaria due to these signs, the health facilities test the people for COVID-19 and the patients are left without diagnosis and treatment.”

Mbogo, who is also part of the Wellcome Trust Research Programme, said many health facilities lacked the reagents and equipment for testing malaria. “All equipment and focus have gone into testing for COVID-19.”

He said many countries had also suspended their seasonal chemoprevention programmes which involves administering monthly doses of antimalarial drugs to children between the ages of 3 months to under 5 years during the peak malaria transmission season.

Data from Global Fund spot-checks of 504 health care facilities which include a mix of community sites, primary, secondary and tertiary health care facilities in urban and rural areas across 32 countries in Africa (including Nigeria) and Asia in 2020 revealed a 31% drop in malaria diagnosis over six months compared to the previous year and a 13% drop in malaria treatment.

Measles

Nigeria is one of ten countries with the highest number of reported cases of Measles.

According to the Center for Disease Control information on global measles control, Nigeria was ranked first among the top 10 countries with global measles outbreaks with 6,170 cases as of June 2021.

In Borno state, in north-eastern Nigeria on May 17, a total of 5,902 suspected cases of measles had been confirmed which included 4,653 cases in children under 5 years old. At least 72 deaths caused by measles have been recorded since the beginning of the year.According to the WHO, an estimated 16.6 million children in Africa missed planned supplemental measles vaccine doses between January 2020 and April 2021 and eight African countries reported major measles outbreaks that affected tens of thousands during the period.Measles is a highly contagious respiratory disease that can result in severe, sometimes permanent, complications including pneumonia, seizures, brain damage and even death. Measles is caused by a virus that lives in the nose and throat mucus of an infected person and spreads easily through breathing, coughing, and sneezing. When someone with measles coughs, sneezes, or talks, infected droplets spray into the air (where other people can inhale them) or land on a surface, where they remain active and contagious for several hours. If others breathe the contaminated air or touch the infected surface, then touch their eyes, noses, or mouths, they can become infected. Measles is so contagious that if one person has it, up to 90% of the people close to that person who are not immune will also become infected. One of the tell tale signs is a rash which develops on the face and neck before spreading to other parts of the body.At least 95% immunization coverage in the population is required to prevent outbreaks, yet coverage with the first dose of the measles-containing vaccine has stagnated at around 69% in the WHO African Region since 2013. Only seven countries in the region achieved 95% measles-containing vaccine coverage in 2019.requiring at least 95% immunization coverage in the population to prevent outbreaks, yet coverage with the first dose of the measles-containing vaccine has stagnated at around 69% in the WHO African Region since 2013.

Only seven countries in the region achieved 95% measles-containing vaccine coverage in 2019. Statistics from WHO indicate that 15 African countries had postponed immunization drives against measles and other diseases in 2020 to help deal with the COVID-19 pandemic.
The WHO Regional Director for Africa, Matshidiso Moeti said recent outbreaks of measles, yellow fever, cholera, and meningitis were an indication that there were still many gaps in immunization coverage and surveillance in Africa.“1 in 5 children in Africa does not receive all the vaccines they need.

A number of countries are off track in their efforts to reduce tetanus, measles and rubella – vaccine-preventable diseases that were once thought to be on the verge of elimination,” she said urging governments to double down on essential health services, including life-saving vaccination campaigns.

Around 9 million children in the African region miss life-saving vaccines each year and one in five children remain unprotected from vaccine preventable diseases, which claim the lives of over 500 000 children under 5 years in Africa every year.

In Niger State, the commissioner of Health Dr Muhammad Makunsidi said the existing gaps in immunisation coverage and surveillance had been exacerbated by the ongoing insecurity in some regions in the country as well as the focus on COVID-19. The government has however instituted public awareness campaigns as well as launched door-to-door immunisation programmes especially targeting children, many of whom have not been able to access vaccines for childhood diseases such as Measles, Rubella , Polio, TB , Diphtheria, Tetanus and Hepatitis B among others.

Tuberculosis

According to the 2019 Global TB report, Nigeria is ranked number one in Africa and sixth globally amongst the 30 high TB burden countries. Nigeria is also among the 14 countries in the world with the triple high burden of TB, TB/HIV and Drug Resistant TB (DR-TB). It is estimated that 429,000 people in Nigeria have TB each year. In addition, there are an estimated 53,000 HIV positive people that get TB each year and an estimated 157,000 people die from TB in Nigeria including an estimated 27,000 people living with HIV.

Like malaria, COVID-19 and tuberculosis share similar symptoms, including fever, dry cough, fatigue, sputum production, shortness of breath, sore throat, headache,, chills, nausea or vomiting, nasal congestion and in extreme cases, haemoptysis —where patients start coughing up blood from the lungs.

The similarity in some symptoms saw the WHO and other health partners integrate tuberculosis case finding into the COVID-19 structure in its outreaches but the fear of contracting and being misdiagnosed with COVID-19 discouraged people in need of timely diagnosis and treatment for tuberculosis from accessing health services.

Disruptions in tuberculosis services of up to 78 per cent have been reported, based on survey data by The Global Fund to Fight AIDS, Tuberculosis, and Malaria (Global Fund) in 106 countries as of June 2020. Nigeria and South Africa, the two high-burden tuberculosis countries in Africa, have reported a 34 per cent and 33 per cent decrease in active tuberculosis case notification, respectively, at some point during the lockdown. missed drug refills have also been reported in other African countries.

Overall, the current measures taken to contain COVID-19 as well as repurposing of resources for the pandemic response are likely to limit access to treatment and diagnostic services potentially increasing new cases including drug-resistant tuberculosis and deaths.

Cholera

Cholera is an acute diarrhoeal disease caused by the Vibrio cholerae bacteria. It is passed on from faeces through contaminated food, drinks and unhygienic environments, and causes severe dehydration. Infected people can die if their illness is not quickly managed with oral rehydration therapy, which involves drinking water with modest amounts of sugar and salts, specifically sodium and potassium.

In Nigeria, huge outbreaks of Cholera were recorded in 1991, 2010, 2014 and 2018. In 2018, there were 43,996 cholera cases and 836 deaths: a case fatality rate of 1.90%.

Nigeria is currently battling with yet another cholera epidemic which has been exacerbated by poor access to clean water, open defecation, poor sanitation, and hygiene.Between January 1 and September 5, 2021, the Nigeria Centre for Disease Control (NCDC) reported there were at least 69,925 suspected cholera in 25 of Nigeria’s 36 states and in the capital, Abuja, At least 2,323 people have died from suspected Cholera.

The NCDC, the Federal Ministry of Health and the National Cholera Emergency Operations Centre has deployed rapid response teams to the most affected states of Benue, Kano, Kaduna, Zamfara, Bauchi and Plateau States.

The National Primary Health Care Development Agency with the support of the WHO conducted a five-day cholera vaccination campaign targeting persons over one year. At the end of the campaign on July 28, a total of 710,212 persons had been vaccinated.

Nsikakabasi George is a public health expert based in Kano state who is currently monitoring the cholera outbreak in Kano state said Cholera outbreaks said access to water and sanitation for the urban poor and the rural communities should be prioritised. “We also have inadequate supplies of vaccines and personnel to cover all the areas where the outbreak has been recorded. The heavy rainfall has made things worse and we also face problems accessing some of the areas due to security concerns,” he said

A community physician and health systems economist, Professor Chima Onoka said the government should strive to increase budget allocations for health. Nigeria has consistently failed to meet its obligation of allocating 15 % of the budget to health. This is a commitment that Nigeria and other African governments made in the 2000 Abuja Declaration.

In 2013, the Federal Ministry of Health launched an elaborate plan to control or eliminate the seven most common NTDs —elephantiatisis, river blindness, bilharzia, parasitic worm infections, trachoma, Leprosy, Buruli ulcer, sleeping sickness and guinea worm disease. The government set itself a target of controlling or eliminating these diseases by last year. Huge gaps in funding —$400million based on the 2016-2020 strategic plan has hampered the programmes to eliminate these diseases across the 774 local government areas in the country.The budgetary allocation to the health sector has never surpassed 7%. The highest it has ever reached is 6.2% in 2012 which is still far below the 15% commitment in the Abuja Declaration. The health allocation in the 2021 fiscal year is 4.5%.
A report analysing the government’s health allocation and spending carried out The Partnership for Advocacy in Child and Family Health at Scale recommended that the government increase its health service delivery, address waste and consider other sustainable funding sources.

“Unless the government commits to adequately funding the health sector and particularly programmes aimed at eradicating chronic endemic diseases, Nigerians will continue to die. Ignoring these diseases is not an option,” says Prof Onoka.

 

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