Deadliest Diphtheria Outbreak in West Africa Yet: Examining the Global Health Implications

17,000 suspected cases, below-par National Vaccination coverage, and a completely broken Primary Health Care System are what now stands between Nigeria and a full-blown public health crisis.

Amidst the now very concerning extensive spread of this disease that was flagged In the Country last year, with health personnel putting up scuffles against this in locations like Kano in Nigeria, it is unfortunate to consider that this has extended to other West African Nations like Guinea and Niger as reported by Medecins San Frontieres (MSF).
The weekly peak number of cases is 700, with an average of 500 seen per week now.
MSF further confirms 9310 cases and 368 deaths seen so far this year.

Since the last publication in April 2023, the authorities have reported suspected cases of diphtheria to the World Health Organization every week. However, Nigeria saw an unprecedented spike in confirmed diphtheria cases between 30 June and 31 August 2023, with 5898 suspected cases documented from 59 local government areas (LGAs) in 11 states. Kano (1816), Katsina (234), Yobe (158), Bauchi (79), Kaduna (45), and Borno (33) reported most of the 99.4% suspected cases.

Diphtheria is a highly contagious vaccine-preventable disease caused mainly by the bacteria Corynebacterium diphtheriae and can be fatal in 5-10% of cases, with a higher mortality rate in young children.
It spreads mainly via direct touch or through the air via respiratory droplets. The disease can strike folks of any age, but unvaccinated children are the most susceptible.
Symptoms typically show up gradually, beginning with a sore throat and fever. In severe circumstances, the bacteria produce a toxin (poison) that creates a thick grey or white patch at the back of the neck that clogs the airways, making it harder to breathe or swallow, also triggering a barking cough.
As a result of swollen lymph nodes, the neck may become enlarged.

Diphtheria antitoxin (DAT) and antibiotics are the approach of choice to treat the disease. Diphtheria vaccination is effective in reducing diphtheria mortality and morbidity significantly.

According to WHO’s most current risk assessment of the diphtheria epidemic in Nigeria, the risk is high at the country level but low at the regional and global levels. In response to the epidemic, the Nigeria Centre for Disease Control (NCDC), in partnership with WHO and other partners, is implementing public health measures like vaccine response, increased monitoring for early case detection, case management, and risk communication.
Nigeria has recorded diphtheria outbreaks in the past, with incidences in 2011 and 2022 worthy of note. In 2023, an outbreak of diphtheria was recorded between January and April 2023, affecting 21 of the 36 states and the FCT.

A recent CNN chat with MSF experts in Kano’s Storm Eye revealed that it has been challenging for medical staff to manage patients successfully, partly because there aren’t enough DAT, as antibiotics and DAT dosages are especially difficult to find because of their low production volume, high manufacturing costs and lead times.
MSF claims it has only been able to offer patients 5,000 DAT doses until now.

“We must increase production capacity in the near future. In the long run, research and development must be funded, according to Dr. Dagemlidet.
Manufacturers produce a batch of 1,500 DAT dosages in four weeks, he continued, and the financial burden of treating a patient with DAT alone might reach 350 euros ($370). He thinks that this has got to change immediately.

Eight to ten vials are requisite for each severe case, which is still significantly less than required to support patients. Patients have a 50% probability of dying if untreated, but that drops for the better to 5% if they receive care, according to Dr. Dagemlidet Tesfaye Worku, MSF’s emergency medical program manager for West and Central Africa, who spoke with CNN.

The Nigeria Centre for Disease Control and Prevention (NCDC) undertakes ongoing coordination and monitoring operations for diphtheria through the weekly meetings of the National Technical Working Group on the disease, following our findings from a World Health Organisation(WHO) at the time of this report on the public health response documented in April this year.
A rapid response Team (RRTs), was first sent to Katsina, Osun, and Yobe States. It was later re-deployed to Kano and Lagos States.
In states with RRTs coverage, clinical and surveillance officers received training and sensitization regarding the presentation, prevention, and surveillance of diphtheria.
The procurement of reagents, sample collecting, and transport media were instituted.
DAT distribution has been in the works to the impacted states since December 2022.
Countrywide intensification of routine immunization programs continues, but the impact of these efforts to stall the recent crises is unfortunately abysmal.

The World Health Organisation advises immediate reporting and handling of suspected cases of diphtheria to guarantee the availability of diphtheria antitoxin, treat cases promptly, and follow up with contacts.
Case management with WHO guidelines calls for the use of antibiotics to kill bacteria, antitoxins to neutralize toxins, and contact tracing to ensure holistic coverage.

High-risk groups like children under five, students, people who have had direct contact with diphtheria cases, and healthcare workers must get priority vaccination with diphtheria-containing vaccines. The community’s involvement and a well-coordinated reaction can help contain the current outbreak.

No Official statement has been made by the Nigerian Ministry Of Health and Social Welfare or the Coordinating Minister of the Ministry.
Prof. Ali Pate, on this potentially looming National crisis.

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Abubakar Stober

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