Date: Sun 29 Dec 2019
Source: The Guardian [edited]

The World Health Organisation (WHO) has confirmed 13 cases of yellow fever, which has resulted in 3 deaths in 4 local government areas of Plateau State.

WHO State Coordinator, Wonk Vingey Bassey, confirmed the incident while presenting a report on a survey conducted on affected councils during an emergency stakeholders' meeting in Jos. The meeting followed the outbreak of the disease in Jos North, Bassa, Riyom and Wase local government areas of the state.

Bassey, who gave the breakdown according to councils, said the deaths were recorded in Wase local government [area]. The coordinator, represented by the consultant Elizabeth Ahinchi, advocated early inspection and reporting of cases of the outbreak, in addition to intensified routine campaigns in communities.

State Commissioner for Health, Dr. Ninkwom Ndam, said the state government is working in collaboration with federal authority and other partners to strengthen healthcare services to citizens. Also, Executive Secretary, Plateau State Healthcare Board, Dr. Livinus Niamkwap, noted that the recent outbreak in the 4 councils calls for proactive measures to avert escalation to other areas.

Participants at the meeting discussed extensively on the way forward, laying emphasis on the need for the provision of mosquito nets, surveillance, awareness campaigns in media stations and worship centres, as well as financial support, among others.  [Byline: Isa Abdulsalami Ahovi]
[A 17 Dec 2019 report indicated that from 1 Jan through 10 Dec 2019, a total of 4189 suspected yellow fever (YF) cases were reported from 604 of 774 local government area (LGAs) across all the 36 states and the federal capital territory in Nigeria (see Yellow fever - Africa (27): Nigeria, WHO Although that report indicated that there have been YF cases in all 36 states, previous reports do not specifically mention Plateau State. Although the need for the provision of mosquito nets, surveillance, and awareness campaigns in media stations and worship centres is real, it is curious that no mention is made of a vaccination campaign or of the proportion of the populations in the affected areas that have been vaccinated previously. Vaccination is the best YF preventive measure. - ProMED Mod.TY]

[HealthMap/ProMED-mail map:
Nigeria: <>]
Date: Sat 28 Dec 2019
Source: Punch [edited]

Lassa fever has reportedly killed one man in Igbeagu community in the Izzi Local Government Area of Ebonyi State. He died on Friday [27 Dec 2019].

O and his sibling, UO, had been admitted to St Vincent Hospital in the area. The 2 of them were suspected to have been infected by the disease.

A source, who spoke on condition of anonymity, said, "We are in a big trouble again. This killer disease has come again. The last time we experienced it, it wasn't funny. It killed over 4 persons. Now it is here again. It is important that stakeholders know about its presence and the implication. They should intervene and save us from it."

Meanwhile, the Ebonyi State Government has directed the evacuation of the victim's sibling and other patients to the South-East Virology Centre, Abakaliki, for further treatment.

Ebonyi State Governor David Umahi, who spoke through his Special Assistant on Media, Mr Francis Nwaze, had equally directed the closure of the hospital with immediate effect.

The governor's aide said, "The governor directed that all the family members and close relatives of the above be quarantined at the South East Virology Centre, Abakaliki for comprehensive medical examination. Also, Governor Umahi has directed that the Ministry of Health under the watch of the Commissioner for Health in conjunction with the members of Staff of Federal Teaching Hospital, Abakaliki to immediately address all issues relating to the Lassa fever outbreak including comprehensive examination of all suspects and clean-up of St. Vincent Hospital. Place precautionary announcements in all media houses in the state on preventive measures of Lassa fever."  [Byline: Edward Nnachi]
[Lassa fever [LF] cases have not been unusual in Ebonyi state this year (2019) beginning with a Lassa fever outbreak in Ebonyi state in February 2019, when the Ebonyi state government successfully treated and discharged 14 Lassa fever patients brought to the centre. To date this year (2019), 7% of all Lassa fever cases have been in the state.

There is no mention of the circumstances under which the individuals contracted Lassa fever virus infections. Transmission of LF virus occurs when individuals are in contact with rodent reservoir host excreta or are within healthcare facilities. It would be interesting to know whether the prevalence of Lassa fever virus has been increasing in populations of rodent hosts in areas where human cases are occurring.

Images of the rodent reservoirs of Lassa fever virus:
_Mastomys natalensis_:
_Mastomys erythroleucus_ and _Hylomyscus pamfi_:

There is no specific mention in the plans above of public education for avoidance of contact with these rodents and their excreta. - ProMED Mod.TY]

[Maps of Nigeria:
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HealthMap/ProMED map available at:
Ebonyi State, Nigeria: <>]
Date: Tue 17 Dec 20
Source: WHO Emergencies preparedness, response, Disease Outbreak News (DONs) [edited]

Nigeria is responding to successive yellow fever outbreaks, with nearly a 3-fold increase in number of confirmed cases in 2019 compared to 2018, suggesting intensification of yellow fever virus transmission. Additionally, there have been cases reported in parts of the country that have confirmed cases for the 1st time since the outbreak started in September 2017. From [1 Jan through 10 Dec 2019], a total of 4189 suspected yellow fever cases were reported from 604 of 774 Local Government Area (LGAs) across all the 36 states and the Federal Capital Territory in Nigeria.

Of the total 3547 samples taken, 207 tested positive for yellow fever by Immunoglobulin M (IgM) in Nigerian network laboratories. In addition, 197 samples from 19 states were confirmed positive using reverse transcriptase polymerase chain reaction (RT-PCR). The case fatality rate for all cases (including suspected, probable and confirmed) is 5.1%, and 12.2% for confirmed cases.

Of the total (197 cases) confirmed cases, 68% (134 cases) were reported from 4 states, including Bauchi, Katsina, Edo and Ebonyi. Cases in Edo state have declined after a reactive vaccination campaign in late 2018. From [1 Jan through 10 Dec 2019], a total of 115 confirmed cases and 23 deaths were reported from Bauchi (62 cases), Katsina (38 cases) and Benue (15 cases). These cases tested positive by RT-PCR at national laboratories and/or RT-PCR and serologic tests at a regional reference laboratory, Institute Pasteur Dakar (IPD). Further epidemiological investigations are underway.

Public health response
The outbreak response activities are being coordinated by a multi-agency yellow fever Incident Management System (IMS). On [5 Nov 2019], an Emergency Operations Centre (EOC) was activated for the 3rd time, in response to the upsurge of confirmed yellow fever cases reported in a wide-geographic distribution including Bauchi, Benue and Katsina. A national rapid response team has been deployed to Bauchi and other affected states to support the outbreak response activities including surveillance, case management support and risk communications.

In addition to the existing laboratories in the country, new and operational laboratories have been added to the national laboratory network in Abuja, Edo and Enugu states.

A targeted response has been implemented in Alkaleri Local Government area (LGA) in Bauchi state. However, reports of ongoing transmission indicate that more vaccination and a wider geographical scope are needed. Katsina state has recently completed a state-wide preventive mass vaccination campaign; however, challenges linked to vaccine accountability and access to security-compromised areas may result in pockets of populations with immunity gaps. Risk of spread through population movements exist in neighbouring Kano and Kaduna states where population immunity is low.

Nigeria is considered a high-risk country by the Eliminate Yellow Fever Epidemics (EYE) strategy. By 2024, it is anticipated that all the states in Nigeria will have undergone campaign activities to protect at-risk populations against yellow fever. This plan may be further updated or accelerated based on risk, vaccine and implementation feasibility. The country is in the process of completing a planned phase-3 vaccination campaign in 2019 and evaluating the recently concluded mass vaccination campaign.

WHO risk assessment
The yellow fever outbreak transmissions reported in Bauchi, Benue and Katsina states since August 2019, with spread to multiple other states, represents an intensification of yellow fever transmission and an elevated risk for yellow fever outbreak to spread and amplify. This is particularly a high risk if yellow fever is introduced into densely populated urban areas where preventive mass vaccination campaigns have not been conducted so far. Areas at risk include those without prior reported cases since 2017 and areas with a large number of under-immunized populations including urban areas such as Kano and Lagos. The preventive mass vaccination campaigns for yellow fever and the ongoing effort to strengthen routine immunization are important activities to reduce the risk of disease spread and amplification.

WHO continues to monitor the epidemiological situation and review the risk assessment based on the latest available information. Based on available information, WHO currently assesses the overall risk as high at the national level, moderate at the regional level, and low at the global level.

Nigeria is facing several concurrent public health emergencies, including circulating vaccine-derived polio virus (cVDPV), measles, monkeypox, Lassa fever, cholera outbreaks, and a humanitarian crisis in the north-east of the country.

WHO advice
Yellow fever is an acute viral haemorrhagic disease transmitted by infected mosquitoes and has the potential to spread rapidly, with serious public health impacts. There is no specific treatment, although the disease is preventable using a single dose of yellow fever vaccine, which provides lifetime immunity. Supportive care is required to treat dehydration, respiratory failure and fever; antibiotics are recommended to treat associated bacterial infections.

The early detection and investigation of yellow fever cases through strong surveillance is key to controlling the risk of yellow fever outbreaks. Prevention of mosquito bites (e.g. repellents, wearing long clothes) is an additional measure that limits the risk of yellow fever transmission. In urban centres, targeted vector control measures are also helpful to interrupt transmission.

WHO recommends vaccination against yellow fever for all international travelers more than 9 months of age going to Nigeria, as there is evidence of persistent or periodic yellow fever virus transmission. Nigeria also requires a yellow fever vaccination certificate for travelers older than one year of age arriving from countries with risk of yellow fever transmission.

Yellow fever vaccines approved by WHO are safe, highly effective and provide life-long protection against infection. In the context of international travel, the amendment to Annex 7 of the International Health Regulations (IHR 2005) changes the period of validity of the related international certificate of vaccination against yellow fever, and the protection provided by vaccination against yellow fever infection from ten (10) years to the life of the person (traveler) vaccinated. Accordingly, as of [11 July 2016], for both existing or new certificates, revaccination or a booster dose of yellow fever vaccine cannot be required of international travelers as a condition of entry into a State Party, regardless of the date their international certificate of vaccination was initially issued.

On [1 July 2019], WHO updated the areas at-risk of yellow fever transmission and the corresponding recommendations for vaccination of international travelers. The list of countries at-risk, and revised recommendations for vaccination against yellow fever are available on the WHO website: International travel and health (ITH).

WHO encourages its Member States to take all actions necessary to keep travelers well informed of risks and of preventive measures, including vaccination. Travelers should also be made aware of yellow fever signs and symptoms and instructed to seek rapid medical advice should they develop signs of illness. Travellers returning to Nigeria who may be infected with possible high levels of the virus in the blood may pose a risk for the establishment of local cycles of yellow fever transmission in areas where the competent vector is present.

WHO does not recommend any restrictions on travel or trade to Nigeria on the basis of the information available on this outbreak.
[The above report provides a comprehensive summary of the yellow fever (YF) situation in Nigeria for this year (2019). Increased surveillance, targeted responses by the national response team, the addition of diagnostic laboratories in several localities and vaccination campaigns are all positive responses to the YF situation. Fortunately, no mention is made of cases in the densely populated cities nor of a shortage of YF vaccine, so campaigns could be able to proceed without delay. As noted in earlier posts, because of the geographic wide-spread distribution of yellow fever (YF) in Nigeria, achieving vaccination coverage of the population to the 80-90% coverage necessary to prevent cases is a serious challenge.

Nigerians traveling to countries abroad where YF virus is transmitted present  a risk of introducing the virus to other areas of Nigeria with abundant vectors that could initiate a new outbreak. Also of serious concern is the possibility of an unvaccinated person becoming infected in Nigeria, at the popular game park for example, going to an area historically free of YF but with abundant vector populations, such as southeast Asia, and initiating an outbreak where few local individuals have been vaccinated. - ProMed Mod.TY]

[Maps of Nigeria:
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Date: Wed 4 Dec 2019
Source: UK Government, Public Health England [edited]

Public Health England (PHE) confirms an individual has been diagnosed with monkeypox [MPX] in England.

Monkeypox is a rare viral infection that does not spread easily between people, and the risk to the general public in England is very low. It is usually a self-limiting illness, and most people recover within a few weeks. However, severe illness can occur in some individuals.  The patient is believed to have contracted the infection while visiting Nigeria.

The patient was staying in southwest England prior to transfer to the specialist high-consequence infectious disease centre at Guy's and St Thomas' NHS Foundation Trust, London, where [the patient is] receiving appropriate care.

As a precautionary measure, PHE experts are working closely with NHS colleagues to implement rapid infection-control procedures, including contacting people who might have been in close contact with the individual to provide information and health advice. This includes contacting passengers who travelled in close proximity to the patient on the same flight to the UK. If passengers are not contacted, then there is no action they should take.

Dr Meera Chand, consultant microbiologist at Public Health England, said: "Monkeypox does not spread easily between people, and the overall risk to the general public is very low. We are following up with those who have had close contact with the patient to offer advice and to monitor them as necessary."

PHE and the NHS have well-established and robust infection-control procedures for dealing with cases of imported infectious disease, and these will be strictly followed to minimise the risk of transmission.

This is not the 1st time that the virus has been detected in the UK. PHE reported the 1st UK cases of monkeypox in September 2018.

Monkeypox is a rare disease caused by monkeypox virus and has been reported mainly in central and west African countries. In most cases, monkeypox is a mild condition that will resolve on its own and has no long-term effects on a person's health. Most people recover within a few weeks [see comment below].

Initial symptoms include fever, headache, muscle aches, backache, swollen lymph nodes, chills, and exhaustion. A rash can develop, often beginning on the face, then spreading to other parts of the body. The rash changes and goes through different stages before finally forming a scab, which later falls off.
[Sporadic cases of monkeypox (MPX) continue to occur in Nigeria this year (2019), so it is not surprising if the individual became infected there and travelled to England during the incubation period. The USA CDC states that the incubation period (time from infection to symptoms) for monkeypox is usually 7-14 days but can range from 5-21 days, allowing adequate time for travel prior to the appearance of symptoms (see <>).

There is no mention in the above report if the individual acquired the MPX infection from wildlife hosts or from contact with infected people. There is no mention above of the current condition of the patient. The health authorities in England are prudent to track individuals who had been in contact with the patient. Consideration of vaccination of contact individuals with the new MPX/smallpox vaccine, especially those providing care of this patient, in this type of situation may be a useful approach to prevent person-to-person transmission.

Prevention of MPX virus infections in the endemic countries in West and Central Africa will not be possible without knowing the source of infection and locality where they occurred. The question remains about the source of recent infections. Monkeys are not the reservoirs of the virus, despite the name that the virus has received. Studies of prevalence of MPX virus in populations of rodent hosts are not mentioned in this or in previous reports. The main reservoirs of MPX virus are suspected to be rodents, including rope squirrels (_Funisciurus_ spp., an arboreal rodent) and terrestrial rodents in the genera _Cricetomys_ and _Graphiurus_. Halting the bushmeat trade and consumption of wild animals to halt MPX virus exposure will be culturally and economically difficult, so continued occurrence of cases can be expected.

The MPX virus clade involved in these and previous cases is not mentioned. As noted in previous ProMED-mail posts, the monkeypox virus clade in the Congo Basin causes more severe disease in humans -- with a case fatality rate of 11-17% -- than the clade in Ghana, which causes few fatalities. The reported case fatality rate in Nigeria is low.

Similar reports of this case can be found at <>, provided by ProMED Mod.MHJ, and in <>, which also shows typical MPX lesions, communicated by Mary Marshall (<>). - ProMED Mod.TY]

[HealthMap/ProMED-mail maps:
United Kingdom: <>
Nigeria: <>]
Date: Wed, 20 Nov 2019 17:17:39 +0100 (MET)

Lagos, Nov 20, 2019 (AFP) - Nigerian President Muhammadu Buhari on Wednesday announced a campaign to end defecation in public, in a country where tens of millions of people going to the toilet outside poses a major health risk.    "Nigeria has committed to end open defecation throughout the country by 2025," a statement by the presidency said a day after the United Nations marked World Toilet Day.     The decree set up a new body called the Clean Nigeria Campaign Secretariat to ensure "that all public places including schools, hotels, fuel stations, places of worship, market places, hospitals and offices have accessible toilets and latrines within their premises". 

According to the United Nations children agency, UNICEF, Nigeria has amongst the highest number of people practising open defecation in the world, estimated at over 46 million people -- almost a quarter of the population.   Around Nigeria each year 87,000 children die from diarrhoea, with more than 90 per cent of deaths caused by a lack of water, sanitation and hygiene, according to the World Bank.   The new agency will be disbanded when the goal of ending open defecation has been met, the presidency said.
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