Date: Wed 22 May 2019
Source: PM News Nigeria [edited]
<https://www.pmnewsnigeria.com/2019/05/22/lagos-uncovers-plot-to-disrupt-ongoing-polio-vaccination/>

The Lagos state government says it has uncovered a plot by a non-governmental organisation (NGO) to disrupt the ongoing polio vaccination in the state by administering harmful vaccines to children. Dr Jide Lawal, permanent secretary, Primary Healthcare Board, made this known on Tuesday night [21 May 2019] in Lagos.

Lawal said that the organisation, which he did not name, was going around schools in the state to administer vaccines believed to be harmful to children. He said that the state Ministry of Health had commenced an investigation into the allegation.

According to Lawal, the ministry suspected that the sabotage was intended to disrupt the ongoing polio immunisation campaign.

"The move by the NGO is intended to thwart other efforts of the state government in maintaining 100% immunisation coverage of eligible children as well as maintain the "polio-free status" attained since 2009.

"For the purpose of clarity, it is important to mention that the safety of lives and the wellbeing of citizens are of utmost importance to the state government, and all efforts are geared toward protecting the citizenry. Hence, we wish to emphasise that the oral polio vaccine is free, safe, and effective in protecting children against polio.

"We will also like to assure you that the administration of this vaccine is not hazardous or dangerous to humans as being erroneously propagated. In fact, the World Health Organisation (WHO) recommends that all children below the age of 5 years get this vaccine for protection against polio, " Lawal said.

He added that the benefits of receiving the polio vaccination and other scheduled immunisations were numerous.

"Good health and survival of children have been associated with immunisation, because it reduces disability, morbidity, and mortality. It also contributes to lowering the incidence of diseases and results in less frequent visits to health facilities.

"Immunisation remains the most cost-effective and efficient child survival strategy for children who are the future of the nation. Also, this informs our unrelenting efforts in protecting our children from the vaccine-preventable killer diseases," he said.

Lawal urged stakeholders, including parents, political and religious leaders, civil society organisations, and mass media to ensure that children under 5 years were immunised free of charge.

He said, "This is to ensure that we reduce the risk of death and disability from vaccine-preventable diseases such as polio."

He said the current vaccination campaign against polio was being conducted by the National Primary Healthcare Development Agency, state Ministry of Health, and Lagos state Primary Healthcare Board.

According to Lawal, this is in partnership with health development partners such as World Health Organisation (WHO) United Nations Children Fund (UNICEF) CDC-AFENET and Rotary.

"While the state collaborates with NGOs, the administration of vaccines is the sole responsibility of health workers trained to conduct the exercise. The public are, therefore, enjoined to be vigilant and authenticate the identity of immunisation officers," Lawal said. "They should report any suspicion about the implementation of any of the state or national immunisation campaigns to the nearest local government, the Ministry of Education, or the Ministry of Health, or call 08023020581," he added.
======================
[I'm posting these media reports as examples of the politics of health. When the incident occurred in Pakistan in April [2019], the media reports had not covered the politics behind the scare tactics. A very sorry state of affairs that politicians are using children and their health to manipulate voters in their areas. One can't help but wonder how much of the global anti-vaccine movement (significantly contributing to the global increase in measles) has a political basis behind it as well.

The change in approach to the campaign activities might well help win over many of the vaccine refusers in Pakistan. One hopes that will be the case.

With respect to WPV [wild poliovirus] in Nigeria, it is important to mention that with respect to the WPV1 [wild poliovirus type 1] isolated in Nigeria in 2016, "It is the 1st WPV1 detected in Nigeria since July 2014. Genetic sequencing of the isolated viruses suggest they are most closely linked to WPV1 last detected in Borno in 2011, indicating the strain has been circulating without detection since that time" (see Poliomyelitis update (11): Nigeria (BO) http://promedmail.org/post/20160811.4410331). Hence caution is needed in interpreting the observation that the absence of new cases since 2016 suggests Nigeria can be safely declared as having interrupted transmission of the WPV. And given the highly political nature of polio in Pakistan, one can't help but wonder if 3 years without a case is a fail-safe time to declare interruption of transmission there as well.

As for this current situation, the media report is unclear whether rumors have been circulating re: administration of harmful vaccines or if the NGO is administering vaccines claiming the government is administering bad vaccine. Notwithstanding the potential impact of this is an increase in vaccine refusal in Lagos as well as in neighboring areas when they learn of this. Another example of the politics of health impacting on the lives of children in a country.

HealthMap/ProMED-mail maps can be found at
Pakistan: <http://healthmap.org/promed/p/140>
Nigeria: <http://healthmap.org/promed/p/62>.  - ProMED Mod.MPP]
Date: Tue 30 Apr 2019
Source: Nigeria CDC monthly yellow fever situation report [edited]
<https://ncdc.gov.ng/themes/common/files/sitreps/33df034e696fc54e144eb5d8f8ce9c66.pdf>

Highlights
-------
In this reporting month of April 2019:
 - 332 suspected cases were recorded
 - 3 new presumptive positive cases were recorded
 - NCDC Central Public Health Laboratory (CPHL) reported 1 new presumptive positive case from Imo State - (Orsu LGA)
 - Yusuf Danshoho Memorial Hospital (YDMH) Kaduna reported 1 presumptive case - case from Kebbi - (Arewa Dandi LGA)
 - Gombe Specialist Hospital (GSH) Gombe reported 1 presumptive case from Gombe LGA
 - 3 new confirmed cases from the Institute Pasteur (IP) Dakar from Edo State - (Uhunmwode -2, Ikpoba-Okha -1).
 - Last IP Dakar confirmed cases were reported 18 Apr 2019
 - 19 states have recorded at least one confirmed case from Institute Pasteur (IP) Dakar since the onset of the outbreak in 2017
 - Yellow fever response activities are being coordinated by the Yellow Fever Technical Working Group (YF TWG).

- From 1 Jan - 30 Apr 2019:
 - 930 suspected cases have been reported in 447 (57.8%) LGAs
 - All suspected cases reported had blood samples collected
 - 35 presumptive positive and 12 inconclusive cases from 12 states in 32 LGAs: Table 1
 - 12 confirmed cases were reported from 2019 samples sent to Institute Dakar [Edo (7) confirmed and 1 inconclusive) Ondo (2), Imo (1) and Osun (1)]
 - One death of a suspected yellow fever case has been recorded from Adamawa
 - Case fatality rate (CFR) is 0.11%
 - Rapid response teams have been deployed to Abia, Imo and Osun States

Summary of outbreak 2017-2018
A yellow fever outbreak has been active in Nigeria since September 2017:
- From 2017 to 2018, 163 cases were confirmed in 17 states: Kwara (8), Kogi (12), Kano (1), Zamfara (19), Kebbi (7), Nasarawa (3), Niger (1), Katsina (2), Edo (90), Ekiti (2), Rivers (1), Anambra (1), FCT (11), Benue (1), Delta (1), Ondo (2) and Abia (1): in 52 Local Government areas (LGAs).
- From September 2017 to December 2018, 283 samples (presumptive positive - 246 and inconclusive - 37) were sent to IP Dakar for re-confirmation.
- All Nigerian states (36 + FCT) reported 4132 suspected cases in 616 (79.6%) LGAs.
- Of all suspected, probable and confirmed cases, 90 deaths were recorded with 31 deaths among confirmed cases.
- The case fatality ratio (CFR) for all cases (suspected, probable and confirmed) is 2.2%, and 19.0% for confirmed cases
- Yellow fever preventive mass vaccination campaigns (PMVC) have been completed in 12 states, led by NPHCDA:
 - 2013 PMVC phase 1 Nasarawa, Cross River, Akwa Ibom.
 - 2018 Phase 2a: Kogi, Kwara and Zamfara and in 58 political wards in 25 LGAs in Borno State.
 - 2018 phase 2b PMVC: Sokoto, Kebbi, Niger, FCT, Plateau and Borno (3 LGAs (Askira/Uba, Chibok, Konduga) States.
 - Yellow fever Reactive vaccination campaigns were implemented in Katsina (Danja LGA), Edo (13) LGAs and Benue (Vandekeiya)
 - 2019 phase 3 PMVC will be implemented in all LGAs where no YF campaigns have been implemented in Edo, Ekiti, Katsina and Rivers States.

Epi- summary
[Table] 1: Showing All Affected States and Cases with Yellow Fever as at Week 18, 30 Apr 2019 [with data for categories that interested readers can see at the source URL]:
- Total number of cases in the line list
- Attack rate per 100 000 population
- Number of LGAs with suspected cases
- Number of LGAs with presumptive/inconclusive cases
- Number of LGAs with confirmed cases from IP Dakar
- Number suspected cases with blood sample collected in Nigeria
- Number of presumptive positives in Nigeria
- Number with inconclusive results in Nigeria
- Total number of samples sent to IP Dakar
- Number positive cases from IP Dakar
- Total number negative in IP Dakar
- Number awaiting result from IP Dakar
- Number of deaths from all cases
- Positives
- Number of deaths from IP Dakar confirmed

Figure 1: Epidemic Curve of All Cases of Yellow Fever in Nigeria as at Week 18, 30 Apr 2019 [graph not shown]
Figure 2: Trend of Confirmed Cases of Yellow Fever in Nigeria 2017-2019
Figure 3: Map of Nigeria Showing States with
Suspected/Presumptive/Confirmed Cases as at Week 18, 30 Apr 2019 [Figure 4 not shown]
Figure 5: Map showing states that implemented PMVC/proposed PMVC from 2019-2021.
=====================
[The above report indicates that 930 suspected cases have been reported this year (2019) from 1 Jan - 30 Apr 2019. There are 332 suspected cases during the April 2019 reporting period, up from 254 suspected cases on 19 Feb 2019. There are 3 new presumptive and 3 new confirmed yellow fever cases during the April 2019 reporting period. The YF virus is endemic in Nigeria, and cases occur there sporadically. Because the 2019 outbreak that began in Edo state may have started as sylvatic (forest) yellow fever spread by various _Aedes_ species with subsequent rapid development suggesting urban yellow fever transmission spread by _Ae. aegypti_, it is reassuring to learn that the Edo state outbreak was declared over with a reported vaccination coverage of 120%. This startling level of coverage may have occurred as a result of individuals vaccinated outside the state being vaccinated in the state as well, and/or by individuals having been vaccinated twice within the state. It is encouraging to learn that phase 3 vaccination will be implemented in all LGAs where no YF campaigns have been implemented thus far in Edo, Ekiti, Katsina and Rivers States. - ProMED Mod.TY]

[HealthMap/ProMED map available at:
Nigeria: <http://healthmap.org/promed/p/62>]
Date: Thu 16 May 2019
Source: AllAfrica, The Guardian report edited
<https://allafrica.com/stories/201905160190.html>

A serving medical doctor has been infected with Lassa fever while 2 persons were confirmed dead in Kebbi state. Another medical doctor disclosed this yesterday [15 May 2019] when The Guardian visited the Federal Medical Centre (FMC), Birnin Kebbi. He said that 2 children died last week [week of 6 May 2019] as a result of the Lassa fever while a medical doctor, who was doing his primary assignment treating the patients, was also infected.

"You see, the management of the FMC has opened a special unit called isolated unit for the Lassa fever patients. We still have some patients inside. Also, a medical doctor, who was managing some patients last month [April 2019], has also been infected and he is presently on admission," he said.

Meanwhile, the state's Commissioner for Health, Alhaji Umar Kambaza, who confirmed the incident, said they were aware of the cases in the state but the government is working towards them.  [Byline: Michael Egbejule, Ahmadu Baba Idris]
========================
[The dates of occurrence of these cases is not given. Presumably, they were hospitalized after 12 May 2019 when the Nigeria CDC update was issued. It is indeed unfortunate that an attending physician became infected in the hospital. Nosocomial infections are not unusual when personal protective equipment and barrier nursing measures are not employed. - ProMED Mod.TY]
Date: Tue 14 May 2019
Source: Devax [edited]
<https://www.devex.com/news/here-s-how-people-in-nigeria-are-avoiding-vaccination-94878>

In the departure hall of Nigeria's busiest airport, Murtala Muhammed International in Lagos, passengers get their travel documents ready for check-in. In addition to a passport, ticket, and visa, travellers to many destinations need a yellow fever vaccination card, as Nigeria struggles with an ongoing outbreak. The cards are automatically issued following immunization at a government hospital and are validated with a signature and stamp from the port health authority. But although 1 in 5 people who contract yellow fever in Nigeria die from it, not everyone gets immunized, and some are finding ways to bypass the travel requirements, increasing the risk of the epidemic-prone disease spreading to other countries.  One way to do it is to buy a falsified vaccination card, readily available at the airport for those who either don't want to be immunized or don't have enough time before they travel.

The Nigerian government told Devex the cards are fake, while evidence at the airport suggests they are authentic but fraudulently obtained. Airport staff and travelers said the cards had been bought at the port health authority's store, duly stamped and signed as a way of generating underhand revenue for staff. Devex was able to buy one for 3000 Nigerian naira [USD 8.50] with no evidence of immunization.  The port health authority denied the involvement of their staff and said that banners at the airport warn travelers of the dangers of fake cards.  "I don't think we are doing a bad thing," an airport worker told Devex. "Without the card, you might miss your flight and that will be [a] waste of money over an ordinary card."

Desperate travellers continue to request them. "Some will even call you to get one for them on their way to the airport. We also have friends and relatives that want to travel and know that we have access to the cards," she said. One traveler who has used such a card on trips to South Africa, Kenya, and Ethiopia said none of the embassies had flagged the card as falsified, nor denied him a visa. He suggested the lengthy process of obtaining the card legally -- which means scheduling a hospital appointment and then waiting 10 days after immunization for the card to become valid -- means many travelers are not able to get it on time.  "I see it as an outcome of a systemic failure. Why will I be going from one office to another and be intentionally delayed because I want to do the right thing when I can get the same card within 2 minutes at the airport for less amount?" he said.

But as the situation at the airport shows, even those who have ready access to vaccines are failing to get them.  At the end of last year [2018], the Nigerian health ministry took steps to introduce electronic verification into the vaccination card system. "The introduction of an electronic version of the yellow card stemmed from the ubiquitous fake versions of the card that are notoriously being issued by unauthorized personnel for years," a health ministry spokesperson told Devex. Although the new system was expected to kick in from 1 Apr [2019], the deadline has been extended to the end of June 2019 to give people more time to sign up.

Dr. Lawal Bakare, founder of EpidAlert, a Nigerian nonprofit working on disease prevention, said it will be more easily available, affordable, and verifiable, with registration and payment made online.  To prevent health authority staff selling falsified documents, cash has been removed from the system. "You cannot pay cash. Money goes directly to government wallet. A reference code is generated and is linked to a traveler's passport number which can be checked against [a] database which those that are selling the fake cards will not have access to," Bakare explained.

Despite the government's investment in the new portal, adoption has been limited. "People were not aware of the new card and we advocated for the shift of the deadline," Bakare said, adding that the distraction of the Nigerian election at the start of the year "did not allow the new yellow cards to get much attention."  His organization is now planning awareness sessions for frequent travelers, multinational companies, universities, and embassies to drive adoption. "We have a duty as a country to protect the global health system," he said. But he added that the new system does not directly tackle the underlying problem behind the emergence of a market for fake vaccine cards, the hesitancy among travellers to be immunized.
 
To tackle that, Bakare said travelers need to know the dangers of falsifying vaccine cards and be encouraged to apply for legitimate cards earlier. "There is no excuse for not receiving necessary immunization and we need a sense of patriotism, doing the right thing and not putting others at risk," he said.  Wonodi advocated for good, regular data and strong coordinating platforms to ensure vaccination programs are reaching the right areas, and that work is happening to engage communities. She expressed optimism about the future of vaccination in Nigeria and across Africa but added that hesitancy remains a risk with the rise of technologies that can spread false information [about vaccine risk] fast.  "The good news is that this same technology ... can also be used to coordinate a response fast. It can also be used to train health workers and community volunteers to deliver services better. It can be used to remind parents to vaccinate their children. It can be used to educate community leaders to support immunization and religious leaders to preach immunization," Wonodi said.  [Byline: Paul Adepoju]
==================================
[Fake yellow fever (YF) vaccination cards have been a recurring problem in several African countries in the recent past, including in Nigeria. The above report indicates that the problem of sale of fake YF vaccination cards persists in Nigeria up to the present time. The sale of fake yellow fever vaccination cards to individuals who did not receive the vaccine presents a serious public health risk inside Nigeria and outside of it. Susceptible, unvaccinated individuals can contribute to a YF outbreak within the country.

YF virus is endemic in Nigeria, and transmission is active this year (2019). From 1 Jan to 3 Mar 2019, there have been 364 suspected YF cases reported in 177 local government areas. An unvaccinated, viraemic individual with a fake card who becomes infected in Nigeria could carry YF virus to localities where vector mosquitoes are present and initiate an outbreak of this serious disease in countries where YF does not occur and the population is unvaccinated, such as tropical South and South East Asia. One wonders whether these countries will deny visas to or admittance of individuals coming from Nigeria unless they can prove that their cards are legitimate. Fortunately, the Nigerian government authorities are initiating an electronic system for card issuance that should assure that vaccination has been accomplished that would put a stop to these false practices. - ProMED Mod.TY]

[Maps of Nigeria:
<http://www.un.org/Depts/Cartographic/map/profile/nigeria.pdf> and
<http://healthmap.org/promed/p/62>]
Date: Sun 21 Apr 2019
Source: Nigeria Center for Disease Control (NCDC) Situation Report [edited]
<https://ncdc.gov.ng/diseases/sitreps/?cat=5&name=An%20update%20of%20Lassa%20fever%20outbreak%20in%20Nigeria>

Highlights
----------
- In the reporting week 16 (15-21 Apr 2019) 6 new confirmed cases were reported from 4 states -- Edo (2), Ondo (2), Taraba (1) and Kebbi (1) states with one new death in Kebbi state
- From 1 Jan-21 Apr, 2019, a total of 2289 suspected cases have been reported from 21 states. Of these, 546 were confirmed positive, 15 probable and 1728 negative (not a case)
- Since the onset of the 2019 outbreak, there have been 123 deaths in confirmed cases. Case fatality ratio in confirmed cases is 22.5%
- 21 States (Edo, Ondo, Bauchi, Nasarawa, Ebonyi, Plateau, Taraba, FCT, Adamawa, Gombe, Kaduna, Kwara, Benue, Rivers, Kogi, Enugu, Imo, Delta, Oyo, Kebbi and Cross River) have recorded at least one confirmed case across 81 Local Government Areas -- Table 1, Figure 1
- 93% of all confirmed cases are from Edo (36%), Ondo (28%), Ebonyi (8%), Bauchi (8%), Taraba (7%) and Plateau (6%) states -- Figure 1
- Predominant age-group affected is 21-40 years (Range: >1 month to 89 years, Median Age: 32 years) -- Figure 6
- The male to female ratio for confirmed cases is 1.2:1 -- Figure 6
- In the reporting week 16 (15-21 Apr 2019), no new health care worker was affected. A total of 17 health care workers have been infected since the onset of the outbreak in 7 States -- Edo (7), Ondo (3), Ebonyi (2), Enugu (1), Rivers (1), Bauchi (1) Benue (1) and Plateau (1) with 2 deaths in Enugu and Edo States
- 13 patients are currently being managed at various treatment centres across the country: Federal Medical Centre Owo (8), Taraba (3) and Plateau (2)
- A total of 7193 contacts have been identified from 20 States. Of these 654 (9.1%) are currently being followed up, 6475 (90.1%) have completed 21 days follow up, while 8 (0.1%) were lost to follow up. 116 (1.6%) symptomatic contacts have been identified, of which 56 (0.8%) have tested positive
- National Lassa fever multi-partner, multi-sectoral Emergency Operations Centre (EOC) continues to coordinate the response activities at all levels

Figure 1 [map]. Distribution of confirmed Lassa fever cases in Nigeria as at 21 Apr 2019
Figure 2 [map]. LGA attack rate of confirmed Lassa fever cases in Nigeria as at 21 Apr 2019
Figure 3 [graph]. Epicurve of Lassa fever confirmed (546) cases in Nigeria - week 1 2019 to week 16 2019
Figure 4 [graph]. Weekly trends of Lassa fever confirmed cases in Nigeria, week 1 2019 to week 16 2019
Figure 5 [graph]. Confirmed Lassa fever cases in Nigeria with state specific case fatality rates (CFR) as at 21 Apr 2019
Figure 6 [graph]. Age-Sex distribution of Confirmed Lassa fever cases in Nigeria as at 21 Apr 2019
=========================
[The 6 new confirmed and 2217 suspected cases (up from 3 confirmed and up to 2289 suspected cases from 2217 cases in the previous report) indicate that Lassa fever virus transmission is continuing but perhaps with reduced incidence. Nigeria is still well within the period of the year when more cases usually occur, as illustrated in the graph in Figure 3. There has been a peak in case numbers between weeks 1 and 11 (1 Jan-17 Mar 2019) over the past 3 years and probably will be the case again this year (2019). There are 123 confirmed deaths, up one from 122 in the previous reporting period. Fortunately, there are no new healthcare workers infected during this reporting period, and the total number of infected healthcare workers remains at 17. This outbreak remains widespread so far in 2019, with confirmed cases occurring in 21 states, and the number of affected LGAs remains at 81.

Transmission of Lassa virus occurs when individuals are in contact with rodent reservoir hosts' 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_:
<https://www.inaturalist.org/taxa/45326-Mastomys-natalensis>
_Mastomys erythroleucus_ and _Hylomyscus pamfi_:
<http://punchng.com/nigerias-large-rat-population-threatens-lassa-fever-war/>

The maps and graphs in the report above are interesting and provide a good picture of how the outbreak has progressed over time. - ProMED Mod.TY]

[Maps of Nigeria:
<http://www.un.org/Depts/Cartographic/map/profile/nigeria.pdf> and
<http://healthmap.org/promed/p/62>]
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