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This open-access article is distributed under
Creative Commons license CC-BY-NC 4.0.
Spatial Spread of Diphtheria and Public Health Engagement in
Nigeria: A Review
Olusola Olufemi, PhD ; and Oluwasayo Olatunde, MD CFP
1Associate Professor of Urban and Regional Planning, Independent Consultant, Ontario, Canada; Associate,
Society for Good Health, Ibadan, Oyo State, Nigeria. 2Department of Family Medicine, Dalhousie University,
Halifax, Nova Scotia, Canada; Department of Family Medicine, University of British Columbia, Vancouver,
British Columbia, Canada.
Corresponding author: solaoluf@yahoo.com
DOI: https://doi.org/10.62154/exjbk906
Abstract
Diphtheria is a potentially fatal and highly contagious vaccine-preventable disease that spreads
between people mainly by direct contact or through the air via respiratory droplets. The disease
can affect all age groups, however, unimmunized children are particularly at risk. This article
examines the spatial spread of diphtheria in Nigeria. The paper examines community awareness
and public health actions taken by various actors and stakeholders to alleviate the diphtheria
outbreak. The risks of spreading diphtheria and the vulnerability of children due to poor
immunisation are frightening. Consistency in data collection and good quality (quantitative) data
provides a basis for timely intervention and future response to the treatment of diphtheria.
Curtailing crowding, reducing multidimensional poverty and social inequalities, and enhancing
hygienic practices (WASH) are practical measures to reduce spread, infection, and death arising
from the diphtheria outbreak in Nigeria and other countries.
Keywords: Diphtheria, Public Engagement, Spatial Spread, Vaccination Education.
Introduction
Diphtheria is a life-threatening disease that requires early detection, rapid treatment, and
intensive care interventions in very severe cases, and it is a potentially fatal infection caused
mainly by toxigenic strains of Corynebacterium diphtheriae and occasionally by toxigenic
strains of C. ulcerans and C. pseudotuberculosis (Sharma et al., 2019). The re-emergence of
diphtheria and its rapid spread in the Nigerian community continues to be a cause of
concern among health care workers and the society at large. The vulnerability of children
and people with zero doses to the diphtheria epidemic is also a major concern. The main
concern of the diphtheria outbreak is the result of low immunisation and poor uptake of
routine immunisation is one of the main causes of the disease (IFRC, 2023). With the present
globalisation and the poor immunisation indices in Nigeria, Nigeria is more vulnerable to
this disease (Sadoh and Oladokun, 2012). The outbreak serves as a reminder of the
importance of herd immunity and the impact of vaccination coverage on controlling the
spread of infectious diseases (Adegboye et al. 2023). This article examines the spatial
spread of diphtheria in Nigerian communities by exploring the social aspects of the
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propagation of the disease, community awareness, and public health actions taken by
various actors to alleviate the outbreak of diphtheria. This is to sensibilize the Nigerian
community to the risks and vulnerability of zero-dose immunisation and to improve
knowledge and awareness of the hazard of diphtheria outbreak.
Objectives
The objectives of this paper are the following.
1. Examine the causes of the spatial spread of diphtheria in Nigeria
2. Sensitise Nigerian communities to the risks and vulnerabilities of zero-dose
immunisation.
3. Improve knowledge and awareness of the hazard of diphtheria outbreak.
Statement of the Problem
The vulnerability of children and persons with zero vaccination constitutes a major
challenge in the fight against the diphtheria outbreak in Nigeria. With increasing
multidimensional poverty, vaccine hesitancy and vulnerability to infectious diseases, many
Nigerians continue to be susceptible to epidemic outbreaks of Cholera, Lassa fever, and
Diphtheria among others. Residents of densely crowded places and unsanitary areas are
also at risk of contracting the disease. Healthcare professionals, hospital front-line workers,
and anyone who has encountered suspected or confirmed diphtheria cases are also at risk
(IFRC, 2023). Therefore, it becomes imperative to understand community involvement in
the process of obtaining access to vaccination promptly. Other problems include limited
training of public health personnel and fragmented policies. Accessing funds in a timely
manner is also crucial to the intervention of diphtheria.
Methodology
This article uses secondary data and a review of the literature through a systematic search
of approximately 30 studies on diphtheria. A search was carried out in the following journals
on Google Scholar, PubMed, ScienceDirect, and Elsevier, using the search terms
'Diphtheria', 'Social aspects of Diphtheria', and 'Diphtheria in Nigeria'.
Theoretical/Conceptual Framework
The 2030 Agenda for Sustainable Development of the United Nations presents a global
guide to address the present needs of people without depriving future generations of the
resources they need to live dignified, healthy and meaningful lives (SDG, 2017 & 2018). This
article adopts the concept of community engagement and participation in health
promotion using the social ecological model of the health approach.
Concept of Community
Community can be conceived from four perspectives (NIH, 2011:5):
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1. Systems perspective: a community like a living creature comprising different parts,
functions, and activities.
2. Social perspective: describes the social and political networks that link the
community together.
3. Virtual perspective: virtual communities that utilise computer-mediated
communication, for example texting, X, Facebook, and YouTube, etc.
4. Individual perspective: Individual sense of community and belonging.
NIH (2011: xvi) notes that 'community' sometimes refers to those affected by the health
issues being addressed and ‘community’ can be used in a more general way to refer to
stakeholders such as academics, public health professionals, and policy makers as
communities'. In the case of the diphtheria outbreak in Nigeria, the community in this
document refers to both (the community and the stakeholders).
Community Engagement
Community Engagement is 'a process of developing relationships that allow stakeholders
to work together to address health-related issues and promote well-being to achieve
positive health impact and results' (WHO, 2017a:4). Health promotion employs community
participation, defined as “the process of working collaboratively with and through groups
of people affiliated by geographic proximity, special interest, or similar situations to address
issues affecting the well-being of those people” (CDC, 1997:9). The goals of community
engagement are to build trust, enlist new resources and allies, create better
communication, and improve overall health outcomes and lasting collaborations (CDC,
1997; Shore, 2006; Wallerstein, 2002). Community engagement is grounded in the
principles of community organisation: fairness, justice, empowerment, participation, and
self-determination (Alinsky, 1962; Chávez et al., 2007; Freire, 1970; Wallerstein and Duran,
2006).
NIH (2011:7) asserts “community engagement can take many forms, and partners can
include organized groups, agencies, institutions, or individuals. Community engagement
can also be seen as a continuum of community involvement” (Figure 1).
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Figure 1: Community Engagement Continuum
Source: NIH (2011:8).
Community engagement has been described as both ‘art and science’ to develop
relationships and direct collective actions towards the common good' (cited in WHO,
2020:7). Although four levels of community engagement are community-orientated
(Information and community mobilisation), community-based (consultation and
involvement), community-managed (collaboration), and community-owned (ownership
and empowerment) (WHO, 2020), there must always be continuous engagement with the
community and stakeholders, as indicated in Figure 2.
Figure 2: Continuous engagement-focused activities to achieve different levels of
engagement.
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Source: IAP2. IPA2 spectrum of public participation, 2018; Turin et al. 2021:2. The levels
of engagement were adapted from the participation spectrum described by the
International Association of Participation Professionals (IAP2).
On the other hand, five different levels are often referred to as the levels of participation –
inform, consult, involve, collaborate, and empower. Empowerment is considered a level
with the highest degree of participation, and refers to 'a process by which people gain
greater control over decisions and actions that affect their lives; Community empowerment
specifically involves people acting collectively to gain greater control over their community,
including their health and quality of life' (WHO, 2018a; WHO, 2020: 7). For health
promotion, community engagement, organising, and collaboration tie into the social
ecological model approach, which focusses on the multiple factors that impact individual,
community health from social, environmental, political, economic, and cultural.
The Social-Ecological Model of Health
The social ecological model conceptualises health broadly and focusses on multiple factors
that could affect health. The social ecological model understands health to be affected by
the interaction between the individual, the group/community, and the physical, social, and
political environments (Israel et al., 2003; Sallis, Owen, and Fisher, 2008; Wallerstein and
Duran, 2003). “The social ecological model understands health to be affected by the
interaction between the individual, the group/community, and the physical, social, and
political environments” (NIH, 2011:20).
Stokols (1996) proposed four core principles that underlie the ways the social ecological
model can contribute to efforts to engage communities:
- Health status, emotional well-being, and social cohesion are influenced by the
physical, social, and cultural dimensions of the environment of the individual or
community and personal attributes (e.g., behaviour patterns, psychology, genetics).
- The same environment can have different effects on an individual’s health depending
on a variety of factors, including perceptions of the ability to control the environment
and financial resources.
- Individuals and groups operate in multiple environments (e.g., workplace,
neighbourhood, larger geographic communities) that “spill over” and influence each
other.
- There are 'personal and environmental leverage points', such as the physical
environment, available resources, and social norms, that exert vital influences on
health and well-being.
The CDC created a four-level model of the factors affecting health grounded in social
ecological theory (2007; Figure 3) to inform health promotion programmes.
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Figure 3: The Social-Ecological Model: A Framework for Prevention Societal
Community Relationship Individual
Source: CDC, 2007
Figure 3 (NIH, 2011: 22) indicates:
1. The first level of the model (at the extreme right) includes individual biology and
other personal characteristics, such as age, education, income, and health history.
2. The second level, the relationship, includes the closest social circle of a person, such
as friends, partners, and family members, all of whom influence a person’s
behaviour and contribute to his or her experiences.
3. The third level, community, explores the settings in which people have social
relationships, such as schools, workplaces, and neighbourhoods, and seeks to
identify the characteristics of these settings that affect health.
4. The fourth level looks at the broad societal factors that favour or impair health”.
Both the community engagement approach and the social ecological model recognise the
complex role played by context in the development of health problems, the role of
stakeholders and the different levels of the individual, the interpersonal level, the
community, society to disease prevention and health promotion (NIH, 2011).
Literature Review
Worldwide, thousands of cases of diphtheria are still reported annually from several
countries in Asia and Africa, usually with a lack of specificity due to underreported cases
along with many outbreaks and changes in the epidemiology of diphtheria (Adegoke and
Adebayo, 2017; Sharma et al., 2019). In 2017, a total of 8,819 cases of diphtheria were
reported worldwide, the highest since 2004 (Clarke et al., 2019). During 2016–2019,
diphtheria outbreaks were reported in multiple countries, including Bangladesh, Yemen,
and Venezuela, and several outbreaks were among vulnerable populations or in areas of
social disruption and conflict.
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According to Völzke et al. (2006), the prevalence of susceptibility to diphtheria was 32.4%
in North-East Germany and multivariate analysis revealed 45% increased odds of women
being susceptible to diphtheria. Women who had not received diphtheria toxoid
vaccination during the previous 10 years had four times greater odds of being susceptible
to diphtheria toxin compared to unvaccinated men. None of the social factors investigated
was associated with susceptibility status. It was concluded that a high proportion of middle-
aged adults was susceptible to diphtheria. Women lacked seroprotection more often than
men, which might be explained, in part, by gender-specific immune responses after
vaccination.
“Diphtheria is a severe bacterial infection that can affect the nose, throat, and occasionally
the skin of a person. It is caused by the Corynebacterium species. The people at the highest
risk of contracting diphtheria are children and people who have not received any or only a
single dose of the vaccine (a diphtheria toxoid-containing vaccine). Sharma et al. (2019)
observes that diphtheria is generally an acute respiratory infection, characterised by the
formation of a pseudo membrane in the throat, but cutaneous infections are possible.
Systemic effects, such as myocarditis and neuropathy, which are associated with increased
risk of death, are due to diphtheria toxin, an exotoxin produced by the pathogen that
inhibits protein synthesis and causes cell death.
Causes of Diphtheria
Diphtheria is a serious bacterial infection that affects the nose, throat, and sometimes the
skin of an individual. It is caused by the bacterium Corynebacterium species, mainly by
toxin-producing Corynebacterium diphtheriae and rarely by toxin-producing strains of C.
ulcerans and C. pseudotuberculosis (Sharma et al., 2019). WHO (2017b) states that
diphtheria is an infection caused by the Corynebacterium diphtheriae bacteria and signs
and symptoms usually begin 2 to 5 days after exposure and range from mild to
severe. Symptoms often progress gradually, beginning with a sore throat and fever. In
severe cases, the bacteria produce a poison (toxin) that causes a thick grey or white patch
on the back of the throat. This can block the airways, making it difficult to breathe or
swallow and creating a snoring cough. The neck may swell in part due to enlarged lymph
nodes. The poison may also enter the bloodstream, causing complications that can include
inflammation and damage to the heart muscle, nerve inflammation, kidney problems, and
bleeding problems due to low blood platelets. Damaged heart muscles can result in
an abnormal heart rate and inflammation of the nerves can result in paralysis. Diphtheria
spreads easily between people by direct contact or through the air through respiratory
droplets, such as coughing or sneezing. It may also be spread by contaminated clothing
and objects.
The NBS and UNICEF (2022:366) report indicates that “access to safe drinking water,
sanitation, and hygiene (WASH) is essential for good health, welfare, and productivity and
is widely recognised as a human right. Inadequate WASH is primarily responsible for the
transmission of diseases such as cholera, diarrhoea, dysentery, hepatitis A, typhoid, and
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polio.' Immunisation is a proven tool for controlling and eliminating life-threatening
infectious diseases and is estimated to prevent between 2 and 3 million deaths each year
(WHO, 2016). It is one of the most cost-effective health investments, with proven strategies
that make it accessible to even the most hard-to-reach and vulnerable populations. The
WHO recommended routine immunisations for children endorses that all children be
vaccinated against tuberculosis, diphtheria, tetanus, pertussis, polio, measles, hepatitis B,
haemophilus influenzae type b, pneumococcal bacteria / disease, rotavirus and rubella
(WHO, 2018b).
Results and Discussion
Spatial Spread of Diphtheria in Nigeria
With headlines like 'Diphtheria: Nigeria confirms 80 deaths” (Premium Times; “Nigeria
records 216 confirmed diphtheria cases – NCDC” (Vanguard Nigeria Online), the outbreak
and spread of diphtheria in Nigeria becomes disconcerting. For a country of 226.7 million
people with 53.9 % of the population urban, and an average life expectancy of 53.87 years
(UN, 2023), the reemergence of diphtheria is a cause for concern. Nigeria is divided into six
geopolitical zones (Figure 4) that are South West (Ekiti, Lagos, Ogun, Ondo, Osun, Oyo),
South East (Abia, Anambra, Eboyi, Enugu, Imo), South-South (Akwa Ibom, Bayelsa, Cross
River, Delta, Edo, Rivers), North West (Jigawa, Kaduna, Kano, Katsina, Kebbi, Sokoto,
Zamfara), North East (Adamawa, Bauchi, Borno, Gombe, Taraba, Yobe), North Central
(Benue, Kogi, Kwara, Nasarawa, Niger, Plateau, Federal Capital Territory).
Figure 4: Six Geopolitical Zones in Nigeria
Source: https://mavink.com/explore/Map-of-Nigeria-Showing-Regions
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The most significant reported diphtheria outbreak in Nigeria occurred in 2011 that affected
rural areas of Borno State (northeast region). There were 98 cases and 21 deaths in the
northeastern region, 21% of these cases resulting in subsequent mortality (WHO, 2018c).
According to Besa et al. (2014), a diphtheria outbreak occurred from February to November
2011 in the village of Kimba and its surrounding settlements, in Borno state, northeastern
Nigeria. A retrospective outbreak investigation was conducted in the village of Kimba and
surrounding settlements to better describe the extent and clinical characteristics of this
outbreak. Of the 98 confirmed cases, 63 (64.3%) of whom were children under 10 years of
age. 98% of the cases had never been immunised against diphtheria and none of the 98
cases received diphtheria antitoxin, penicillin, or erythromycin during their illness (Besa et
al., 2014).
The World Health Organisation reporting system indicates that there has been a constant
dwindle of outlined diphtheria occurrences from 5039 in 1989 to 2468 in 2001 and 312 in
2006 (Aborode et al., 2023). A total of 1870 cases were reported in Nigeria in 2018 (Shariff
et al., 2023). However, there was a reemergence of diphtheria in 2022. The Nigeria Centre
for Disease Control and Prevention (NCDC) was first notified of suspected diphtheria cases
on 1 December 2022. On 20 January 2023, the NCDC officially declared the situation as an
outbreak in Lagos and Kano States. These two states have a combined population of more
than 30 million (Adegboyega et al., 2023). By July 2023 Kano, Yobe, Kaduna, Katsina,
Federal Capital Territory (FCT), Lagos and Osun States reported severe cases (Figure 5).
However, Kano has consistently remained the epicentre of the diphtheria outbreak (Figure
6).
Figure 5: States Spread of Diphtheria Outbreak in Nigeria, July 2023
Source: Nigerian Red Cross Society, IFRC, 2023
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Figure 6: Incidence (per million population) of confirmed diphtheria cases in Nigeria by
State, May 2022 -December 24, 2023
Source: NCDC, 2023a [A Publication of the National Diphtheria Emergency Operations
Centre (EOC)].
Cumulatively, from May 2022 to December 2023 a total of 22,293 suspected cases were
reported in 36 states across 297 local government areas, while 13,387 (60.1%) cases were
confirmed and distributed across 21 states and 158 local government areas. According to
NCDC (2023a), Kano, Yobe, Katsina, Bauchi, Borno, Kaduna and Jigawa accounted for
96.2% of suspected cases and Kano, Bauchi, Yobe, Katsina, Borno, Jigawa, Plateau and
Kaduna accounted for 99.4% of confirmed cases (Table 1). The suspected and confirmed
cases are lost in the northern parts of Nigeria where multidimensional poverty, the Boko
Haram insurgency, farmer-herdsmen incursions and conflicts, and internal displacement
continue to hinder residents from accessing health care. NCDC (2023a) notes that the
majority of confirmed cases were among children aged 1-14 years and only 3,376 (25.2%)
out of the confirmed cases of 13,387 were fully vaccinated with a diphtheria toxoid-
containing vaccine. A total of 598 deaths have been recorded among the confirmed cases.
Kano reported 382 deaths (63.9%) and Yobe reported 73 deaths 12.2%).
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Table 1: Distribution of diphtheria cases and deaths in Nigeria, May 2022-December 2023
States
Number of
Suspected
Cases
Number of
Confirmed
Cases
% of
Confirmed
cases
Number of
Deaths among
Confirmed
cases
CFR among
Confirmed
Cases (%)
Kano
14,126
10,085
71
382
4
Yobe
2238
1009
45
73
7
Katsina
1734
599
35
48
8
Bauchi
1376
1059
77
23
2
Borno
1148
483
42
30
6
Kaduna
573
28
5
8
29
Jigawa
256
45
18
5
11
Zamfara
152
7
5
0
0
Gombe
136
6
4
1
17
FCT
127
13
10
5
38
Taraba
90
2
2
0
0
Plateau
66
31
47
15
48
Kebbi
46
1
2
0
0
Sokoto
41
4
10
0
0
Lagos
37
6
16
5
83
Kogi
36
0
0
0
-
Osun
16
3
19
1
33
Bayelsa
15
0
0
0
-
Oyo
14
0
0
0
-
Enugu
12
1
8
0
0
Niger
11
2
18
0
0
Ekiti
10
1
10
1
100
Imo
9
0
0
0
-
Nasarawa
7
1
14
1
100
Abia
3
0
0
0
-
Delta
2
0
0
0
-
Edo
2
0
0
0
-
Ondo
2
0
0
0
-
Rivers
2
0
0
0
-
Adamawa
1
0
0
0
-
Akwa
Ibom
1
0
0
0
-
Anambra
1
0
0
0
-
Cross
River
1
1
100
0
0
Kwara
1
0
0
0
-
Ogun
1
0
0
0
-
Total
22,293
13,387
-
598
-
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Source: NCDC, 2023a [A Publication of the National Diphtheria Emergency Operations
Centre (EOC) December 2023].
From Table 1 the top seven states with the highest number of confirmed cases and deaths
are in the north. Although Nigeria has a high level of poverty and inequality, the spatial
divide relating to the outbreak of diphtheria could not be more evident, especially in the
northern states. Multidimensional poverty and deprivation are intensified in the northern
states due to conflict (Boko Haram insurgency), climate crisis (flooding, drought,
desertification, heat), and internally displaced persons, among others.
The World Bank’s multidimensional poverty measures (MPM) is unique among in including
information on both monetary and non-monetary poverty. Non-monetary deprivation
includes water, sanitation, electricity, educational enrolment, and attainment. Almost half
of Nigeria’s population (47.3%) were multidimensionally poor in 2018/19 (World Bank,
2022). Poverty was exacerbated by the COVID-19 pandemic. Using the World Bank’s MPM,
a household is classified as multidimensionally poor if it is deprived of at least one third of
the weighted multidimensional poverty indicators, namely monetary poverty, educational
enrolment, educational attainment, water, sanitation and electricity. Multidimensional
poverty was concentrated in northern Nigeria. The overall multidimensional poverty rate
for the north (pooling the North Central, North East, and North West zones) was 67.3
percent in 2018/19, compared with 25.0 percent for the south (pooling the South East,
South South, and South West zones” (World Bank, 2022, p.32). Northern Nigeria was more
deprived than southern Nigeria in all six multidimensional poverty indicators. This disparity
can also be observed in the outbreak and spread of diphtheria and vaccine gaps.
Vaccination Gaps and Diphtheria Treatment
Save the Children International indicated that Nigeria already has one of the lowest
vaccination rates in the world, and only 42% of children under 15 years of age in Nigeria are
fully vaccinated against diphtheria, and in the October 2023 outbreak, 80% of the
confirmed cases are unvaccinated people (Ibrahim, 2023). Three in every four confirmed
cases or 73.6% of all cases are of children under 14, with those aged between 5-14 years
bearing the brunt of the disease (Dapam, 2023). Figure 7 indicates significant incidences
among vaccinated and unvaccinated children. The number of deaths is higher among
unvaccinated children between the ages of 1 and 14 years.
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Figure 7: Age distribution and vaccination status of deaths among confirmed diphtheria
cases in Nigeria, May 2022-December 2023
Source: NCDC, 2023b [A Publication of the National Diphtheria Emergency Operations
Centre (EOC) December 2023]
Gender differences in confirmed cases of diphtheria outbreak are revealed in Figure 8.
Apparently, between the ages of 2 and 4 years more men are affected, while more women
are affected by the diphtheria outbreak from age 15 and older compared to men in the
confirmed cases by gender in Nigeria. The proportion of fully and partially vaccinated is still
very low compared to the number of unvaccinated. For example, in February 2023 out of
the 216 confirmed cases, 184 (85.2% ) were aged 2 to 14 years from both sexes, and 27 were
fully vaccinated, 84 were unvaccinated, and 20 were partly vaccinated (Obinna, 2023).
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Figure 8: Age-sex distribution of confirmed diphtheria cases in Nigeria, May 2022 – June
2023
Source: NCDC, 2023c
Low rates of immunisation delayed clinical recognition of diphtheria and the lack of
antitoxin treatment and appropriate antibiotics contributed to this epidemic and its
severity (Besa et al., 2014). Nigeria has a low vaccination due to the low accessibility to
access to diphtheria antitoxin (WHO, 2018b). Diphtheria outbreaks tend to reflect
insufficient vaccination coverage, low vaccination coverage, and delays in diagnosis. The
absence of antitoxin and antibiotics for treatment in health facilities was also a factor. WHO
(2023a) notes that Nigeria’s most recent immunisation data was published in 2022 and it
showed stark coverage gaps. In August 2022, the National Bureau of Statistics (NBS) and
other health partners released the 2021 Multiple Indicator Cluster Survey (Mics) and the
Survey (Nics). The multiindicator survey provides, among other subjects, child mortality,
health, education, sanitation, and hygiene, while the Nics assesses vaccination coverage. A
total of 41,532 households were sampled nationally for the Mics, and 6,740 households for
the immunisation survey. The immunisation survey showed that only 56.6% of children
between ages 12 and 23 months had received the third dose of DTP at any time prior to the
survey. This rose slightly to 57.9% in children aged 24 to 35 months. The Executive Director
of the National Primary Health Care Development Agency noted that a total of 1,692,762
children, between 6 months and 4 years of age, have been diligently administered the
pentavalent vaccine, a vital safeguard against this disease.
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Diphtheria can be treated with timely administration of diphtheria antitoxin and
antimicrobial therapy, and the prevalence of toxigenic Corynebacterium spp. highlights the
need for appropriate clinical and epidemiological investigations to quickly identify and treat
affected individuals, along with public health measures to prevent and contain the spread
of this disease (Sharma et al., 2019). Although effective vaccines are available, this disease
has the potential to re-emerge in countries where the recommended vaccination
programmes are not sustained, and increasing proportions of adults are becoming
susceptible to diphtheria. The disease can be treated by administering diphtheria antitoxin
as well as antibiotics. Vaccination against diphtheria has dramatically reduced diphtheria
mortality and morbidity. Diphtheria antitoxin is a medication made up of antibodies used
in the treatment of diphtheria. Erythromycin IV (intravenous) refers to intravenous
administration of the antibiotic medication erythromycin. Erythromycin is a macrolide
antibiotic that is used to treat various bacterial infections. It works by inhibiting the growth
of bacteria, helping the body’s immune system fight infection. The therapy of diphtheria
comprises antitoxin and penicillin or erythromycin; however, Nigeria currently does not
routinely stock diphtheria antitoxin (DAT) (Sadoh and Oladokun, 2012). Therefore, children
with diphtheria scarcely received DAT, which was reported to reduce mortality mainly if
administered early in the course of the disease (Aborode, et. al, 2023).
Regarding drug sensitivity (Figure 9) Diphtheria appears to be highly resistant to
Ciprofloxacin and Trimethropim-Sulfamethaxole (TS) while the disease is highly
indeterminate to Benzylpenicillin and Cefotaxime and highly sensitive to Erythromycin and
tetracycline treatments.
Figure 9: Drug sensitivity results of toxigenic Corynebacterium diphtheriae isolated in
Nigeria, May 2022-December 2023
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Source: NCDC, 2023a [A Publication of the National Diphtheria Emergency Operations
Centre (EOC) December 2023].
Vaccine campaign outreaches were carried out in approximately 48 local government areas
in the seven most impacted northern states (Table 2) in November 2023 by administering
Penta vaccine to 1.9 million 6 weeks old children and about 3.4 million Td vaccine to children
aged 4 to 14 years of age.
Table 2: Reactive vaccination campaign coverage for pentavalent and Td vaccine by
states as of 25th November 2023
State
#LGA)
Target
Population
for Penta
(6weeks-
<4years
Total
Vaccinated
with Penta
Coverage
for Penta
Target
Population
for Td (4-14
years)
Total
vaccinated
with Td
Coverage
for Td
Kano (14)
511,406
555,134
109%
1,089,647
1,111,310
102%
Katsina
(9)
448,369
396,843
89%
716,165
644,623
90%
Bauchi
(5)
282,615
243399
86%
419,640
338,208
81%
Kaduna
(5)
242,613
251,126
104%
516,531
502,657
97%
Yobe (8)
196,564
205,006
104%
417,843
438,431
105%
Jigawa
(3)
183,161
180,287
98%
281,092
275,686
98%
Borno (4)
71,926
70,127
97%
153,132
156,809
102%
Total
(48)
1,936,654
1,901,922
98%
3,594,050
3467724
96%
Source: NCDC, 2023a [A Publication of the National Diphtheria Emergency Operations
Centre (EOC) December 2023].
In addition to diphtheria treatment and vaccination gaps, there are also access challenges.
According to WHO (2023b), the COVID-19 pandemic impacted vaccine uptake by creating
barriers to accessing vaccination services and decreasing the demand and uptake of
immunisation among caregivers. Movement restrictions and lockdowns also resulted in
decreased delivery of general healthcare services, increased transportation costs, fewer
engagements to promote vaccine uptake, and the discontinuation of mobile vaccination
campaigns that targeted hard-to-reach communities.
Limitations to Vaccine Access
According to WHO (2023a) due to insecurity, especially in northeast Nigeria, vaccination
coverage remains suboptimal, especially in areas controlled by nonstate armed groups.
Therefore, the outbreak of diphtheria further complicates and strains the already
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overstretched resources. The global supply of diphtheria antitoxin (DAT) is limited, and this
may affect the availability of the required doses in a timely manner. The overall risk of
diphtheria in Nigeria was assessed as high at the national level, low at the regional level,
and low at the global level. The overall vaccination coverage of 56% in Nigeria remains
suboptimal, with significant variations in the coverage of DPT3 immunisation in Nigerian
states (WHO, 2023b). Southern Nigeria has a higher vaccination rate than northern Nigeria
(Truelove, Kegan, and Moss, 2019). The decline in the vaccination rate has put vulnerable
people, such as children and unvaccinated individuals living in poor sanitary conditions, at
a greater risk (Adegboye et al., 2023). Other reasons for poor access to vaccination include
poverty and hunger, lack of knowledge, lack of education, insurgency, banditry & conflict,
poor funding, poor infrastructure, poor storage, early child marriage, and data deficiency.
Engaging Community and Public Health Response to Diphtheria Outbreak
The Nigeria Centre for Disease Control and Prevention (NCDC) continues to take the lead
and is at the forefront of the public health response to diphtheria in Nigeria through
coordination, surveillance, laboratory investigation, risk communication, case
management, and immunisation activities. NCDC efforts are supported by other actors and
stakeholders, both international agencies and national and regional/local actors.
Understanding the importance of community engagement in curbing the spread of the
disease, the NCDC has prioritized risk communication. Public health advisories on
diphtheria have been distributed, and social behavioural change materials have been
distributed in collaboration with partners. Treatment centres and wards have been
established in affected states, and the availability of diphtheria antitoxin (DAT) and IV
erythromycin has significantly reduced the fatality rate. Despite these efforts, vaccine
uptake remains a challenge. The National Primary Health Care Development Agency
(NPHCDA) has administered the pentavalent vaccine to 1,692,762 children aged 6 months
to 4 years and the TD vaccines to 3,166,419 children aged 4 to 14 years. However, a
significant number of confirmed cases are either unvaccinated or partially vaccinated,
indicating a gap that must be addressed.
As reiterated by IFRC (2023) and NCDC (2023; Ezigbo, 2023), the following agencies have
intervened in the response to the diphtheria epidemic in Nigeria:
1. The NCDC has instituted the following:
a. An ongoing coordination, monitoring of diphtheria surveillance and response
activities through the weekly diphtheria National Technical Working Group
meetings.
b. Rapid Response Teams (RRTs) have been deployed to Katsina, Osun and Yobe
States and re-deployed to Kano and Lagos States to support response
activities. While sensitisation/training of clinical and surveillance officers has
taken place in states where RRTs were deployed, on the presentation,
prevention and surveillance of diphtheria.
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c. Cascaded trainings were conducted in their respective states by some of the
laboratory scientists/physicians trained at the National Reference Laboratory
(NRL) of the NCDC, Abuja.
d. Harmonisation of surveillance and laboratory data between states and
laboratories is ongoing.
e. Procurement of reagents and sample collection and transportation
materials/media processes has been initiated.
f. Drug sensitivity tests are ongoing at NCDC NRL on isolates sent from states.
g. Distribution of diphtheria antitoxin (DAT) to affected states has been ongoing
since December 2022. The Centre has developed and disseminated Standard
Operating Procedures for Diphtheria Antitoxin (DAT) use in health facilities and
treatment centres.
h. Strengthening of routine immunisation activities across the country continues.
i. The National Emergency Operations Centre (EOC) was activated in January
2023, following an increase in- Diphtheria cases. The Emergency Operations
Centre (EOC), which is hosted at NCDC, is being coordinated in collaboration
with the Federal Ministries of Health, Environment and Water Resources,
National Primary Health Care Development Agency (NPHCDA), World Health
Organisation (WHO), IFRC, NRCS, and other implementing partners. The Multi-
sectorial National EOC activated at level 02, coordinated by NCDC, has
continued to work closely with all states, relevant stakeholders and partners, to
provide the necessary support for the prevention and control of diphtheria in
Nigeria.
j. NCDC is supporting states through deployment of rapid response teams,
development, and dissemination of National Guidelines for Diphtheria,
deployment of PCR kits, to five states. Katsina, Kano, Osun, Yobe, and Lagos
with adequate laboratory testing of samples, case management, contract
tracing, RCCE and partnering with stakeholders.
2. Nigerian Red Cross Society (NRCS):
a. Organising meetings, epidemic control for volunteers, community-based
health and first aid (CBHFA), health action teams, and Mothers Clubs.
b. NRCS response plan and how to engage the state governments and
deployed 500 community-based volunteers in 4 states.
c. Nigerian Red Cross and IFRC are currently part of the Risk Communication
and Community Engagement (RCCE) pillar where they aim to support the
social mobilisation of people to increase uptake of DAT vaccines during the
intensification of routine vaccination (RI) in the affected states by the
NPHCDA.
3. The European Union through its European Civil Protection and Humanitarian Aid
operators have provided 150,000 euros as a form of replenishment for the DREF to
the NRCS.
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4. British Red Cross are involved in the areas of WASH (Water, Sanitation and
Hygiene) activities.
5. National Authorities:
a. Since September 2011, the Nigerian Ministry of Health, and Médecins Sans
Frontières (MSF) offered case management.
b. The National Primary Health Care Development Agency (NPHCDA)
intensification of routine immunisation to increase vaccine uptake and
reduce the number of people not vaccinated or with zero dose vaccines
such as the pentavalent vaccine. The comprehensive response plan of
NPHCDA has been activated to detect early cases, contain spread, and
prevent further transmission through a multiphased strategy.
6. WHO:
a. Access to routine immunisation was denied during COVID-19, causing low
coverage, thus exacerbating the incidence, undernourishment, banditry,
IDP (6.2 m children between 2019 and 2023 who lack access to routine
immunisation, according to WHO).
b. WHO is currently providing Diphtheria Antitoxins (DAT) in the country as
requested by NCDC. WHO is also providing laboratory testing kits such as
PCR to the NCDC laboratory to support and facilitate the fast and efficient
testing of Diphtheria samples to produce definite results.
c. Plans are underway to deliver 1800 vials of diphtheria antitoxin to Nigeria.
The Nigeria Centre for Disease Control and Prevention requested WHO to
purchase DAT and erythromycin IV for the management of cases of
diphtheria.
7. UNICEF: UNICEF supports the NPHCDA in routine immunisation of children to
reduce the number of unvaccinated children and zero-dose children in Nigeria.
Nigeria is home to the second largest number of zero-dose children in the world.
Zero-dose children remain vulnerable to vaccine-preventable diseases, along with
under-immunised or “missed dose” children, which refers to those who do not
complete their immunisation as stated in the National Immunisation Schedule
(Adejoro, 2023).
8. MSF: Médecins sans Frontières (MSF) is bolstering the technical assistance of Risk
Communication and Community Engagement (RCCE) to distribute crucial
information on diphtheria in affected communities as part of its efforts to combat
the current diphtheria outbreak. To ensure that the messages are distributed
effectively and disseminated by the locally impacted areas, MSF is designing the
guidelines and printing media materials and resources for the messages and critical
data on diphtheria.
9. Indonesian Government: Approximately 1.5 million vaccines were made available
in Nigeria by the Indonesian government and the Ministry of Health is processing
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the shipment of vaccines to affected states which will be administered directly to
people at risk of diphtheria, such as children under 5 years of age.
10. Media:
a. In addition to the coverage of the print media, talk shows such as 'Your View' carried
a discussion on diphtheria on 22 August 2023, bringing experts to discuss diphtheria
and spread information and raise community awareness.
b. Regular media involvement such as this helps to proactively inform the public on
raising awareness and addressing misconceptions about the diphtheria outbreak.
c. The diphtheria jingles and PSA are aired on the national network news 7 a.m. and 4
p.m. on Radio Nigeria.
d. NCDC continues to conduct social listening on social media channels to address
misinformation and disinformation about diphtheria.
11. Sensitisation and community engagement to win those who are hesitant to get
vaccinated for their children. Outreach programmes in markets, churches to curb
the spread.
12. Support of the World Bank, Breakthrough Action Nigeria and other partners to
design, validate and distribute diphtheria social behavioural change (SBC) materials
to all states.
13. Engaging with state officials on the adaptation of diphtheria SBC materials (e-
posters, flyers, and jingles) to their local languages.
14. Engaging school heads or Principals on diphtheria prevention and control measures
in communities have been engaged in Kano state. Through state governments,
primary and secondary school authorities, community and religious leaders in high-
burden states have been involved in prevention and control measures of diphtheria.
However, IFRC (2023) confirms that about 1,585,080 people have been affected by the
diphtheria outbreak, while the crisis category is yellow, and has been classified as an
epidemic. CDC (2023) has placed Nigeria at level 2 (practice enhanced precautions),
according to the outbreak, and recommends vaccination as essential to protect against
diphtheria, avoid contact with people with symptoms, avoid touching wounds of others,
practice hygiene-hand washing, covering nose and mouth when you cough or sneeze, and
seek medical care when feeling sick.
Recommendations
A health promotion framework for the diphtheria intervention (Figure 10) must include the
following:
• Health educators who have direct communication with families, households, and
communities, especially in rural areas, and who have a hard time reaching
communities to educate on:
• Diphtheria epidemiology (in simple language for understanding)
• Benefits and costs of vaccination
• Complications of zero vaccination
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• Service improvements in number of public health immunization officers in the rural
areas
• Case management of diphtheria patients and their families
• Minimising obstacles to vaccine uptake, distribution, and costs.
• Advocacy: Enhancing community engagement and empowerment based on
mutual trusting relationships between the community and stakeholders.
Figure 10: Community Engagement and Health promotion framework for Diphtheria
Intervention
Source: Authors, 2024
Community engagement is key and a glue to achieving health promotion and meaningful
health outcomes when it comes to diphtheria vaccination. Community engagement and
mobilisation tailored to the actual needs of the targeted population can be very successful
when there are community educators, parent-to-child education, and cultural aspects of
the community are taken into account. The community and stakeholders should develop
structures and tools to promote community empowerment and health improvement,
community organising, community participation, capacity, and coalition building.
Conclusions
The public health response and community engagement efforts to address the diphtheria
outbreak are laudable. More needs to be done in the areas of bridging immunisation gaps,
education (especially maternal education) and providing basic infrastructure to reduce
transmission of diphtheria. Educating mothers and allowing them to grasp the importance
of vaccination and getting their children immunised on time is essential to reducing
infections. For hard-to-reach communities, the use of donkeys, motorcycles, bicycles, and
Health
Educator
Service
Improvements
Advocacy
Health
Promotion
Community
Engagement
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other rudimentary forms of transportation is critical to get vaccines and information out
and reduce the fatality rate in cases. Consistency in data collection and good quality
(quantitative) data provides a basis for timely intervention and future response to the
treatment of diphtheria. Community mobilisation efforts and sensitisation of men, men in
the home, community leaders, and faith-based leaders should be intensified to break the
myths of vaccination and improve social behaviour change. Curtailing crowding, reducing
multidimensional poverty and social inequalities, and enhancing hygiene practices (WASH)
are practical measures to reduce spread, infection, and death arising from the diphtheria
outbreak.
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