NIGERIA FIELD EPIDEMIOLOGY AND LABORATORY TRAINING PROGRAMMENIGERIA FIELD EPIDEMIOLOGY AND LABORATORY TRAINING PROGRAMMENIGERIA FIELD EPIDEMIOLOGY AND LABORATORY TRAINING PROGRAMME
Dr. Kumshida Yakubu Balami1, Dr. Muawiyyah Babale Sufiyan2, Dr. Lawi Auta
Mshelia3, Dr. Collins Owili4, Dr. Sulaiman Saidu Bashir2, Dr. Muhammad Shakir
Balogun1, Prof. Kabir Sabitu2, Dr. Patrick Nguku1, Dr. Chikwe Ihekweazu5
1Nigeria Field Epidemiology And Laboratory Training Program
2Department of Community Medicine, Ahmadu Bello University, Zaria
3Borno State Ministry Of Health
4World Health Organisation, Borno State Office
5Nigeria Centre For Disease Control
Effect of Oral Cholera Vaccine on the
Geographical Spread of Cholera Epidemic in
Borno State, North-eastern Nigeria, 2017 - 2018
1
NIGERIA FIELD EPIDEMIOLOGY AND LABORATORY TRAINING PROGRAMMENIGERIA FIELD EPIDEMIOLOGY AND LABORATORY TRAINING PROGRAMMENIGERIA FIELD EPIDEMIOLOGY AND LABORATORY TRAINING PROGRAMME
Introduction (1/3)
• Oral Cholera Vaccine (OCV) plays an important role
– prevention and control measure in epidemics
• Cholera is an acute enteric infection
– caused by the bacterium Vibrio cholerae
– epidemics are associated with two serogroups 01 or 0139
• Transmission mainly faecal-oral route
– via ingestion of contaminated food or water 2
NIGERIA FIELD EPIDEMIOLOGY AND LABORATORY TRAINING PROGRAMMENIGERIA FIELD EPIDEMIOLOGY AND LABORATORY TRAINING PROGRAMMENIGERIA FIELD EPIDEMIOLOGY AND LABORATORY TRAINING PROGRAMME
Introduction (2/3)
• National Epidemiological bulletin, globally yearly1
– Cholera case-patients: 1.3 - 4.0 million
– Cholera deaths: 2,000 -143,000
– Africa - 55%
– Nigeria - 20.9%
– case fatality rates (CFR): 1.9% - 6.1%
• There has been a resurgence of cholera in Africa since in the
mid-1980s
– > 80% of the world‘s cases occurred in 19993
NIGERIA FIELD EPIDEMIOLOGY AND LABORATORY TRAINING PROGRAMMENIGERIA FIELD EPIDEMIOLOGY AND LABORATORY TRAINING PROGRAMMENIGERIA FIELD EPIDEMIOLOGY AND LABORATORY TRAINING PROGRAMME
Introduction (3/3)
• Cholera Epidemic is a global health problem
– internally displaced persons (IDPs)
– complex emergencies
• Insurgency in North-eastern Nigeria
– disrupted social services and displaced thousands
• IDPs camps are overcrowded
– with inadequate water, sanitation and hygiene (WASH)4
NIGERIA FIELD EPIDEMIOLOGY AND LABORATORY TRAINING PROGRAMMENIGERIA FIELD EPIDEMIOLOGY AND LABORATORY TRAINING PROGRAMMENIGERIA FIELD EPIDEMIOLOGY AND LABORATORY TRAINING PROGRAMME
Objectives
• Confirm
• Characterise
• Institute control measures
– first ever use of Oral Cholera Vaccine (OCV) in Nigeria
• Determine the effect of OCV on the geographical spread of
the cholera epidemic in Borno State 5
NIGERIA FIELD EPIDEMIOLOGY AND LABORATORY TRAINING PROGRAMMENIGERIA FIELD EPIDEMIOLOGY AND LABORATORY TRAINING PROGRAMMENIGERIA FIELD EPIDEMIOLOGY AND LABORATORY TRAINING PROGRAMME
Methods
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7
Map of Nigeria
Highlighting three (3)
North-eastern States
worst hit by Insurgency
NIGERIA FIELD EPIDEMIOLOGY AND LABORATORY TRAINING PROGRAMMENIGERIA FIELD EPIDEMIOLOGY AND LABORATORY TRAINING PROGRAMMENIGERIA FIELD EPIDEMIOLOGY AND LABORATORY TRAINING PROGRAMME
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Map of
Nigeria
Highlighting
Borno State
NIGERIA FIELD EPIDEMIOLOGY AND LABORATORY TRAINING PROGRAMMENIGERIA FIELD EPIDEMIOLOGY AND LABORATORY TRAINING PROGRAMMENIGERIA FIELD EPIDEMIOLOGY AND LABORATORY TRAINING PROGRAMME
Case Definition
• A suspected cholera case is any person ≥ 2years in Borno
State presenting with acute watery diarrhoea with or
without vomiting and severe dehydration or died as a
result, between 16th August, 2017 – 13th January 2019
9
NIGERIA FIELD EPIDEMIOLOGY AND LABORATORY TRAINING PROGRAMMENIGERIA FIELD EPIDEMIOLOGY AND LABORATORY TRAINING PROGRAMMENIGERIA FIELD EPIDEMIOLOGY AND LABORATORY TRAINING PROGRAMME
Results
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NIGERIA FIELD EPIDEMIOLOGY AND LABORATORY TRAINING PROGRAMMENIGERIA FIELD EPIDEMIOLOGY AND LABORATORY TRAINING PROGRAMMENIGERIA FIELD EPIDEMIOLOGY AND LABORATORY TRAINING PROGRAMME
First cholera epidemic,16th Aug., - 21st Dec., 2017
11
OCV 1OCV 2
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Second cholera epidemic13th Feb., - 16th July 2018
12
0
5
10
15
20
25
30
35
4015
/03
/18
17
/03
/18
19
/03
/18
21
/01
/18
22
/03
/18
23
/4/2
018
24
/4/2
018
26
/02
/18
26
/04
/18
27
/03
/18
28
/03
/18
1/2
/20
18
1/1
8/2
018
1/2
2/2
018
1/2
4/2
018
1/2
6/2
018
1/2
8/2
018
1/3
0/2
018
2/1
/20
18
2/3
/20
18
2/5
/20
18
2/7
/20
18
2/9
/20
18
2/1
1/2
018
2/1
3/2
018
2/1
5/2
018
2/1
7/2
018
2/1
9/2
018
2/2
1/2
018
2/2
3/2
018
2/2
5/2
018
2/2
8/2
018
3/2
/20
18
3/4
/20
18
3/6
/20
18
3/8
/20
18
3/1
0/2
018
3/1
2/2
018
3/1
4/2
018
3/3
0/2
018
4/5
/20
18
4/8
/20
18
4/1
0/2
018
4/1
2/2
018
4/1
5/2
018
4/1
9/2
018
4/2
2/2
018
4/2
4/2
018
4/2
7/2
018
4/2
9/2
018
5/1
/20
18
5/3
/20
18
5/5
/20
18
5/7
/20
18
5/9
/20
18
5/1
1/2
018
5/1
4/2
018
5/1
6/2
018
5/1
8/2
018
5/2
0/2
018
5/2
2/2
018
5/2
4/2
018
5/2
7/2
018
5/3
1/2
018
6/2
/20
18
6/6
/20
18
6/1
4/2
018
6/1
6/2
018
6/1
8/2
018
6/2
0/2
018
6/2
2/2
018
6/2
4/2
018
6/2
6/2
018
6/2
8/2
018
6/3
0/2
018
9/5
/20
18
Nu
mb
er
of
Cases
NIGERIA FIELD EPIDEMIOLOGY AND LABORATORY TRAINING PROGRAMMENIGERIA FIELD EPIDEMIOLOGY AND LABORATORY TRAINING PROGRAMMENIGERIA FIELD EPIDEMIOLOGY AND LABORATORY TRAINING PROGRAMME
Third cholera epidemic 5th Sept., 2018 - 13th Jan., 2019
13
0
20
40
60
80
100
120
140
160
180
200
17
-9-1
81
22
/09
/201
8
23
/09
/202
7
24
/8/2
018
26
/8/2
018
28
/8/2
018
3/1
O/2
018
7/3
0/2
018
8/2
/20
18
8/5
/20
18
8/7
/20
18
8/9
/20
18
8/1
1/2
018
8/1
3/2
018
8/1
5/2
018
8/1
7/2
018
8/1
9/2
018
8/2
1/2
018
8/2
3/2
018
8/2
5/2
018
8/2
7/2
018
8/2
9/2
018
8/3
1/2
018
9/2
/20
18
9/4
/20
18
9/6
/20
18
9/8
/20
18
9/1
0/2
018
9/1
2/2
018
9/1
4/2
018
9/1
6/2
018
9/1
8/2
018
9/2
0/2
018
9/2
2/2
018
9/2
4/2
018
9/2
6/2
018
9/2
8/2
018
9/3
0/2
018
10
/2/2
018
10
/4/2
018
10
/6/2
018
10
/8/2
018
10
/10
/201
8
10
/12
/201
8
10
/14
/201
8
10
/16
/201
8
10
/18
/201
8
10
/20
/201
8
10
/22
/201
8
10
/24
/201
8
10
/26
/201
8
10
/28
/201
8
10
/30
/201
8
11
/1/2
018
11
/3/2
018
11
/5/2
018
11
/7/2
018
11
/9/2
018
11
/11
/201
8
11
/13
/201
8
11
/15
/201
8
11
/17
/201
8
11
/19
/201
8
11
/21
/201
8
11
/23
/201
8
11
/25
/201
8
11
/27
/201
8
11
/29
/201
8
12
/1/2
018
12
/3/2
018
(bla
nk)
Nu
mb
er
of
Ca
se
s
Date seen at the Health Facility
NIGERIA FIELD EPIDEMIOLOGY AND LABORATORY TRAINING PROGRAMMENIGERIA FIELD EPIDEMIOLOGY AND LABORATORY TRAINING PROGRAMMENIGERIA FIELD EPIDEMIOLOGY AND LABORATORY TRAINING PROGRAMME
OCV Status of third epidemic case-patients
14
OCV Status Number of Cases Percentage
No 6214 99.7%
YES 16 0.3%
YES 1 DOSE 6 38%
YES 2 DOSE 10 63%
Grand Total 6230 100%
NIGERIA FIELD EPIDEMIOLOGY AND LABORATORY TRAINING PROGRAMMENIGERIA FIELD EPIDEMIOLOGY AND LABORATORY TRAINING PROGRAMMENIGERIA FIELD EPIDEMIOLOGY AND LABORATORY TRAINING PROGRAMME
15
Distribution of cholera cases
during the first epidemic
August - December 2017
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Public Health Action
15
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Oral Cholera Vaccination
• The first ever use of Oral Cholera Vaccine (OCV) in Nigeria
• Shanchol Cholera Vaccine was licenced for use
• Using the Polio vaccination structure
– we conducted an OCV campaign in two phases
▪ targeting all people >1yr of age
▪ affected communities
▪ IDP camps 17
NIGERIA FIELD EPIDEMIOLOGY AND LABORATORY TRAINING PROGRAMMENIGERIA FIELD EPIDEMIOLOGY AND LABORATORY TRAINING PROGRAMMENIGERIA FIELD EPIDEMIOLOGY AND LABORATORY TRAINING PROGRAMME
• Vaccination coverage of at least 95%
• sensitize 100% of the population in the affected areas
• Intensify active surveillance for cholera
18
Objectives of OCV campaign
NIGERIA FIELD EPIDEMIOLOGY AND LABORATORY TRAINING PROGRAMMENIGERIA FIELD EPIDEMIOLOGY AND LABORATORY TRAINING PROGRAMMENIGERIA FIELD EPIDEMIOLOGY AND LABORATORY TRAINING PROGRAMME
OCV Campaign Operations - Strategy
• Door-to-door delivery
– Polio Immunization Structure was engaged
– Vaccinated every person >1yr old with one dose of OCV
– Issued a vaccination card - OCV2 only
– Provided key messages on cholera
• Use of permanent facilities
• Outreach services 19
NIGERIA FIELD EPIDEMIOLOGY AND LABORATORY TRAINING PROGRAMMENIGERIA FIELD EPIDEMIOLOGY AND LABORATORY TRAINING PROGRAMMENIGERIA FIELD EPIDEMIOLOGY AND LABORATORY TRAINING PROGRAMME
OCV Outcome
First Dose (Phase)
• OCV doses
– 914,565
• Total Target Population
– 855,492
• Total Number vaccinated
– 896,919
• Coverage rate
– 105%
Second Dose (Phase)
• OCV doses
– 914,565
• Total Target Population
– 896,919
• Total Number vaccinated
– 891,137
• Coverage rate
– 99%
20• Wastage rate - 0.4% No Adverse Event Following Immunisation was reported
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21
Map of Borno
State highlighting
Two-dose OCV
campaign in
selected LGAs
and Wards
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Geographical spread of second epidemic in relation to two-dose OCV areas
Distribution of cholera cases during the
second epidemic February - July 2018
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23
Geographical spread of third cholera epidemic in relation to OCV areas
Distribution of cholera cases during the third
epidemic 23rd August 2018 - 13th January 2019
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Successes during OCV Implementation
• High demand for the vaccine
• Full participation of the State Polio EOC
– Planning and monitoring
• Daily
– evening review meeting
– call in data
– revisit Plans
– In-process monitoring and household coverage survey
• Post implementation evaluation (coverage survey) 24
NIGERIA FIELD EPIDEMIOLOGY AND LABORATORY TRAINING PROGRAMMENIGERIA FIELD EPIDEMIOLOGY AND LABORATORY TRAINING PROGRAMMENIGERIA FIELD EPIDEMIOLOGY AND LABORATORY TRAINING PROGRAMME
Conclusion
• High reactive OCV coverage
• With a two-dose OCV we controlled the protracted cholera
epidemic
• Second epidemic in an entirely different geographical location
• Most of the cases in the third epidemic were in wards not
previously vaccinated with OCV 25
NIGERIA FIELD EPIDEMIOLOGY AND LABORATORY TRAINING PROGRAMMENIGERIA FIELD EPIDEMIOLOGY AND LABORATORY TRAINING PROGRAMMENIGERIA FIELD EPIDEMIOLOGY AND LABORATORY TRAINING PROGRAMME
Limitations• Inadequate vaccine cold chain storage system
• Insurgency
– Incomplete and late daily call - in data due to network challenges
– Non – commencement of implementation at the time
– External supervisors unable to access some LGAs
• Broken down Incinerators
• Non use of vaccination cards during the first dose (Phase 1) 25
NIGERIA FIELD EPIDEMIOLOGY AND LABORATORY TRAINING PROGRAMMENIGERIA FIELD EPIDEMIOLOGY AND LABORATORY TRAINING PROGRAMMENIGERIA FIELD EPIDEMIOLOGY AND LABORATORY TRAINING PROGRAMME
Recommendations• Borno State Ministry of Health and Partners
– Intensify health promotion and education
– Provide adequate clean water supply
– Provide more cold chain capacity and additional vaccine carrier per team
– Undertake exhaustive repairs of all the broken down incinerators
• Federal Ministry of Health/NPHCDA
– Support Borno State to achieve above recommendations
– Plan for a preventive OCV Campaign
• NFELTP/NCDC
– A timely designed study to determine the vaccine efficacy, effect of OCV on
cholera rapid diagnostic test 26
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Acknowledgements
33
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34
Thank
you for
your
Attention
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