As at January 12, 2021, Nigeria has had over a hundred thousand confirmed cases of the novel 2019 coronavirus disease (COVID-19) infection. The pandemic has continued to challenge healthcare systems across states, forcing them to innovate as they learn, adapt and respond to the disease. Responding to various aspects of the pandemic is also helping to build the capacities of young public health practitioners, preparing them to handle bigger responsibilities in global health security.
Even though Lagos State currently has the greatest burden of infection with 36,875 laboratory confirmed cases, the low numbers recorded in certain states may not be a reflection of their response efforts. In Imo State, 801 COVID-19 cases have been confirmed, 39 are currently being managed while 746 have recovered and been discharged. The state has also recorded 16 COVID-19 related deaths.
As with other states, one of the challenges Imo State has faced in responding to the pandemic is a lack of funding. Funding plays a critical role in every pillar of the COVID-19 response. Imo State Epidemiologist, Hyacinth Egbuna, says it’s also important to extend funding to other infectious diseases monitored under the Integrated Disease Surveillance and Response (IDSR) system. “Outbreaks happen when we miss opportunities to detect diseases on time,” he said.
REDISSE — A proactive response
Global health security involves anticipating events of public health concern and designing interventions to prepare for them before they have a widespread impact on the public. The Prevent Epidemics Nigeria campaign for instance has engaged in public awareness and advocacy for sustained funding to improve epidemic preparedness in Nigeria since 2018. Proactively putting measures in place to forestall disease outbreaks is always better than waiting for them to happen before responding.
One intervention in place to respond to epidemics is the World Bank’s Regional Disease Surveillance Systems Enhancement (REDISSE) program, a finance instrument provided to the Federal Government of Nigeria and implemented by the Nigeria Centre for Disease Control (NCDC). The REDISSE Project finances regional level policy dialogue and activities that promote information exchange and efficient use of country and shared resources for disease surveillance and response. It targets countries in the ECOWAS sub-region and adopts a cross-sectoral — human and animal health — implementation model to help minimise the impact of disease outbreaks. It was designed as a response to the 2014 Ebola outbreak, which revealed the critical role of funding for epidemic preparedness. It launched in Nigeria on 27 April 2018, 20 months before the COVID-19 was first reported in Wuhan, China.
The project’s five components are surveillance and information systems, laboratory capacity, preparedness and emergency response, human resource management, and institution capacity building, project management, coordination and advocacy. The REDISSE project aims to strengthen national and regional cross-sector capacities for disease surveillance and also provide immediate and effective response in the case of eligible health emergencies.
When the pandemic reached Nigeria, the NCDC supported every state to develop their Incident Action Plan (IAP) and disbursed 100 million Naira to enable them implement it effectively, says Chimezie Anueyiagu, the Technical Assistant (TA) for the project in Imo State. “The NCDC deployed TAs to every state to provide guidance and build capacity of state officers to enable them implement their IAP,” he added. While there’s no definite time frame to the duration of the technical assistance, Anueyiagu said the focus is to ensure appropriate skills transfer that will build confidence in the state officers to take ownership and pilot the implementation of their IAP.
Setting up for success
Before deploying the TAs, a needs assessment helped to identify gaps that have the potential to derail the implementation of the IAP. Some of the responsibilities of Anueyiagu and other TAs include tracking the IAP implementation and ensuring proper coordination and alignment of state and national response. Overall, they helped ensure the approved activities in IAP are executed in line with the grant guidelines and agreement.
To avoid resistance from state officials, advocacy was a key component of the work done by the technical assistants. This helped ensure the state officers and other stakeholders involved in the response are clear on the mission of the TAs. Anueyiagu highlighted that meaningful engagement with all relevant stakeholders from the Governor, Commissioner for Health, to the Director of Public Health is critical as they have numerous competing interests.
All of this has helped the different components of the COVID-19 response in the state as pointed out by the Commissioner for Health, Dr Damaris Osunkwo. “The COVID-19 pandemic has provided us an opportunity to strengthen surveillance structures in our state,” she said, adding that the Surveillance Outbreak Response Management and Analysis System (SORMAS) introduced by NCDC helps them collect real time data about COVID-19 and other notifiable diseases for further action and escalation to appropriate higher authorities. Data officers at different levels have also been trained and equipped to help with data collection and transmission.
Dr Osunkwo said the quality training delivered by the Africa Centre for Disease Control (AfricaCDC) and the NCDC for health workers and other volunteers contributed to the success of contact tracing activities in the state.
On testing, which has been a major pain point in the national COVID-19 response, she said the state governor engaged the support of the United States Agency for International Development (USAID) and they responded by repurposing their GeneXpert mobile laboratory being used for tuberculosis testing in the state. This helped compliment the efforts of the first private molecular laboratory authorised to conduct COVID-19 testing in the state. They decentralised the collection centres across all the local governments and are able to collect a minimum of 10 samples from the 27 local government areas in the state daily.
Both laboratories are currently unable to handle the large samples collected in the community testing drives. The state now sends samples to the NCDC reference laboratory in Abuja and waits for days before they can receive results. Also, the private molecular laboratory also introduced fees for their services which is not sustainable for the state. This has become a challenge for the state’s response efforts, says Dr Osunkwo, and will be resolved if the state can be supported to build and equip their own laboratory.
She also said they faced a lot of resistance from citizens at the early stage of the response due to misconceptions about the infection. People refused to comply with officials tasked with taking them to isolation centres and they also provided misleading information to ensure they are not traced if their samples turn out to be positive for COVID-19. But with consistent risk communication, she said this narrative has changed and now, most citizens volunteer information on their own. The harsh impact of the pandemic lockdown which resulted in nearly all economic activities being halted also made it difficult for citizens to comply with some of the public health safety measures and this proved challenging for the response.
A silver lining
Despite the challenges faced by the response in the state, different pillars collaborated to ensure coordination of the response. “Outbreak investigation and control revolve around a framework. While we had a level of capacity and competence available to us, we faced the challenge of dealing with a novel virus that its literature was unfolding rather than being available for reference,” says Dr Austin Okeji, the Director of Public Health at the Imo State Ministry of Health. He said they were quick to leverage on the expertise and availability of the NCDC and other public health institutions like the World Health Organisation and the Africa CDC who readily shared information and offered technical support. “So we knew clearly who we could approach to access certain technical information and also give them feedback on the prevailing situation in our state and the challenges we were facing,” Dr Okeji said.
Dr Aniekeme Uwah, is a Volunteer Epidemiologist for Africa CDC supporting the state’s COVID-19 response for over six months. He supported the advocacy to set up a Public Health Emergency Operations Centre (PHEOC) to help in response coordination, shared insights with the state epidemiologist to prepare situation reports after data analysis, and worked with the 20 community health workers (CHWs) deployed by the centre. These CHWs helped with improving contact tracing, sensitisation and mobilisation for community testing. To improve testing capacity, he helped in strengthening the partnership between the state and the private laboratory supporting the response. He also joined the advocacy to the Federal Medical Centre Owerri to repurpose their GeneXpert machine for tuberculosis diagnosis for COVID-19 testing.
Dr Uwah says Imo State has “done well in risk communication and capacity development of state health officials” because outbreak response is a collaborative effort. He also added that using testing as an indicator, the state is doing better than most states.
Alluding to this, Dr Osunkwo said one of the main successes of responding to the outbreak is in capacity building. “We have been able to train a lot of our officials and can now respond to any outbreak based on the knowledge they have,” she said, adding that “It has helped us build infrastructure like hospitals, treatment centres and the emergency operations centre which is like an information hub from where we interact with the world and also come back to strategise.”
Furthermore, the state has been able to build more partnerships with the NCDC, WHO, USAID and the private sector. Insights from the community testing initiative which started as a response strategy to the pandemic will also be applied in combating future outbreaks, says Dr Osunkwo. “These are some of the blessings in disguise of the pandemic,” she said.
She believes epidemic preparedness before outbreaks happen is critical and it’s important to collaborate when it eventually happens because “two good heads are better than one.”
Stella Ozims, the Owerri North Local Government Social Mobilisation Officer and Health Educator, is one of those who received capacity building to improve on their work. Even though she had the role before the pandemic, the new insights received during the training prepared her to swing into action. With her team, they visited communities, met their traditional rulers and other stakeholders. Beyond their advocacy, they taught them safety measures to protect themselves using information, education and communication (IEC) materials and factsheets produced in English and Igbo language. She said enlightened community leaders made their work easy because they are able to encourage their subjects to comply.
Chidinma Okere is a trader in Obibiezena community, one of the places Ozims worked. She visited the community health centre on an immunisation day to sell and decided to have her sample collected for the COVID-19 test after she was informed about it. “I willingly agreed to do it because I’ve heard a lot about COVID-19 and you can’t say who has it or not,” Okere said. Even though she was a little concerned about the possible outcome of the testing, she went ahead to do it hoping it would turn out negative since she didn’t have any of the symptoms listed in the public health advisories.
Capacity beyond COVID-19
The coronavirus pandemic has affected everyone in different ways globally. Even as countries race to get the approved vaccines to the most vulnerable and the search for safe and effective drugs continue, prevention is always better. Prevention implies adequate preparation as Dr Osunkwo pointed out to minimise the negative impact when outbreaks happen.
Initiatives such as the REDISSE project will continue to be remembered for proactively investing in epidemic preparedness before the pandemic, by funding and strengthening cross-sector, national and regional surveillance structures. Through it, invaluable capacity has been developed and skills have been transferred to a new generation of public health and global health security practitioners.
After months of supporting their assigned states, technical assistants like Anueyiagu would have built skills in advocacy, interpersonal relations, operations, team management and skills transfer which are invaluable in transforming the Nigerian public health space for the better.
Every response to an infectious disease outbreak provides opportunities to learn. Dr Osunkwo said starting community testing earlier would have made a significant difference and taking more proactive measures to protect frontline health workers in both the private and public sector would have reduced infection among health workers. This could have been done by providing enough personal protective equipment, consistent risk communications, and infection prevention and control training. In addition, she believes involving communities early would have helped in the outbreak management and ensure compliance with public health guidelines.
Taking note of these opportunities for improvement and making efforts to address them in future responses is an effective way of making the most of the REDISSE project and other public health interventions as Imo, and the rest of the country, continue to respond to the COVID-19 outbreak.
Great to see the coordination and collaborative efforts of the various institutions.