key: cord-0008170-3hiq72pc
authors: Aregbeshola, Bolaji S
title: Public health crisis and local health security in Nigeria
date: 2016-10-17
journal: Lancet Infect Dis
DOI: 10.1016/s1473-3099(16)30393-0
sha: 8d56d36d3e016dd9bf96296923e59232de5e122d
doc_id: 8170
cord_uid: 3hiq72pc

nan

On Aug 11, 2016, the Government of Nigeria notifi ed WHO of two new cases of the wild poliovirus. 1 These cases were identifi ed after Nigeria celebrated 2 years of successful interruption of the virus. According to the report, the two new cases were identifi ed in Borno State, the state at the heart of the Boko Haram insurgency. No doubt, the discoveries are a setback to global polio control eff orts.

Genetic sequencing of the cases has shown that the strain responsible for this outbreak is most likely the one that was last reported to be circulating in the state in 2011. Although lowlevel transmission of the virus is not unexpected, a missed persistent polio transmission in the region cannot be confi dently ruled out.

The Boko Haram insurgency has been a threat to the gains in polio control in Nigeria. 2 The discovery of these new polio cases comes after the Nigerian military has gained ground on the insurgency, thereby opening up previously unreachable regions. A third case has since been identified and there is fear that more might be discovered. 3 The reduction from half of all 53 cases identified in Nigeria found in Borno and Yobe States in 2013, to only one case in 2014, was suspected to be the outcome of a poor surveillance system. 2 These three cases might be a confirmation of that assertion. Further compounding the problem is that two-thirds of Borno State could not be covered for vaccination in 2015 because of insecurity. 4 With a change in the tactics by the insurgents to attacking soft targets (eg, markets, schools, and camps containing internally displaced people), the challenge to health workers who will play a major part in containing this outbreak in the communities comes to immediate attention. In 2013, nine polio vaccinators on active duty in Kano were gunned down by Boko Haram. 5 This could be another strategy that the insurgents use to attract attention to themselves.

Although we commend the effort of the Nigerian Government and its partners, we believe more needs to be done to contain this wild poliovirus outbreak. To this end, we state our position as the Epidemiological Society of Nigeria: security concerns need to be continuously addressed, polio immunisation campaigns need to be done and supported by the military, oral polio vaccine should be actively used for vaccination during immunisation campaigns, and a responsive community participatory approach and event-based surveillance should be enhanced.

We declare no competing interests. 

The world is constantly under threat of emerging and re-emerging diseases. The outbreak of Ebola virus disease in parts of west Africa has reinforced the need for strong public health leadership, organisation, and better preparedness to rise up to new health challenges. Having been accused of slow response in the face of Ebola crisis, 1 WHO moved quickly to declare Zika virus a public health emergency. Most African countries need to fortify their health security because they are affected by both disasters and diseases, which pose a major threat to the infrastrucure. 2 Although Nigeria was successful in its eff ort to control the spread of Ebola virus, the country is still facing numerous public health challenges and needs to strengthen local health security.

Since the Boko Haram insurgency, some 2·2 million people have been reportedly displaced in northeastern Nigeria 3 posing a major challenge to the system of local health security. According to WHO, more than half of health infrastructures in Borno State are not functioning. Additionally, three cases of wild polio were recently reported by government in Borno State. 4 Five cases of Lassa fever have also been reported within a short space of time in Bauchi, Gombe, Plateau, and River States. Therefore, there is a need for governments to protect people against these threats through strong public health infrastructures and health-care systems.

There have been outbreaks of diseases such as cholera, Lassa fever, yellow fever, and severe acute respiratory syndrome in the past among other diseases, 5 but many countries soon forget to learn lessons and thus, do not take appropriate actions to prevent public health crisis. Nigeria can only respond effectively to disaster and contain disease outbreaks if the health system is viable; 6 besides, functioning health-care systems are the bedrock of health security. 7 Nigerian government should not wait for the participation of international health leaders before preventing, detecting, and responding to health crises. It behoves of government to secure the health of the people and provide a safer future for them. 

Teresa Galán-Puchades, in her Correspondence on dogs and Guinea worm eradication, 1 noted several critical points about the Guinea Worm Eradication Program (GWEP) in Chad. We would like to clarify several of the issues. Dog infections have been addressed programmatically in Chad for the past 4 and a half years. The situation in Chad is diff erent from previous reports of sporadic Guinea worm infections in dogs. What is not made clear by Galán-Puchade is that human Guinea worm has infected dogs occasionally, but when eliminated from the human population, dog infections disappear. 2, 3 By contrast, in Chad, dog infections are probably responsible for the small number of cases in human beings. 4 We expect human infections in Chad to stop once transmission of Guinea worms among dogs is interrupted. Lastly, all evidence suggests transmission is not occurring via common drinking water sources, but via a paratenic aquatic host that people and dogs are eating raw or only partly cooked. 4 Previous laboratory studies have shown that dogs (and cats and monkeys) are good experimental hosts for Dracunculus medinensis. 5,6 Hence, the ease with which this infection was established in dogs is not surprising.

The reward paid to dog owners probably has a key role in dog infections being reported by owners, which is exactly what was hoped for. However, the increase in dog infection rates has resulted from active surveillance undertaken in larger and larger areas within Chad by the GWEP.

Residents of endemic villages have been interviewed to learn what is known about Guinea worm disease. Discussions have also been held with former offi cials of Chad's GWEP from 1993-98 to gain some insight and perspective on the matter. None of these reliable sources ever encountered a Guinea worm infection in a dog during years of working in endemic areas when hundreds of cases in human beings were being reported. 4 We recently showed that tadpoles were readily infected with D medinensis and harboured larvae that were infectious to ferrets. 7 Tadpoles have been shown to harbour those larvae into the adult frog stage, and that these larvae were infective in mammalian definitive hosts. 8, 9 We recently discovered the occurrence of a D medinensis larva in a wild-caught frog in Chad. 10 In Chad, most water bodies are too large to treat with chemical larvicide, so it is applied to cordoned areas suspected of being contaminated, thus preventing new infections in the following year.

D medinensis from dogs and human beings in Chad are genetically indistinguishable, hence interventions in place now and in the near future aim to interrupt transmission from both hosts.

We declare no competing interests. The fi ndings and conclusions in this Correspondence are our own and do not necessarily represent the offi cial position of the US Centers for Disease Control and Prevention.

Centers for Disease Control and Prevention, Atlanta, GA 30329, USA; and The Carter Center, Atlanta, GA, USA

Dogs and Guinea worm eradication

Dracunculus and dracunculiasis

Dracunculiasis (Guinea worm disease) and the eradication initiative

The peculiar epidemiology of dracunculiasis in Chad