HPV vaccine integration, diphtheria battle, other major health sector events

As we bid farewell to 2023, the healthcare journey has been one of highs and lows. From unexpected outbreaks like diphtheria to the impact of already existing brain drain in the sector, the year was peppered with moments that tested Nigeria’s health systems.

In 2023, the battle against diseases like cholera, and Lassa fever continued, emphasising the ongoing challenges faced by certain regions in Africa’s most populous nation. Yet, amidst these struggles, the launch of operational guidelines for the National Health Insurance Authority (NHIA) Act brings hope for positive change, pointing towards a more inclusive healthcare system.

In this report, PREMIUM TIMES analyses a year in healthcare – acknowledging the difficulties faced, highlighting successes achieved, and pointing out the path ahead for a healthier future.

Diphtheria outbreak

The resurgence of diphtheria in 2023 emerged as an unexpected and formidable foe, challenging health systems across the country.

Diphtheria is a serious bacterial infection caused by the Corynebacterium species that affects the nose, throat, and sometimes, an individual’s skin.

The Nigeria Centre for Disease Control and Prevention (NCDC) noted that people most at risk of contracting diphtheria are children and adults who have not received any or a single dose of the pentavalent vaccine, people who live in a crowded environment, in areas with poor sanitation and healthcare workers who are exposed to suspected or confirmed cases of diphtheria.

More than 500 people, mostly children, have died of diphtheria in Nigeria since the current outbreak began in 2022.

Data published by the NCDC spanning Epi-Week 19 2022 to Epi-Week 48 2023 indicates that 20,684 suspected cases have so far been reported from 33 states across 280 LGAs.

Kano State, the epicentre of the disease with 13,461, followed by Yobe with 2,234, Katsina 1,509, Bauchi 1,139, Borno 968, Kaduna 486 and Jigawa 256 accounted for 96.9 of suspected cases reported.

Of the 20,684 suspected cases, 12,086 (58.4 per cent) were confirmed cases distributed across 148 LGAs in 20 states.

The data shows that 8,393 (69.4 per cent) of the confirmed cases were among children aged 1 – 14 years.

Health experts say the resurgence of the bacterial infection is mainly due to low immunisation among children, who are considered most vulnerable to the disease.

Alarmingly, only 3,202 (26.5 per cent) out of the 12086 confirmed cases were fully vaccinated with a diphtheria toxoid-containing vaccine.

Introduction of HPV vaccine

A significant breakthrough in the health sector in 2023 is the integration of the Human Papillomavirus (HPV) vaccine into the routine immunisation system.

This strategic move is a proactive measure aimed at safeguarding teenage girls against cervical cancer, a prevalent form of cancer that develops in a woman’s cervix and ranks as the fourth most common cancer cases among women globally.

The Nigerian government said it aims to reach 7.7 million girls with the life-saving vaccine, the largest number in a single round of HPV vaccination in Africa.

The inclusion of the HPV vaccine is a significant victory for Nigeria, where cervical cancer stands as the third most prevalent cancer and the second leading cause of cancer-related deaths among women aged 15 to 44. In the latest available data from 2020, the country reported 12,000 new cases and 8,000 deaths attributed to cervical cancer.

While the exact causes of cancer remain unknown, research has identified 14 out of 100 HPV strains as responsible for at least 99 per cent of cervical cancer cases.

Notably, the WHO highlights that HPV types 16 and 18 contribute to at least 70 per cent of cervical cancers and pre-cancerous cervical lesions. Additionally, there is evidence linking HPV to cancers of the anus, vulva, vagina, penis, and oropharynx.

But with the existence of vaccines, WHO estimates that cervical cancer could be the first cancer to be eliminated if 90 per cent of girls are vaccinated against HPV.

Doctors’ strike

The recurring issue of healthcare professionals’ strikes persisted in Nigeria throughout 2023. Various unions within the sector expressed their discontent, highlighting systemic challenges afflicting the healthcare system.

For instance, doctors under the umbrella of the Nigerian Association of Resident Doctors (NARD) embarked on strike at various periods in 2023. The doctors demanded among other issues, the immediate payment of the 2023 Medical Residency Training Fund (MRTF), tangible steps on the “upward review” of the Consolidated Medical Salary Structure (CONMESS), and payment of all salary arrears owed its members since 2015.

The doctors also want massive recruitment of clinical staff in the hospitals and abolishment of the bureaucratic limitations to the immediate replacement of doctors and nurses who leave the system. They also want the immediate review of hazard allowance by all the state governments as well as private tertiary health institutions where any form of residency training is done.

The impact of these strikes was particularly pronounced as resident doctors constitute a significant portion of medical personnel in Nigeria’s tertiary hospitals. Consequently, the healthcare delivery system faced substantial disruptions during their periods of industrial action.

During one of their strikes, the federal government had threatened to enforce the “no work, no pay” policy against the striking resident doctors, who remained adamant on their decision.

Recently, the Nigerian Medical Association (NMA) also threatened to withdraw their services across health institutions in the country should the federal government fail to implement the upward review of CONMESS.

In the upcoming year, governments at all levels must prioritise the demands of health workers and create conducive working environments to maximise their contributions and prevent more industrial actions.

Mental health bill

The enactment of the Mental Health Bill 2021 stands as a momentous milestone in the health sector for the year 2023.

Former President Muhammadu Buhari officially signed the bill into law, marking a significant achievement after two previous unsuccessful attempts in 2003 and 2013.

The bill, harmonised by both the upper and lower chambers of the National Assembly in 2021, represents the inaugural legislative reform in the mental health field since the nation gained independence. Notably, it will supersede the outdated Lunacy Act of 1958.

As mental health takes centre stage in global conversations, this legislative stride positions Nigeria at the forefront of proactive mental health policies.

The enactment of the Mental Health Bill 2021 not only addresses the gaps in the existing legal framework but also sets the stage for enhanced mental health services, destigmatisation, and a more inclusive and supportive approach to mental well-being for all citizens.

New leadership

In 2023, a change in leadership marked a significant development in Nigeria’s health sector. On 21 August, Muhammad Pate, a professor of Internal Medicine and Infectious Diseases, assumed the role of Coordinating Minister of Health and Social Welfare. Assisting him in this crucial position is Tunji Alausa, who takes on the role of Minister of State for Health and Social Welfare.

They succeeded Osagie Ehanire, who served as the minister from 2019 to 2023, and Olorunnimbe Mamora, the former Minister of State for Health.

Mr Pate, with his extensive background, has a unique opportunity to make a substantial impact on the nation’s healthcare system for the second time.

The professor stepped into his position with a second opportunity to significantly impact the nation’s healthcare system. When he served earlier as Nigeria’s minister of state for health, he made a notable impression during his brief tenure.

He initiated a global coalition aimed at bolstering healthcare systems, even as he saw to the implementation of innovative programmes dedicated to addressing pressing concerns, notably the prevention of mother-to-child transmission of HIV.

Additionally, Mr Pate spearheaded a flagship initiative to rejuvenate routine vaccinations and primary healthcare. He also chaired a presidential task force focused on eradicating polio while introducing new vaccines into the nation’s healthcare regimen.

The optimism surrounding the new leadership stems from the wealth of experience that Mr Pate brings to the position. Expectations are high that his strategic approach and past experience will contribute to reshaping and revitalising Nigeria’s health sector, addressing critical issues and ensuring a positive trajectory for the nation’s healthcare.

Launch of operational guidelines for the NHIA Act

The unveiling of the operational guidelines for the 2022 National Health Insurance Authority (NHIA) stands out as a significant milestone that resonated throughout the health sector in 2023.

This initiative is a crucial component of the government’s commitment to ensuring that all Nigerians have access to cost-effective healthcare services. At the launch, the Coordinating Minister of Health and Social Welfare, Mr Pate, emphasised the crucial role of providing affordable and high-quality healthcare to all Nigerians in the pursuit of Universal Health Coverage (UHC).

He noted that the NHIA Act of 2022 has put these guidelines into operation, offering a clear direction. This operationalisation aims to facilitate a collective effort by the government to enhance the affordability of healthcare for everyone, with a particular focus on the poorest and most vulnerable members of the Nigerian population.

He said the operational guidelines were developed through extensive engagement with diverse stakeholders, ensuring a comprehensive and inclusive approach to shaping the future of healthcare accessibility in the country.

Brain drain

The ongoing trend of healthcare professionals, including medical doctors, nurses, and other personnel, migrating to developed nations represents a significant and disheartening development in the health sector for the year 2023. Numerous statistics highlight the mass exodus of Nigerian doctors in pursuit of better opportunities abroad.

This mass departure has resulted in a significant void in Nigeria’s healthcare system, leaving few healthcare workers to address the needs of the country’s population exceeding 200 million.

While the reasons behind this migration are multifaceted, including the pursuit of better remuneration, improved working conditions, and professional development opportunities, the collective impact on the nation’s health system is undeniably severe.

For the new year 2024, health experts said it is important to recognise the intrinsic value of healthcare professionals and to create an environment that fosters their growth, job satisfaction, and dedication to serving the population.

Dengue fever outbreak

The unexpected emergence of Dengue fever towards the close of 2023 posed a significant challenge to the health sector.

As of 16 December, the NCDC reported 13 confirmed cases of Dengue fever in three LGAs in Sokoto State. The World Health Organisation (WHO) linked the surge in Dengue fever to global warming, characterised by elevated average temperatures, increased precipitation, and an extended period of drought.

Dengue fever is a viral infection caused by the Dengue virus (DENV) and is transmitted to humans through mosquito bites. Although human-to-human transmission has not been established, individuals infected for the second time face a higher risk of severe Dengue. The virus is prevalent in tropical and sub-tropical climates, particularly in urban and semi-urban areas worldwide.

While most people with Dengue experience mild or no symptoms and recover within one to two weeks, severe cases can be life-threatening. Symptoms may include high fever, intense headache, eye pain, muscle and joint pains, nausea, vomiting, swollen glands, and rashes.

Increased Lassa Fever cases

Lassa fever continues to pose a significant public health challenge in Nigeria, driven by factors such as inadequate environmental sanitation, low awareness, and delayed case presentations. The impact of this deadly disease persisted throughout 2023, maintaining its grip on the country.

As of 10 December, over 200 Nigerians had died from Lassa fever; a disease that is preventable with good hygiene and treatable if presented early at hospitals.

The latest epidemiological report published by NCDC for week 49 of 2023, spanning 4 to 10 December, indicated a rise in the number of suspected cases, reaching 8,707, compared to the same period in 2022, which recorded 7,907 cases.

The report revealed that from week 1 to week 49 of 2023, 206 deaths were reported with a case fatality rate (CFR) of 17.3 per cent, which is lower than the CFR for the same period in 2022 of 18.3 per cent.

The country also documented 1,191 confirmed cases of Lassa fever in 2023, surpassing the 1,028 cases reported within the equivalent timeframe in 2022.

According to the report for 2023, 28 states have recorded at least one confirmed case across 116 LGAs. While 76 per cent of all confirmed Lassa fever cases were reported from three states namely; Ondo, Edo, and Bauchi, 23 per cent were reported from 25 states with confirmed Lassa fever cases.

Lassa fever is an acute viral haemorrhagic fever caused by the Lassa virus. The natural reservoir for the virus is the Mastomys natalensis rodent (commonly known as the multimammate rat or the African rat).

Other rodents can also be carriers of the virus. The virus spreads through direct contact with the urine, faeces, saliva, or blood of infected rats; contact with objects, household items, and surfaces contaminated with the urine, faeces, saliva, or blood of infected rats, and consuming food or water contaminated with the urine, faeces, saliva, or blood of infected rats. Person-to-person transmission can also occur through direct contact with blood, urine, faeces, vomitus, and other body fluids of an infected person.

Cholera persists

While there has been a decrease in cholera cases in 2023 compared to the previous year, the persistent presence of this acute diarrheal infection, caused by the ingestion of food or water contaminated with the bacterium Vibrio cholera, remains a concern in the country.

According to the NCDC epidemiological report for weeks 1-39, as of 1 October, a total of 3,276 suspected cases, including 102 deaths, have been reported from 27 states.

Comparatively, suspected cases of cholera in the current year decreased by 79 per cent and cumulative deaths decreased by 77 per cent compared to what was reported at Epi-week 39 in 2022.

Notably, age groups below five years are predominantly affected followed by the 5-14 years age group, encompassing both males and females.

Zamfara State, reporting 907 cases, accounts for 28 per cent of all suspected cases among the 27 states that have reported cholera cases. Obubra Local Government Area (LGA) in Cross River State, with 515 cases, contributes to 16 per cent of all suspected cases reported nationwide.

Other states, including Cross River (718 cases), Bayelsa (341 cases), Katsina (302 cases), Ebonyi (227 cases), Niger (161 cases), and Abia (149 cases), collectively account for 58 per cent of the suspected cases recorded this year.