National and subnational governance and decision-making processes during the COVID-19 pandemic in Nigeria: an empirical analysis.

Governance of the COVID-19 pandemic required decision-makers to make and implement decisions amidst uncertainty, public pressure and time constraints. However, few studies have attempted to assess these decision-making processes empirically during health emergencies. Thus, we aimed to understand governance, defined as the process of decision-making and implementation of decisions, during the COVID-19 pandemic in Nigeria. We conducted key informant interviews and focus group discussions with national and subnational government officials, civil society organisation (CSO) members, development partners and academic experts. Our study identified several themes on governance and decision-making processes. First, Nigeria established high-level decision-making structures at the federal and state levels, providing clear and integrated multisectoral decision-making mechanism. However, due to the emergence of conflicts between government levels, there is a need to strengthen intergovernmental arrangements. Second, while decision-makers relied on input from academic experts and CSOs, additional efforts are required to engage such stakeholders in decision-making processes, especially during the early stages of health emergencies. Third, Nigeria's previous experiences responding to disease outbreaks aided the overall response, as many capacities and coordination mechanisms for cohesive action were present. Fourth, while decision-makers took a holistic view of scientific, social and economic factors for decision-making, this process was also adaptive to account for rapidly evolving information. Lastly, more efforts are needed to ensure decisions are inclusive, equitable and transparent, and improve overall public trust in governance processes. This study provides insights and identifies opportunities to enhance governance and decision-making processes in health emergency responses, aiding future pandemic preparedness efforts.

Pathogens that Cause Illness Clinically Indistinguishable from Lassa Fever, Nigeria, 2018.

During the 2018 Lassa fever outbreak in Nigeria, samples from patients with suspected Lassa fever but negative Lassa virus PCR results were processed through custom gene expression array cards and metagenomic sequencing. Results demonstrated no single etiology, but bacterial and viral pathogens (including mixed co-infections) were detected.

Analysis of sociodemographic and clinical factors associated with Lassa fever disease and mortality in Nigeria.

Over past decades, there has been increasing geographical spread of Lassa fever (LF) cases across Nigeria and other countries in West Africa. This increase has been associated with significant morbidity and mortality despite increasing focus on the disease by both local and international scientists. Many of these studies on LF have been limited to few specialised centres in the country. This study was done to identify sociodemographic and clinical predictors of LF disease and related deaths across Nigeria. We analysed retrospective surveillance data on suspected LF cases collected during January-June 2018 and 2019. Multivariable logistic regression analyses were used to identify the factors independently associated with laboratory-confirmed LF diagnosis, and with LF-related deaths. There were confirmed 815 of 1991 suspected LF cases with complete records during this period. Of these, 724/815 confirmed cases had known clinical outcomes, of whom 100 died. LF confirmation was associated with presentation of gastrointestinal tract (aOR 3.47, 95% CI: 2.79-4.32), ear, nose and throat (aOR 2.73, 95% CI: 1.80-4.15), general systemic (aOR 2.12, 95% CI: 1.65-2.70) and chest/respiratory (aOR 1.71, 95% CI: 1.28-2.29) symptoms. Other factors were being male (aOR 1.32, 95% CI: 1.06-1.63), doing business/trading (aOR 2.16, 95% CI: 1.47-3.16) and farming (aOR 1.73, 95% CI: 1.12-2.68). Factors associated with LF mortality were a one-year increase in age (aOR 1.03, 95% CI: 1.01-1.04), bleeding (aOR 2.07, 95% CI: 1.07-4.00), and central nervous manifestations (aOR 5.02, 95% CI: 3.12-10.16). Diverse factors were associated with both LF disease and related death. A closer look at patterns of clinical variables would be helpful to support early detection and management of cases. The findings would also be useful for planning preparedness and response interventions against LF in the country and region.

Evaluation of infection prevention and control practices in Lassa fever treatment centers in north-central Nigeria during an ongoing Lassa fever outbreak.

BACKGROUND: Outbreaks of Lassa fever (LF) in Nigeria have become more frequent, with increasing more healthcare worker infections. Prevention of infection is dependent on strict compliance to infection prevention and control (IPC) practices in treatment centres where patients are managed. OBJECTIVE: To evaluate IPC practices during an ongoing LF outbreak in the two major tertiary hospitals serving as the referral LF treatment centres in the north-central region of Nigeria. METHODS: This cross-sectional survey was carried out by the IPC subteam of the National Rapid Response Team of the Nigeria Centre for Disease Control (NCDC) deployed to Plateau State, north-central Nigeria during the 2019 LF outbreak. Information on IPC in these facilities was collected using the NCDC viral haemorrhagic fevers (VHFs) isolation and treatment facility IPC survey tool. RESULTS: Both treatment centres had national VHF IPC isolation guidelines and few health workers had received IPC training. In both centres, there were no clearly demarcated entry points for staff going into clinical areas after putting on personal protective equipment, and there were also no standard operating procedures in place for reporting occupational exposure of staff to infected blood or body fluids in both centres. DISCUSSION: The LF treatment centers located in Plateau State during the 2019 LF outbreak were not fully implementing the national VHF IPC guidelines. Periodic assessments of IPC are recommended for proper management of cases and effective control of LF in the State.

The One Health approach to incident management of the 2019 Lassa fever outbreak response in Nigeria.

Globally, effective emergency response to disease outbreaks is usually affected by weak coordination. However, coordination using an incident management system (IMS) in line with a One Health approach involving human, environment, and animal health with collaborations between government and non-governmental agencies result in improved response outcome for zoonotic diseases such as Lassa fever (LF). We provide an overview of the 2019 LF outbreak response in Nigeria using the IMS and One Health approach. The response was coordinated via ten Emergency Operation Centre (EOC) response pillars. Cardinal response activities included activation of EOC, development of an incident action plan, deployment of One Health rapid response teams to support affected states, mid-outbreak review and after-action review meetings. Between 1st January and 29th December 2019, of the 5057 people tested for LF, 833 were confirmed positive from 23 States, across 86 Local Government Areas. Of the 833 confirmed cases, 650 (78%) were from hotspot States of Edo (36%), Ondo (26%) and Ebonyi (16%). Those in the age-group 21-40 years (47%) were mostly affected, with a male to female ratio of 1:1. Twenty healthcare workers were affected. Two LF naïve states Kebbi and Zamfara, reported confirmed cases for the first time during this period. The outbreak peaked earlier in the year compared to previous years, and the emergency phase of the outbreak was declared over by epidemiological week 17 based on low national threshold composite indicators over a period of six consecutive weeks. Multisectoral and multidisciplinary strategic One Health EOC coordination at all levels facilitated the swift containment of Nigeria's large LF outbreak in 2019. It is therefore imperative to embrace One Health approach embedded within the EOC to holistically address the increasing LF incidence in Nigeria.

Factors associated with delayed presentation to healthcare facilities for Lassa fever cases, Nigeria 2019: a retrospective cohort study.

BACKGROUND: Large outbreaks of Lassa fever (LF) occur annually in Nigeria. The case fatality rate among hospitalised cases is ~ 20%. The antiviral drug ribavirin along with supportive care and rehydration are the recommended treatments but must be administered early (within 6 days of symptom onset) for optimal results. We aimed to identify factors associated with late presentation of LF cases to a healthcare facility to inform interventions. METHODS: We undertook a retrospective cohort study of all laboratory confirmed LF cases reported in Nigeria from December 2018 to April 2019. We performed descriptive epidemiology and a univariate Cox proportional-hazards regression analysis to investigate the effect of clinical (symptom severity), epidemiological (age, sex, education, occupation, residential State) and exposure (travel, attendance at funeral, exposure to rodents or confirmed case) factors on time to presentation. RESULTS: Of 389 cases, median presentation time was 6 days (IQR 4-10 days), with 53% attending within 6 days. There were no differences in presentation times by sex but differences were noted by age-group; 60+ year-olds had the longest delays while 13-17 year-olds had the shortest. By sex and age, there were differences seen among the younger ages, with 0-4-year-old females presenting earlier than males (4 days and 73% vs. 10 days and 30%). For 5-12 and 13-17 year-olds, males presented sooner than females (males: 5 days, 65% and 3 days, 85% vs. females: 6 days, 50% and 5 days, 61%, respectively). Presentation times differed across occupations 4.5-9 days and 20-60%, transporters (people who drive informal public transport vehicles) had the longest delays. Other data were limited (41-95% missing). However, the Cox regression showed no factors were statistically associated with longer presentation time. CONCLUSIONS: Whilst we observed important differences in presentation delays across factors, our sample size was insufficient to show any statistically significant differences that might exist. However, almost half of cases presented after 6 days of onset, highlighting the need for more accurate and complete surveillance data to determine if there is a systemic or specific cause for delays, so to inform, monitor and evaluate public health strategies and improve outcomes.

Patient characteristics associated with COVID-19 positivity and fatality in Nigeria: retrospective cohort study.

OBJECTIVE: Despite the increasing disease burden, there is a dearth of context-specific evidence on the risk factors for COVID-19 positivity and subsequent death in Nigeria. Thus, the study objective was to identify context-specific factors associated with testing positive for COVID-19 and fatality in Nigeria. DESIGN: Retrospective cohort study. SETTING: COVID-19 surveillance and laboratory centres in 36 states and the Federal Capital Territory reporting data to the Nigeria Centre for Disease Control. PARTICIPANTS: Individuals who were investigated for SARS-CoV-2 using real-time PCR testing during the study period 27 February-8 June 2020. METHODS: COVID-19 positivity and subsequent mortality. Multivariable logistic regression analyses were performed to identify factors independently associated with both outcome variables, and findings are presented as adjusted ORs (aORs) and 95% CIs. RESULTS: A total of 36 496 patients were tested for COVID-19, with 10 517 confirmed cases. Of 3215 confirmed cases with available clinical outcomes, 295 died. Factors independently associated with COVID-19 positivity were older age (p value for trend<0.0001), male sex (aOR 1.11, 95% CI 1.04 to 1.18) and the following presenting symptoms: cough (aOR 1.23, 95% CI 1.13 to 1.32), fever (aOR 1.45, 95% CI 1.45 to 1.71), loss of smell (aOR 7.78, 95% CI 5.19 to 11.66) and loss of taste (aOR 2.50, 95% CI 1.60 to 3.90). An increased risk of mortality following COVID-19 was observed in those aged ≥51 years, patients in farming occupation (aOR 7.56, 95% CI 1.70 to 33.53) and those presenting with cough (aOR 2.06, 95% CI 1.41 to 3.01), breathing difficulties (aOR 5.68, 95% CI 3.77 to 8.58) and vomiting (aOR 2.54, 95% CI 1.33 to 4.84). CONCLUSION: The significant risk factors associated with COVID-19 positivity and subsequent mortality in the Nigerian population are similar to those reported in studies from other countries and should guide clinical decisions for COVID-19 testing and specialist care referrals.

Research as a pillar of Lassa fever emergency response: lessons from Nigeria.

Emerging and re-emerging infectious diseases are becoming more frequent and developing countries are especially at increased risk. A recurring infectious disease outbreak in Nigeria has been that of Lassa fever (LF), a disease that is endemic in Nigeria and other West African countries. Nigeria, between 1st January and 27th October 2019, reported 743 confirmed cases of LF and 157 deaths in confirmed cases. Lassa fever outbreaks continue to be recurrent after fifty years of its identification. The true burden of the disease in Nigeria is unknown while gaps in knowledge about the infection still persist. Based on the Nigeria national Lassa fever research agenda and the World Health Organisation's roadmap initiative for accelerating research and product development which enables effective and timely emergency response to LF disease epidemics among other infectious diseases; a research pillar was added to the seven existing LF emergency operations centre response pillars in 2019. We describe lessons learnt from the integration of a research pillar into the LF national emergency response.

Measures to control protracted large Lassa fever outbreak in Nigeria, 1 January to 28 April 2019.

Lassa fever cases have increased in Nigeria since 2016 with the highest number, 633 cases, reported in 2018. From 1 January to 28 April 2019, 554 laboratory-confirmed cases including 124 deaths were reported in 21 states in Nigeria. A public health emergency was declared on 22 January by the Nigeria Centre for Disease Control. We describe the various outbreak responses that have been implemented, including establishment of emergency thresholds and guidelines for case management.

A cluster of nosocomial Lassa fever cases in a tertiary health facility in Nigeria: Description and lessons learned, 2018.

BACKGROUND: Lassa fever is an acute viral haemorrhagic disease endemic in Nigeria. The 2018 Lassa fever outbreak in Nigeria was unprecedented, with 8% of all cases occurring among healthcare workers (HCWs). A disproportionately high number of these infections occurred in HCWs working in a tertiary health facility in Nigeria. This paper describes the cluster of Lassa fever infections among HCWs in a treatment centre and the lessons learnt. METHODS: We analysed clinical, epidemiological and laboratory data from surveillance and laboratory records kept during the 2018 outbreak. Interviews were conducted with surviving HCWs using a questionnaire developed specifically for the investigation of Lassa fever infections in HCWs. Descriptive analysis of the data was performed in Microsoft excel. RESULTS: The index case was a 15-year-old male who presented at the health facility with fever and uncontrolled nasopharyngeal bleeding, following a recent uvulectomy by a traditional healer. Overall, 16 HCWs were affected (15 confirmed and 1 probable) with five deaths (CFR-31.6%). Of the 15 confirmed cases, five (33.3%) were asymptomatic. Nine HCWs were direct contacts of the index case; the remaining six HCWs had no direct contact with the index case. HCW interviews identified a low index of suspicion for Lassa fever leading to inadequate infection prevention and control (IPC) practices as possible contributing factors to nosocomial transmission. CONCLUSION: Maintaining a high index of suspicion for Lassa fever in all patients, especially in endemic areas, is essential in adhering to adequate IPC practices in health facilities in order to prevent nosocomial transmission of Lassa fever among HCWs. There is a need to continually train and sensitise HCWs on strict adherence to IPC measures while providing care, irrespective of a patient's provisional diagnosis.

Increase in Lassa Fever Cases in Nigeria, January-March 2018.

We reviewed data pertaining to the massive wave of Lassa fever cases that occurred in Nigeria in 2018. No new virus strains were detected, but in 2018, the outbreak response was intensified, additional diagnostic support was available, and surveillance sensitivity increased. These factors probably contributed to the high case count.