Mpox and Chickenpox Coinfection: Case Series From Southern Nigeria.

BACKGROUND: We describe clinicoepidemiologic characteristics of mpox-chickenpox coinfection in Nigeria. METHODS: A retrospective cohort analysis was performed of confirmed mpox cases in Nigeria from January 2022 to March 2023. Mpox and chickenpox were confirmed by real-time polymerase chain reaction (RT-PCR). RESULTS: Of 94 (60.0%) suspected cases, 56 had confirmed mpox, of whom 16 (28.6%) had chickenpox coinfection. The median age of confirmed mpox cases was 29 years (interquartile range, 20-37 years), 24 were men (60.7%), 6 (10.7%) were bisexual, and 5 (8.9%) died. Mpox-chickenpox-coinfected patients had more complications than mpox-monoinfected cases (56.3% vs 22.5%, P = .015). CONCLUSIONS: The high frequency of mpox-chickenpox coinfection argues for accelerated access to mpox and chickenpox vaccines in Africa.

Atypical Mpox in a Nigerian Tertiary Health Facility.

BACKGROUND: We describe diverse clinical characteristics and course of confirmed mpox cases managed in a Nigerian tertiary health facility. METHODS: Clinical and epidemiologic data were analyzed, highlighting the unusual presentations of polymerase chain reaction (PCR)-confirmed mpox cases observed during the 2022 outbreak. RESULTS: Out of 17 suspected cases, 13 (76.4%) were PCR confirmed for mpox. The mean ± SD age for the participants was 28.62 ± 10.29 years (range, 2-55), of which 9 (64.3%) were male. Of the 13 PCR-confirmed cases, 5 (38.5%) had varicella zoster virus coinfection, 2 (15.4%) had HIV coinfection, and 1 (7.7%) had diabetes mellitus comorbidity. All patients experienced rash, with 6 (46.2%) having significant genital lesions and 1 (7.7%) having a severe perianal lesion. A lack of prodromal symptoms was reported in 3 (23.1%), and a prolonged prodrome (>1 week) occurred in 5 (38.5%). Skin lesions were polymorphic in 6 (46.2%), and solitary skin lesions occurred in 3 (23.1%), which persisted for >120 days in 7.7%. CONCLUSIONS: Clinical recognition, diagnosis, and prevention remain a concern in resource-limited settings. Our findings highlight the need to further evaluate unusual skin lesions and to include mpox screening for genital skin lesions that are presumed to be sexually transmitted infections. Revision of clinical case definition and enhanced surveillance are key to early recognition and prevention of spread.

Mpox Epidemiology and Risk Factors, Nigeria, 2022.

To investigate epidemiology of and risk factors for laboratory-confirmed mpox during the 2022 outbreak in Nigeria, we enrolled 265 persons with suspected mpox. A total of 163 (61.5%) were confirmed to have mpox; 137 (84.0%) were adults, 112 (68.7%) male, 143 (87.7%) urban/semi-urban dwellers, 12 (7.4%) self-reported gay men, and 3 (1.8%) female sex workers. Significant risk factors for adults were sexual and nonsexual contact with persons who had mpox, as well as risky sexual behavior. For children, risk factors were close contact with an mpox-positive person and prior animal exposure. Odds of being mpox positive were higher for adults with HIV and lower for those co-infected with varicella zoster virus (VZV). No children were HIV-seropositive; odds of being mpox positive were higher for children with VZV infection. Our findings indicate mpox affects primarily adults in Nigeria, partially driven by sexual activity; childhood cases were driven by close contact, animal exposure, and VZV co-infection.

Demographic characteristics, clinical presentation and in-hospital outcome among patients with Covid-19 in a Nigerian tertiary hospital.

Background: We described the demographic/clinical characteristics and in-hospital outcome of patients with COVID-19 at the University of Nigeria Teaching Hospital (UNTH) during the first wave to inform evidence-based responses during subsequent waves in Africa. Methodology: We conducted retrospective cohort analyses of adult patients ≥18 years with PCR or GeneXpert-confirmed SARS-CoV-2 infection. Data was extracted from patients' medical records from 1st May to 30th September 2020. Based on disease severity, patients were either hospitalized (82) or managed at home (90). Logistic regression and cox-proportional hazard models were used to determine predictors of severe COVID-19 disease and in-hospital mortality, respectively. Results: Of 172 cases, 113 (65.7%) were males, and the mean age was 45 ± 19 years. The majority were urban dwellers (72.1%), 19.8% had a positive history of contact with a confirmed/suspected case, 15.7% were healthcare workers while 68 (39.5%) had co-morbidities. Symptomatic patients comprised 73.3% of cases. Fever (p=0.02) and breathlessness (p=0.03) were commoner in males while diarrhoea (p<0.01) was predominant in females. On multivariate analysis, severe COVID-19 was predicted by the presence of co-morbidity (AOR= 14.44, 95% C.I= 4.79- 43.58, p <0.001)and prior antibiotic/antimalarial use (AOR= 6.35, 95% C.I= 2.24- 18.05, p =0.001) while being a non-healthcare worker (AOR= 0.18, 95% C.I= 0.04-0.78, p=0.02) was protective. However, none of the variables assessed predicted in-hospital mortality. Conclusion: Our findings underscore the contributions of demographic variables in COVID-19 transmission and gender differences in clinical presentation. Underlying comorbidity likewise prior antimicrobial use increased the likelihood of severe COVID-19. The absence of mortality predictors in our study may be related to the relatively small number of deaths. Further studies are recommended to unravel the predominance of severe disease in healthcare workers.

Clinical characteristics and predictors of human mpox outcome during the 2022 outbreak in Nigeria: a cohort study.

BACKGROUND: Research from sub-Saharan Africa that contributes to our understanding of the 2022 mpox (formerly known as monkeypox) global outbreak is insufficient. Here, we describe the clinical presentation and predictors of severe disease among patients with mpox diagnosed between Feb 1, 2022, and Jan 30, 2023 in Nigeria. METHODS: We did a cohort study among laboratory-confirmed and probable mpox cases seen in 22 mpox-treatment centres and outpatient clinics across Nigeria. All individuals with confirmed and probable mpox were eligible for inclusion. Exclusion criteria were individuals who could not be examined for clinical characterisation and those who had unknown mortality outcomes. Skin lesion swabs or crust samples were collected from each patient for mpox diagnosis by PCR. A structured questionnaire was used to document sociodemographic and clinical data, including HIV status, complications, and treatment outcomes from the time of diagnosis to discharge or death. Severe disease was defined as mpox associated with death or with a life-threatening complication. Two logistic regression models were used to identify clinical characteristics associated with severe disease and potential risk factors for severe disease. The primary outcome was the clinical characteristics of mpox and disease severity. FINDINGS: We enrolled 160 people with mpox from 22 states in Nigeria, including 134 (84%) adults, 114 (71%) males, 46 (29%) females, and 25 (16%) people with HIV. Of the 160 patients, distinct febrile prodrome (n=94, 59%), rash count greater than 250 (90, 56%), concomitant varicella zoster virus infection (n=48, 30%), and hospital admission (n=70, 48%) were observed. Nine (6%) of the 160 patients died, including seven (78%) deaths attributable to sepsis. The clinical features independently associated with severe disease were a rash count greater than 10 000 (adjusted odds ratio 26·1, 95% CI 5·2-135·0, p<0·0001) and confluent or semi-confluent rash (6·7, 95% CI 1·9-23·9). Independent risk factors for severe disease were concomitant varicella zoster virus infection (3·6, 95% CI 1·1-11·5) and advanced HIV disease (35·9, 95% CI 4·1-252·9). INTERPRETATION: During the 2022 global outbreak, mpox in Nigeria was more severe among those with advanced HIV disease and concomitant varicella zoster virus infection. Proactive screening, management of co-infections, the integration and strengthening of mpox and HIV surveillance, and preventive and treatment services should be prioritised in Nigeria and across Africa. FUNDING: None.

Humoral and cellular immune responses to Lassa fever virus in Lassa fever survivors and their exposed contacts in Southern Nigeria.

Elucidating the adaptive immune characteristics of natural protection to Lassa fever (LF) is vital in designing and selecting optimal vaccine candidates. With rejuvenated interest in LF and a call for accelerated research on the Lassa virus (LASV) vaccine, there is a need to define the correlates of natural protective immune responses to LF. Here, we describe cellular and antibody immune responses present in survivors of LF (N = 370) and their exposed contacts (N = 170) in a LASV endemic region in Nigeria. Interestingly, our data showed comparable T cell and binding antibody responses from both survivors and their contacts, while neutralizing antibody responses were primarily seen in the LF survivors and not their contacts. Neutralizing antibody responses were found to be cross-reactive against all five lineages of LASV with a strong bias to Lineage II, the prevalent strain in southern Nigeria. We demonstrated that both T cell and antibody responses were not detectable in peripheral blood after a decade in LF survivors. Notably LF survivors maintained high levels of detectable binding antibody response for six months while their contacts did not. Lastly, as potential vaccine targets, we identified the regions of the LASV Glycoprotein (GP) and Nucleoprotein (NP) that induced the broadest peptide-specific T cell responses. Taken together this data informs immunological readouts and potential benchmarks for clinical trials evaluating LASV vaccine candidates.

An Epidemiological Investigation of Lassa Fever Outbreak in Ebonyi State South Eastern Nigeria Lessons Learnt (January to March 2018).

Background: We investigated an outbreak of Lassa fever that occurred in Ebonyi state, Southeast Nigeria from January to March 2018. Methodology: The Emergency operational centre (EOC) model was used for the outbreak coordination. Cases and deaths were identified through the routine surveillance system. Blood specimens collected from suspected cases were sent for confirmation at the Virology Centre, Alex Ekwueme Federal University Teaching Hospital, Abakaliki (AEFUTHA). Active case search was instituted, and identified contacts of confirmed cases were followed up for the maximum incubation period of the disease. Other public health responses included infection prevention and control, communication and advocacy as well as case management. Data collected were analysed using the Epi info statistical software package. Results: We identified 89 suspected Lassa Fever (LF) cases out of which 61 were confirmed. The mean age was 35±16.2 and the age group mostly affected was 30-39 years. More than half (59.7%) of the confirmed cases were females. The Case Fatality Rate (CFR) was 26.2% among the laboratory confirmed cases. Five of the deaths occurred among health care workers. Out of 325 contacts of the confirmed cases, 304(99.7%) completed the follow-up and only 1(0.3%) of them developed symptoms consistent with LF and was confirmed by the laboratory. Conclusions: The high CFR in those presenting late to the hospital underscores the need for intensive public enlightenment that encourages early presentation to hospital. Majority of the confirmed cases were primary cases, hence efforts should be intensified in breaking the chain of transmission in the animal-man interphase. Death of healthcare workers involved in management of Lassa fever raises the importance of providing life insurance for concerned healthcare workers.

Early onset of neurological features differentiates two outbreaks of Lassa fever in Ebonyi state, Nigeria during 2017-2018.

Lassa fever (LF) is an acute viral haemorrhagic illness with various non-specific clinical manifestations. Neurological symptoms are rare at the early stage of the disease, but may be seen in late stages, in severely ill patients.The aim of this study was to describe the epidemiological evolution, socio-demographic profiles, clinical characteristics, and outcomes of patients seen during two Lassa fever outbreaks in Ebonyi State, between December 2017 and December 2018. Routinely collected clinical data from all patients admitted to the Virology Centre of the hospital during the period were analysed retrospectively. Out of a total of 83 cases, 70(84.3%) were RT-PCR confirmed while 13 (15.7%) were probable cases. Sixty-nine (83.1%) patients were seen in outbreak 1 of whom 53.6% were urban residents, while 19%, 15%, and 10% were farmers, students and health workers respectively. There were 14 (16.8%) patients, seen in second outbreak with 92.9% rural residents. There were differences in clinical symptoms, signs and laboratory findings between the two outbreaks. The case fatality rates were 29.9% in outbreak 1 and 85.7% for outbreak 2. Neurological features and abnormal laboratory test results were associated with higher mortality rate, seen in outbreak 2. This study revealed significant differences between the two outbreaks. Of particular concern was the higher case fatality during the outbreak 2 which may be from a more virulent strain of the Lassa virus. This has important public health implications and further molecular studies are needed to better define its characteristics.

Prevalence and outcome of Lassa fever among hospitalized patients in Ebonyi State, Nigeria, 2018-2019.

Lassa fever (LF) is a viral hemorrhagic illness endemic in West Africa. Annually, about 300,000-500,000 people are being infected, with about 5000 deaths. Symptoms of LF include high grade fever, headache, malaise, abdominal pain, vomiting, diarrhea, or sore throat. Terminal features may include bleeding from all orifices (mouth, nose, ear, anus and vagina), facial and neck oedema or pleural effusion. People of all ages, gender, and occupations were included in this study. A total of 440 patients' samples and Bio data were used for this study. The samples were analyzed for Lassa fever virus RNA using Real Time Reverse Transcriptase Polymerase Chain Reaction. The data obtained were analyzed using SPSS 20.0 and version 7 of Epi-Info statistical software. Analysis of these samples showed LASV prevalence of 25.7%. Chi-square analysis (p ≤ 0.05) showed that LASV infection does not depend on age, gender, or occupation. Our research re-emphasized the fact that LASV is a serious cause of fatality in humans. Our data showed that among 327 negative patients, 19 died. On the contrary, 113 LASV confirmed positive cases had 42 deaths. This result is highly significant. More so, Lassa fever disease outcome was compared across gender. There was no significant difference between the two genders. Death or recovery from LF infection does not depend on sex. However, recovery from LF significantly depends on age of the patient. Fatal outcome is significantly higher among adults/elderly. We aim to raise awareness to the recurrence of LASV in Ebonyi State and urgent need for other medical interventions, including other therapeutic measures, and possible vaccine production, considering the impact of this virus.

Development of an RT-LAMP assay for the detection of Lassa viruses in southeast and south-central Nigeria.

Lassa virus (LASV) causes Lassa fever (LF), a viral hemorrhagic fever endemic in West Africa. LASV strains are clustered into six lineages according to their geographic location. To confirm a diagnosis of LF, a laboratory test is required. Here, a reverse transcription loop-mediated isothermal amplification (RT-LAMP) assay using a portable device for the detection of LASV in southeast and south-central Nigeria using three primer sets specific for strains clustered in lineage II was developed. The assay detected in vitro transcribed LASV RNAs within 23 min and was further evaluated for detection in 73 plasma collected from suspected LF patients admitted into two health settings in southern Nigeria. The clinical evaluation using the conventional RT-PCR as the reference test revealed a sensitivity of 50% in general with 100% for samples with a viral titer of 9500 genome equivalent copies (geq)/mL and higher. The detection limit was estimated to be 4214 geq/mL. The assay showed 98% specificity with no cross-reactivity to other viruses which cause similar symptoms. These results suggest that this RT-LAMP assay is a useful molecular diagnostic test for LF during the acute phase, contributing to early patient management, while using a convenient device for field deployment and in resource-poor settings.

Lassa fever in pregnancy with a positive maternal and fetal outcome: A case report.

BACKGROUND: The signs and symptoms of Lassa fever are initially indistinguishable from other febrile illnesses common in the tropics and complications of pregnancy. Surviving Lassa fever during pregnancy is rare. Only few cases have been documented. The antiviral drug of choice is ribavirin. CASE DESCRIPTION: A 25-year-old multigravida farmer with fever who was initially thought to have malaria in pregnancy at 29 weeks gestation. Further changes in her clinical state and laboratory tests led to a confirmation of Lassa fever. The Liver enzymes were markedly deranged and the packed cell volume was 27%. She commenced on ribavirin and subsequently was delivered of a live male neonate who was RT PCR negative for Lassa fever virus. Her clinical state improved, repeat RT PCR on day 15 was negative and she made full recovery. DISCUSSION: The case reported had similar clinical features of fever and abdominal pain and resulted in the initial diagnoses of Malaria in pregnancy. When she failed to respond to antimalarial and antibiotics treatments, a strong suspicion of viral hemorrhagic fever was made. At this time the patient was in advanced stage of the disease with bleeding from vagina and puncture sites. On the third day of admission she was delivered of a live male neonate who remained negative after 2 consecutive RT PCR tests for Lassa fever virus. Lassa fever carries a high risk of death to the fetus throughout pregnancy and to the mother in the third trimester. Mothers with Lassa fever improved rapidly after evacuation of the uterus by spontaneous abortion, or normal delivery. She was clinically stable following delivery. Her laboratory investigations were essentially normal. Throughout her management transmission based precautions were observed. None of the six close contacts developed symptoms after been followed up for 21 days. CONCLUSION: This report adds to the body of literature that individuals can survive Lassa fever during pregnancy with good maternal and fetal outcome.

Genetic characterization of Lassa virus strains isolated from 2012 to 2016 in southeastern Nigeria.

Lassa virus (LASV) is endemic in parts of West Africa where it causes Lassa fever (LF), a viral hemorrhagic fever with frequent fatal outcomes. The diverse LASV strains are grouped into six major lineages based on the geographical location of the isolated strains. In this study, we have focused on the lineage II strains from southern Nigeria. We determined the viral sequences from positive cases of LF reported at tertiary hospitals in Ebonyi and Enugu between 2012 and 2016. Reverse transcription-polymerase chain reaction (RT-PCR) showed that 29 out of 123 suspected cases were positive for the virus among which 11 viral gene sequences were determined. Phylogenetic analysis of the complete coding sequences of the four viral proteins revealed that lineage II strains are broadly divided into two genetic clades that diverged from a common ancestor 195 years ago. One clade, consisting of strains from Ebonyi and Enugu, was more conserved than the other from Irrua, although the four viral proteins were evolving at similar rates in both clades. These results suggested that the viruses of these clades have been distinctively evolving in geographically separate parts of southern Nigeria. Furthermore, the epidemiological data of the 2014 outbreak highlighted the role of human-to-human transmission in this outbreak, which was supported by phylogenetic analysis showing that 13 of the 16 sequences clustered together. These results provide new insights into the evolution of LASV in southern Nigeria and have important implications for vaccine development, diagnostic assay design, and LF outbreak management.