Yellow fever is again becoming endemic in Nigeria due to two major reasons: superstition leading to vaccine resistance and poor vaccine storage, a PREMIUM TIMES investigation in two states that witnessed the outbreak revealed.

As a result of poor power supply, primary health centres (PHCs) cannot provide cold-chains for the storage of vaccines for the immunisation of local communities.

Health experts have said ending the disease in the country requires equipping PHCs to effectively carry out uninterrupted immunisation, sensitising residents, especially those in rural areas, on the importance of the preventive health measures and checking illegal vaccine trade.

In early October last year, reports emerged of multiple deaths from a ‘strange disease’ in Enugu and Delta states.

The authorities in Enugu on November 6, 2020 said the disease had killed over 50 persons in parts of the state since it was first reported in late September.

A day later, the health commissioner of neighbouring Delta State, Mordi Ononye, also said about 22 persons had died in the state, but locals said that figure was conservative.

The Director-General of the Nigeria Centre for Disease Control (NCDC), Chikwe Ihekweazu, in a statement on November 8, 2020, said initial investigations confirmed the strange disease was Yellow fever.

Mr Ihekweazu said most of the cases had symptoms including fever, headache, fatigue, jaundice and vomiting (with or without blood).

“As of November 6, three samples from Delta and one sample from Enugu State tested positive for Yellow fever at the Irrua Specialist Teaching Hospital Laboratory in Edo and the NCDC’s National Reference Laboratory in Abuja,” he said.

While the disease was also spreading in other states amid the fight against COVID-19, Enugu and Delta reported the most cases in the 2020 Yellow fever outbreak.

The fatalities were unprecedented for both states. According to NCDC data detailing trends of Yellow fever outbreaks from 2018 to early 2020, both states until last year had reported only a few cases with no fatalities.

READ ALSO: Three states report 76 deaths from yellow fever in 11 days – NCDC

Following the emergencies, the state governments mid-November 2020 flagged off a ‘massive Yellow fever vaccination’ campaign.

PREMIUM TIMES undertook a week-long trip in December to observe the campaign in both states. It revealed how low turnout due to superstition, poor awareness in rural settings, weak cold chains for preservation at PHCs and scarcity of vaccines in urban areas threatened the process.

The challenges to the campaign have resulted in a wider spread of the disease and more fatalities.

‘Enugu vaccine campaign’

The Enugu State Government on November 19 said it had started mass vaccination against Yellow fever in three local government areas where it had confirmed an outbreak, targeting almost a million residents for immunisation.

George Ugwu, the executive secretary of the Enugu State Primary Health Care Development Agency (ENS-PHCDA), named the areas as Igboeze North (333,551 residents); Nsukka (398,094 residents) and Isi-Uzo (190,818 residents).

He said the targeted numbers represented 85 per cent of the population of the areas.

He added that the state government had enough Yellow fever vaccine in stock and had trained and sent vaccinators to carry out the exercise in PHCs, special outreach centres and house-to-house.

But health officials at the PHCs visited in some of the affected areas told this reporter that many residents initially refused to accept the vaccines, frustrating a quick and effective response to the emergency.

At the Opi Health Centre in Idi-Opi, one of the affected communities in Nsukka East LGA, the reporter met about 18 residents waiting to receive the vaccine in an open ward.

Mabel Eze, a nurse, said it was the second round of the exercise.

“During the first batch many people refused to come,” she said. “They did not believe that the strange deaths were caused by Yellow fever. They attributed it to spiritual causes and refused to accept the vaccines.”

According to the nurse, some indigenes even convinced others that immunisation was ‘dangerous’ for their health.

“People only started coming in this second phase after more people died and they also noticed that those who took the vaccine did not die,” she said.

There was no electricity supply at the facility, named as ‘Early Bed Clinic’ on its signpost. This means it could not store vaccines for long.

Yellow fever vaccines are stored in cold temperature. But the clinic had no public power supply or generator and its solar energy panel was faulty and nonfunctional.

“What we do is when we get stock of the vaccines, we buy ice packs and store them in cooler flasks. This process is not efficient because we cannot store the vaccine like that for a long period, making us to always bring them in low quantities,” Mrs Eze said.

The nurse said this slows down the vaccination process and was allowing the disease to keep spreading.

The Yellow fever vaccine focal person in the area, Geraldine Okoye, said people from surrounding communities report to the centre for vaccination but, due to poor storage capacity, only a few are vaccinated in a day.

Deserted PHC

The PHC at Opi Agu, another affected community in the area, presented a clearer picture of Nigeria’s decrepit primary healthcare system. The facility looked deserted. You could hardly read out the inscription on its rusty signpost leaning on a tree as the two legs were broken.

There was no patient in the facility when the reporter visited. Cobwebs covered the beds. There was no toilet or running water and the drug shelves were empty.

In fact, the entire facility looked abandoned with cobwebs and broken roofs at every corner. The only two health workers said they had been at the facility since it was opened in 2008.

Callister Nwona, one of the Community Health Extension Workers, said the infrastructural challenges of the facility were the reason for its desertion.

She said the situation also affected the turn out of people for vaccination.

“Many people refused to come here for vaccination because they feel we don’t have the capacity to give it. You can see how this place looks deserted. We don’t have light (electricity) to store vaccines,” she said.

The nurse showed the reporter a decrepit well which was their only source of water.

“People only started coming for the Yellow fever vaccine when more deaths started occurring. We buy ice packs to store the little quantity of vaccines we get from the local government.”

The PHC at Ugbaike, Enugu-Ezike, Igbo-Eze North East LGA, had solar and public power supply, unlike the one in Opi Agu. The only challenge was persuading people to turn up for vaccination, health workers at the facility said.

Ripple effect

Nnabuife Ezeani, an indigene of Opi who lives in Enugu town, said lack of access to vaccines and people’s refusal to take one had caused more deaths from the disease.

Vaccine hawkers capitalised on the inadequate supply of vaccines in hospitals to sell free vaccines to unwary citizens, such as Mr Ezeani in Enugu urban areas, PREMIUM TIMES discovered, details of which will be provided in the second part of this investigation.

Mr Ezeani, a lawyer, shared how a former councillor, Chinedu Ezeani, and a deputy headmaster in one of the schools in Opi Agu died because of their refusal to take the vaccine.

“Many people died because they refused to take vaccines due to their belief that Yellow fever was not the cause of the ‘strange deaths.’

“The body of Chinedu Ezeh, a 37-year-old former councillor in our area, is in the mortuary as I am talking to you. He refused to take the vaccine when he showed the symptoms, saying nothing would happen and believing in traditional medicines.

“The deputy headmaster at the Opi Agu primary school also died in that manner. When he got really sick, he refused the vaccines. When he was hospitalised, he promised to come back and kill everything off with beer.”

This reporter visited the deceased’s school. Community Primary School, Nkwo Agu, was established in 1947 and looked as if it had not been rehabilitated since then.

Most of the roofs had given way, potholes covered the ground and the walls needed a fresh coat of paint. There were no doors or windows in the classrooms.

Gregory Eziah, the headmaster, said the death of his deputy was a monumental loss to the school. “It is really difficult to forget him. He didn’t show much symptoms until his death.”

Mr Eziah said the death of his deputy spurred a mass vaccination of the entire school.

Prevention and tackling misinformation

This reporter met the king of Opi Agu, Pius Agbo, during a routine fumigation exercise in households and forests in the community. He said he had to enforce mass vaccination of the residents.

“When the vaccination started, many people refused to take the drug. The first thing we did was to sensitise the people. After that we made a general announcement through the town criers that anybody that refused to be vaccinated would be ostracised from the community.

“Opi Agu is a very big community with about 41 villages, so enforcing this kind of order did not come easy. Many people still did not come for the vaccination and some of them died. The body of a man is currently in the mortuary as I am talking to you. He refused to be vaccinated. More than 15 people died from this disease in my community,” he said.

Sunday Cosmas, an entomologist, was directing the team of fumigators while the reporter spoke with the Igwe of Opi Agu.

“I work with the National Arbovirus and Vectors Research Centre in Enugu. Our director, Emeka Asadu, sent us here to basically do two things: Larva source destruction, which is killing the vectors of mosquitoes by fumigating their breeding sites and water containers and killing the mosquitoes themselves,” he said.

“We are moving from house to house and community to community,” he said.

The Disease Surveillance Inspection Officer (DSIO) at Igbo-eze LGA, the epicentre of the Enugu outbreak, also narrated the ordeal they faced in battling the contagion.

“In late September, LG health authorities started receiving reports of strange deaths from Umu Opi and Uke on a daily basis and the LG disease surveillance and inspection office were alerted about the deaths. People were calling from Ete Uno also.

“We first collected names of those manifesting symptoms and those that died and alerted the Enugu epidemiological unit which took samples to the lab in Abuja where it was confirmed that it was Yellow fever.”

The official said the symptoms included jaundice or yellowing of the eyes, vomiting of blood, headache, cold and high fever.

He said a Yellow fever vaccination campaign was then launched in the affected communities.

“The vaccines were given free but the challenge is that many people had myths and superstitions about the sickness, as it was the first of such in these areas. They said it was caused by evil spirits. It took more deaths and constant sensitisation for people to get immunised.”

Delta vaccination campaign

Delta State started its Yellow fever vaccination programme about the same time as Enugu in November.

The targeted communities were in Ikah North East and South LGAs that bore the brunt of the outbreak in the state.

Most of the communities had not experienced a Yellow fever outbreak before, hence the superstition around the ‘strange deaths.’

Idumesah in Ikah North East LGA is one of the affected communities. The village practices gerontocracy, where the eldest man is the village head, the Okpana or Okparan-uku.

Most of the people that died in the community were youth. The villagers believed the deaths were because the village head had taken away the staff of the village deity, Mmuo. This prompted protests by the youth and women against the village head.

This myth was however dispelled by health officials who explained that the strange deaths were caused by Yellow fever.

At the Idumesa PHC, a health worker, Martin Akudo, said men between the ages of 15 and 44 started dying in late September.

“There were riots and rituals were performed because the general belief was that the deaths were due to spiritual reasons. When vaccination started, many refused to come until doctors and health officials came with sensitisation programmes,” he said.

Mr Akudo said the belief that the deaths were from spiritual causes was also disproved by people also dying in the same manner in neighbouring communities.

Prevention

The town crier, Edesah Osah, took this reporter to the palace of the Okpana, the village head.

At the palace, the Okparan-uku, Mburuchie Vincent Odili, who spoke through the town crier, said he was accused out of ignorance.

He thanked the state government and federal health authorities for intervening with the Yellow fever vaccination and fumigation.

The monarch also advised the community to keep the environment clean and use mosquito nets distributed by the government to prevent future outbreaks of the disease.

“For now, we have been able to control the outbreak. People that initially refused the vaccines later took them,” he said.

The PHC at Ute-Erumu, a neighbouring community that was also affected, was locked when this reporter visited. Some residents said they accepted the vaccines after a sensitisation programme by health officials.

Ute-Okpu PHC is one of the best within the area. Built to standard, it has constant electric supply and a standby generator. All the general wards and private rooms had air conditioners.

The head of the facility was not around during the visit but one of the nurses said an effective Yellow fever vaccination was coordinated from the facility.

“The only challenge was in convincing the people to take the vaccines as many refused to take it initially,” the nurse who refused to give her name as she was not authorised to speak, said.

Statistics

While Enugu and Delta were the epicentres of the Yellow Fever outbreak in Nigeria in 2020, there were cases of the disease in other parts of the country last year.

According to the latest NCDC Yellow Fever situation report of December 25, cases were reported in 13 states. These are Akwa Ibom, Bauchi, Benue, Borno, Delta, Ebonyi, Enugu, Gombe, Kogi, Osun, Oyo, Plateau and Taraba.

A total of 3,112 suspected cases and 109 confirmed cases were reported from 30 LGAs in the 13 states. A total of 17 deaths was recorded among the confirmed cases with a (Case Fatality Rate) CFR of 17 per cent including Enugu (9), Delta (6), Bauchi (1) and Ebonyi (1).

Meanwhile, there were 249 deaths overall, believed to be from Yellow fever, the highest yearly tally since the resurgence of the disease in 2017.

Yellow fever is an  acute viral haemorrhagic disease that can kill within 10 days if symptoms become severe.

Nigeria’s earliest outbreak of the fever was reported in Lagos in 1864, with subsequent regular outbreaks reported until 1996.

No confirmed cases were then reported for 21 years, until September 2017 when the viral infection was rediscovered in Kwara State.

The Yellow fever vaccination was introduced in Nigeria in 2004 as one of the vaccines expected to be given to children during routine immunisation. In spite of this, the country is still witnessing outbreaks of the disease.

The increasingly regular occurrence of outbreaks is largely because many people are not immunised, according to the NCDC. Vaccine hesitancy — a reluctance or refusal to be immunised — was named by the World Health Organization as one of the top  10 threats to global health in 2019.

The National Primary Health Care Development Agency (NPHCDA) said the vaccines procured by the government could not cover the entire country, hence the low immunization rate.

“The yellow fever vaccines are free only for children under 5. The only time vaccines are free for the general public is when there is an outbreak and a campaign is flagged off as it was done in Enugu and Delta”, an NPHCDA official said.

“Once the campaign is over, anybody that needs the vaccine will have to source it.”