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      Nigeria’s public health response to the COVID-19 pandemic: January to May 2020

      1 , 1 , 1 , 1 , 1 , 2 , 3 , 4 ,   1 , 5 , 6 , 1 , 1 , 1 , 1 , 1 , 7 , 1 , 1 , 1 , 1 , 1 , 1 , 1 , 1 , 1 , 6 , 6 , 4 , 4 , 1 , 1 , 2 , 4 , 1 , 1 , 1 , 1 , 1 , 7 , 8 , 1 , 1 , 1 , 1 , 9 , 10 , 6 , 6 , 11 , 12 , 12 , 1 , 1 , 1 , 1 , 1 , 2 , 2 , 1 , 1 , 13 , 14 , 15 , 16 , 16 , 17 , 18 , 18 , 19 , 19 , 20 , 20 , 21 , 22 , 4 , 4 , 23 , 24 , 6 , 2 , 25 , 1
      Journal of Global Health
      International Society of Global Health

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          The novel coronavirus disease 2019, COVID-19, which is caused by severe acute respiratory syndrome virus 2 (SARS-CoV-2) [1] was first reported in December 2019 by Chinese Health Authorities following an outbreak of pneumonia of unknown origin in Wuhan, Hubei Province [2,3]. SARS-CoV-2 is likely of zoonotic origin, similar to SARS and Middle East Respiratory Syndrome (MERS), and transmitted between humans through respiratory droplets and fomites. Since its emergence, it has rapidly spread globally [4]. The World Health Organisation (WHO) declared the novel coronavirus outbreak a Public Health Emergency of International Concern (PHEIC) on January 30, 2020 [5]. As COVID-19 spread to more countries and caused an increasing number of deaths, WHO led a mission to China with a team of experts from eight countries including Nigeria, to determine the extent of the outbreak, robustness of the response and identify best practices. Subsequently, on March 11, 2020, WHO declared COVID-19 a pandemic, calling for countries to take urgent and aggressive action [6,7]. There is a growing body of literature on innovative country-level responses to COVID-19, which describes the current approaches to developing policies and strategies relevant to the pandemic [8,9]. As the most populous country in Africa, and the sixth most populous in the world, Nigeria plays a significant role in the global response. Nigeria’s epidemic response is carried out in the context of a fragile and under-resourced existing health delivery system, and complicated by economic, political, social, and security issues throughout the country. Yet, confronting epidemics is not new to Nigeria. The 2014 Ebola epidemic sensitized the health system, government, and communities to the menacing impact of highly infectious diseases such as COVID-19 and the need to mount rapid, proactive measures [10]. In addition, the emergence of a strengthened Nigeria Centre for Disease Control (NCDC) has enhanced diagnostic and surveillance capacity in the country. We report the emergence of COVID-19 in Nigeria, describing the public health response up till May 2020. Photo: Regular data monitoring at Nigeria COVID-19 EOC to guide public health response (Source: Nigeria Centre for Disease Control, used with permission). COVID-19 IN NIGERIA On February 27, 2020, the Federal Ministry of Health confirmed the first COVID-19 case in Ogun State, Nigeria, making the country the third country in Africa to recognise an imported COVID-19 case after Egypt and Algeria. The index case occurred in an Italian citizen who flew from Milan, Italy to Lagos, Nigeria on February 24, 2020, and travelled on to his company site in Ogun State the same day in a private vehicle. On February 26, 2020, he presented at the company clinic with symptoms consistent with COVID-19 and was referred to the Infectious Disease Hospital (IDH) in Lagos where a COVID-19 diagnosis was confirmed by real-time reverse transcription polymerase chain reaction (RT-PCR) on February 27, 2020. A total of 216 contacts in Lagos and Ogun States, including the passengers on the February 24 air flight, were identified for 14-day follow-up, with 40 of these contacts identified as high-risk. Eleven days later, an asymptomatic contact of the index case in Ogun State was confirmed as the nation’s second case of COVID-19. The epidemiology of COVID-19 in Nigeria has since evolved, with cases identified in 35 of 36 states in the country, plus the Federal Capital Territory (FCT) ( Figure 1 ). Although Lagos State was initially the epicentre of the outbreak, Kano State and the FCT have now joined Lagos State as high-burden states, contributing 64 · 5% of the cumulative total cases in Nigeria by the end of May 2020. Between February 27 and May 31, 2020, 63 882 persons have been tested for COVID-19 in Nigeria, of which 10 162 (15.9%) were confirmed as being infected with SARS-CoV-2 by RT-PCR. Males appear to be disproportionately affected accounting for 67.7% (6,882) of the confirmed cases. A total of 287 deaths have been recorded among the confirmed COVID-19 cases, resulting in an observed case fatality ratio (CFR) of approximately 2.8% [11]. Figure 1 Trend of States reporting COVID-19 confirmed cases in Nigeria from Epidemiological Weeks 9, 12, 15, 18 to 22 (May 31, 2020). NIGERIA’S PREPAREDNESS AND RESPONSE TO COVID-19 Nigeria’s pre-outbreak preparedness measures Following reports of the coronavirus disease in Wuhan, China in December 2019, the NCDC published a notification of a new virus on its website on January 7, 2020. Subsequently, on January 26, 2020, the NCDC established a multisectoral National Coronavirus Preparedness Group (NCPG) in order to ensure a cohesive and effective coordination of the country’s preparedness efforts ( Table 1 ). The NCPG met daily to review global COVID-19 epidemiology, assess the risk of spread, and initiate measures to strengthen the country’s preparedness for early detection and timely response in the event of a COVID-19 outbreak in Nigeria. An inter-ministerial Multisectoral Technical Working Group was inaugurated at the Federal Ministry of Health on January 31, 2020, to further strengthen preparedness. Table 1 COVID-19 preparedness and response public health actions/interventions in Nigeria, January – May 2020 Outbreak phase Public actions/health interventions Strategy Pre-outbreak (January 1 – February 27) • Inauguration of multisectoral National Coronavirus Preparedness Group (CPG) by NCDC Prevention • Inauguration of inter-Ministerial Coordination Committee by Honourable Minister for Health • Review of Nigeria’s Pandemic Influenza Preparedness and Response Plan • Activation of interim Medical Countermeasure Plan • Conduct of table-top Logistic Capacity Assessment for COVID-19 • Training and capacity building of health care workers on infection prevention and control (IPC), sample collection and testing and clinical management of COVID-19 • Designation of three molecular Laboratories for COVID-19 testing • Designation of COVID-19 treatment centres • Points of Entry (PoE) surveillance at international borders including airports and land crossings • Conduct of COVID-19 simulation exercise Outbreak (February 27 – May 31) Stemming initial cases (February 27 – March 17) • Inauguration of national multisectoral COVID-19 Emergency Operation Centre (EOC) Containment • Development of national Incident Action Plan and State Pre-Incident Action Plan • Development of guidelines for surveillance, IPC, case management, schools, mass gatherings etc. • Pre-positioning of COVID-19 response materials in 36 States and the Federal Capital Territory (FCT) • Genetic sequencing of the index case conducted • Establishment of Presidential Task Force (PTF) on COVID-19 • Deployment of Rapid Response Teams (RRTs) to support response activities in Lagos and Ogun • Tracing of contact of confirmed cases • Points of entry screening in high priority states with international airports including Lagos State • Intensive risk communication including press releases, radio jingles, media appearances, social media • Establishment of NCDC COVID-19 microsite Addressing initial clusters of cases (March 18 – April 10) • Implementation of domestic and international travel restriction Suppression/Containment • Strengthening and expansion of COVID-19 laboratory diagnostic capacity from five to 18 • Strengthening and expansion of COVID-19 treatment centres • Domestic and international travel restrictions • Lockdown of non-essential activities and stay-at-home orders in the FCT, Lagos and Ogun States • Implementation of community active case search in Lagos and FCT Focus on community transmission (April 11 – To Date) • Revision of the national case definition to increase case detection Mitigation • Inter-State border screening in FCT, Lagos, and Ogun States • Mid-action review meeting conducted • Mandatory institutional quarantine and testing for international returnees Measures instituted by the NCPG included strengthening in-country diagnostic capacity for the testing of COVID-19 by leveraging and optimising three existing laboratories within the NCDC molecular laboratory network and assessing existing infectious disease treatment centres with a focus on identifying gaps and developing plans for case management. Interim protocols and guidelines for case management of COVID-19 were developed while the Nigeria Pandemic Influenza Preparedness and Response plan was reviewed for relevance to COVID-19 response. Infection prevention and control (IPC) and case management trainings were conducted for frontline health care workers in designated treatment centres. Findings from a WHO risk assessment identified 13 countries, including Nigeria, as high-risk priority zones for proactive surveillance, detection and containment of the spread of COVID-19 [12]. Consequently, an in-country risk assessment was conducted to assess border screening at the country’s international airports, and surveillance efforts were enhanced at the four international airports across the country to include temperature checks for all passengers and screening questionnaires for passengers arriving from countries with community transmission of COVID-19. The NCDC also began to release updates on the outbreak and recommended preventive measures to the public. The first public health advisory was issued on January 22, 2020, with updated versions subsequently published on the NCDC website and disseminated using multiple streams including social media. In addition, to assess and test the functional capabilities of all response systems in terms of preparedness, the NCDC and its partners conducted a national multi-stakeholder simulation exercise on February 27 and 28, 2020. Nigeria’s outbreak response measures Following the confirmation of the first COVID-19 case in Nigeria on February 27, 2020, the NCPG transitioned to a national multisectoral Emergency Operations Centre (EOC) at the NCDC. The EOC was activated at level three, the highest level of response in the country intended for public health emergencies requiring national coordination and use of all available resources for the response. The EOC comprises multiple pillars, including: coordination, surveillance and epidemiology, case management, laboratory, points of entry (PoE), IPC, risk communication, logistics, and research. POE and case management pillars are led by the Departments of Port Health Services and Hospital Services of the Federal Ministry of Health respectively. Sub-national EOCs were activated in both Lagos and Ogun states to coordinate the response in the first two affected states. National multidisciplinary rapid response teams (RRTs) were strategically deployed to the initial two states (Lagos and Ogun), plus FCT, and then to all states to strengthen coordination and response activities at the state and local government area (LGA) levels. The national RRTs, comprising NCDC staff and graduates/residents of the Nigeria Field Epidemiology and Laboratory Training Program (NFELTP), provided technical and logistical support at the state and sub-state levels. At the national level, the Presidential Task Force (PTF) on COVID-19 was established by the President of Nigeria on March 9, 2020, with an overarching mandate to coordinate and oversee the country’s multi-sectoral and inter-governmental efforts both to contain the outbreak and to mitigate the impact of the COVID-19 pandemic in Nigeria. The National COVID-19 Multi-Sectoral Pandemic Response Plan was adopted by the PTF in March and serves as a blueprint for a whole-of-Government response. The PTF provided high-level strategic leadership to the national response guided by scientific evidence. Daily PTF media briefings were held to enlighten Nigerians on evolving evidence, address trending issues and provide update on the government’s response. Technical evidence-based recommendations from the PTF informed the President of Nigeria’s policy decisions for the various phases of the outbreak. Overall, Nigeria’s response strategies were aimed at suppressing the transmission of COVID-19 by testing all suspect cases, isolating all confirmed cases, and tracing all contacts of confirmed cases, with the implementation of country-wide or regional non-pharmaceutical interventions as appropriate. The Nigerian response was characterised by robust collaborations with partners. Development and implementation of response strategies were facilitated by technical and material support from several local and international partners including the WHO, Africa CDC and philanthropic organisations. The need to generate relevant research evidence led to the formation of the Nigeria COVID-19 Research Consortium (NCRC) whose aim is to develop and implement a research agenda on COVID-19 with identified national priorities, in line with WHO’s global research roadmap. NCRC also serves as the coordinating body for COVID-19 research in Nigeria. Given the novelty of the virus, the evolving nature of transmission in Nigeria from imported cases to clusters of cases to community transmission and level of response implemented, the NCDC EOC convened a mid-action review meeting on May 9, 2020, to strategically review the existing response approach, share lessons learnt, and identify key opportunities for improvement and further collaboration. The outcome and key recommendations of the meeting in line with the emerging data and global best practices have been used to improve response strategies, drive control and prevention measures against the disease, as well as focused interventions to strengthen the health system. The gaps identified include poor utilization of state level public health EOCs for coordinated responses, sub-optimal utilization of data to guide decision making, delayed turn-around-times of laboratory results, non-standardization of case management across treatment centers and poor adherence to IPC practices in health care facilities. Several intervention measures were instituted which include training and mentorship of State EOC teams on the incident management system as a tool for outbreak response coordination, development and operationalization of data management, analysis and use plans, deployment of the electronic surveillance system to laboratories to speed up the release of results, the establishment of a community of practice for COVID-19 case managers and deployment of online IPC training programme for health care workers. RESPONSE STRUCTURES Travels, lockdowns and COVID-19 spread As of March 22, 2020, the initial 30 confirmed cases COVID-19 in Nigeria were travellers from abroad or their immediate contacts. This informed the initial international travel ban for passengers coming from countries with ongoing high transmission (initially China, Italy and Germany; subsequently extended to eight high-burden countries) to minimize rising imported cases. Ultimately, land borders were closed, all international flights were banned, and mandatory institutional quarantine and testing for international returnees to Nigeria was instituted on March 23, 2020 to reduce further importation of the disease from high-risk countries ( Figure 2 ). Figure 2 Epidemic curve of laboratory confirmed COVID-19 cases by date of reporting with mitigation strategies implemented in Nigeria, 2020. On March 30, 2020, the President of Nigeria issued a series of stringent non-pharmaceutical interventions, including stay-at-home orders and cessation of non-essential movements and activities (collectively referred to as a “lockdown strategy”) in Lagos and Ogun States and FCT for an initial period of 14 days, extended for an additional 21 days in the same three states and adding Kano State. The states were selected based on a combination of the burden of disease and their risk: Lagos State was the initial epicentre of disease and had the highest number of cases; Ogun State borders Lagos State, was the source of the index case, and has a highly urban population with a high rate of travel into Lagos State; the FCT had the second-highest number of cases at that time. After the initial two-week lockdown period, incidence in Kano increased rapidly, prompting inclusion in the lockdown. The lockdown included closure of schools and workplaces, bans on religious and social gatherings, cancellation of public events, curfews, restrictions on movement, and cessation of interstate and international travel. Alongside the federal lockdown in Lagos, and Ogun States and the FCT, many states adopted measures as well, including school closure, movement restrictions, and curfews. The lockdown strategy was a drastic and temporary measure implemented with two objectives: first, to slow the spread of the virus across the country, and second, to buy time for the health system to increase its preparedness. During the lockdown period, the NCDC worked with all states to enhance contact tracing activities and increase capacity for case detection and treatment. Treatment centres were expanded from an initial single centre in Lagos with 35 beds, as of February 29, 2020, to 38 centres with 1055 beds by April 14; by May 30, 2020 Nigeria had 121 treatment centres with 6550 beds. In the four-week period, the number of laboratories able to carry out COVID-19 testing increased from the initial three to 13 laboratories in 10 states as of April 15, to 28 in 18 states by the end of May. More than 13 000 health care workers were trained on IPC as well as on COVID-19 case management and personal protective equipment (PPE) and response commodities were deployed across the country to reinforce and better prepare the multi-sectoral response. Despite bans on interstate travel, the virus had already spread geographically. Ten states reported their first COVID-19 cases during the first 14-day phase of the Federal lockdown, while an additional 13 states reported index cases in the second phase of the lockdown. Index cases in several states were traced to domestically exported cases from Lagos State and FCT. Nearly three-quarters (74%, n = 7532) of current cases have no known epidemiological link, suggesting substantial community transmission. Cumulatively, as of May 31, 2020, 337 of Nigeria’s 774 LGA have reported a confirmed case. Although laboratory capacity was scaled up rapidly, testing numbers did not increase as planned. Testing capacity in terms of PCR machines as of mid-April was approximately 2500 tests per day and increased to more than 5000 per day as three Mega PCR Laboratories were activated for COVID-19 testing in Lagos and FCT by late May. However, inadequate testing reagents, due to delayed orders, and airport closures, hindered testing scale-up. Limited numbers of sample collection teams and testing centres, as well as hesitancy among some of the population to test, have also constrained increased testing. In the first two weeks of April, on average fewer than 300 tests per day were conducted; this increased to approximately 640 per day in the last two weeks of April, 1145 per day during the first two weeks of May, and 1410 per day during the last two weeks of May. Easing of lockdown The drastic lockdown measures came with a significant economic and social cost. Crime and domestic violence reportedly increased during the period [13] and many people were unable to exercise their usual income-generating activities with effects most pronounced on vulnerable populations and those living in poverty [14]. Upon the completion of five weeks of a federally mandated lockdown, a gradual segmented easing of lockdown measures was initiated on May 4, 2020. This was a phased approach for an initial period of two weeks to create a balance between public health and economic consequences by progressively returning the population to normal activities. This easing of lockdown measures was supplemented by increased testing and contact tracing by rapid response teams, testing centres, and state public health department teams. On March 30, the eve of the lockdown, 71% of contacts of confirmed cases were followed up; by the end of May, this had increased to 91%. The nationwide mitigation measures implemented by the government of Nigeria in the first two weeks post-lockdown includes an 8:00 pm to 6:00 am curfew, mandatory use of face masks in public, a continued ban on interstate and international movement, prohibition of mass gatherings of more than 20 people, and mandatory testing and supervised isolation of at least 14 days for repatriated citizens. DISCUSSION Globally, countries continue to employ diverse strategies to control the COVID-19 pandemic. These strategies are aimed at preventing, detecting, controlling, and mitigating the impact of the pandemic while taking into account the economic, social, cultural and religious factors unique to each country. Ultimately, the effectiveness of these strategies will be determined and sustained by country-level and community ownership [15]. Nigeria has, to date, the second-highest number of confirmed COVID-19 cases in Africa, and accounts for 7% of all confirmed cases on the continent. This may be an underestimate of the actual case load given the relatively low testing rate in Nigeria. As of May 31, Nigeria had conducted 63 882 COVID-19 tests, equivalent to 293 tests per million population; in comparison, Ghana had conducted 184 343 (5948 per million population) and South Africa had conducted 488 609 tests (8251 per million population) [16]. The relatively low CFR could be attributable to the robust case management measures coupled with a favourable demographic profile of the country, with 70% of the population below 25 years of age. By the end of May 2020, all but one state, Cross River State, reported COVID-19 cases. Cases were concentrated in the two most densely populated states, Lagos and Kano, as well as the FCT. Many of the initial cases reported outside of these three states have been imported from Lagos State, the FCT, or Kano State. Meanwhile, the rising case numbers in conflict-affected areas such as Borno State pose additional concerns and require context-specific interventions to avert a looming health crisis, especially in camps for internally displaced persons [16,17]. Undetected imported cases may have played a key role in the beginning and accelerated the transition from clustered to community transmission in the Nigeria outbreak. This is because, as the outbreak began, prior to closure of international borders, arriving international passengers were allowed to self-quarantine (without testing) but encouraged to seek testing if symptoms developed. This may have led to multiple undetected imported cases. The rapid emergence of cases among individuals with no travel history or recognized epidemiological links to other cases despite contact tracing suggests multiple undetected cases may have been imported into the country or that potential contacts of the identified cases were missed. This guided subsequent approach such that following border closure, arriving passengers (eg, on repatriation flights) had mandatory supervised quarantine for 14 days. Nigeria’s states were facing critical challenges as the number of cases continues to increase across the country. Foremost among these is the limited number of COVID-19 treatment centres. Though greatly expanded since the outbreak’s start, the limited number of beds, health workers, and critical care equipment such as oxygen and ventilators may quickly lead to an overwhelmed health system unable to minimize COVID-19 mortality and contain the spread of the disease. The NCDC continues to work closely with all state governments and partners to ensure adequate infrastructure is in place for timely case detection, management of cases, and to build capacity of the public health and clinical workforce. Although national testing capacity has significantly increased with private sector engagement, testing coverage and pace is still relatively low. By the end of May 2020, 293 tests had been conducted per million population, about 5% of what Ghana had done, with an average positivity rate of 15.9% overall. Nigeria needs to rapidly scale up testing to be able to quickly identify existing cases, isolate them, and control the pandemic. Securing sufficient testing supplies and personal protective equipment for health care personnel are immediate challenges of the response. Lock down containment measures were aimed at slowing the spread of the outbreak to new states, delaying the progression to community transmission, and increasing health system capacity at the initial phase of the outbreak. Though the lockdown slowed down COVID-19 transmission, it had undesired collateral effects on social protection, security, and daily subsistence for many. It is safe to assume that these negative consequences of the pandemic disproportionately affected women, people living in poverty, petty traders and those dependent on income from small and medium enterprises. The adverse effects of the lockdown exacerbated already difficult situations for many, rendering prolonged enforcement of preventive interventions such as lockdown and physical distancing unsustainable. A systematic approach was adopted to balance economic reopening with public health concerns, demonstrated in the phased easing of lockdown alongside a whole-of-society outbreak control strategy. This approach mobilises all sectors and communities to take ownership of and responsibility for response efforts towards control of the war against COVID-19 in Nigeria. The easing of lockdown measures came at a time when confirmed cases were on the uptick; however, the immense socioeconomic impact witnessed during the lockdown period necessitated a more balanced approach to public health interventions [17]. Furthermore, the easing of the federal lockdown allowed for a state-owned approach consistent with Nigeria’s governance structure and health system. CONCLUSION Nigeria mounted a swift and aggressive response to COVID-19, leveraging on its existing epidemic preparedness and learning from other parts of the globe where transmission began earlier. The country’s initial response included early activation of the national EOC at the NCDC, establishment of the multi-sectoral COVID-19 PTF, and decisive actions to stop international travel and impose a time-limited lockdown in highly affected areas. By rapidly implementing this set of interventions, Nigeria likely slowed down the rate of virus transmission and bought extra time to implement a robust case detection, testing, and treatment centre capacity. However, these efforts, especially testing, needs more private sector involvement to significantly ramp up COVID-19 diagnostic centres across the country. Sensitising and mobilising citizens to take responsibility by strict implementation of preventive non-pharmaceutical measures is key to flattening the curve. A rapid, holistic, cohesive, whole-of-government approach that encompasses civil society and local-communities in the response will be absolutely critical to combating the COVID-19 pandemic in Nigeria [18] and rebuilding stronger health systems towards adjusting to a “new normal”.

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          WHO Declares COVID-19 a Pandemic

          The World Health Organization (WHO) on March 11, 2020, has declared the novel coronavirus (COVID-19) outbreak a global pandemic (1). At a news briefing, WHO Director-General, Dr. Tedros Adhanom Ghebreyesus, noted that over the past 2 weeks, the number of cases outside China increased 13-fold and the number of countries with cases increased threefold. Further increases are expected. He said that the WHO is “deeply concerned both by the alarming levels of spread and severity and by the alarming levels of inaction,” and he called on countries to take action now to contain the virus. “We should double down,” he said. “We should be more aggressive.” Among the WHO’s current recommendations, people with mild respiratory symptoms should be encouraged to isolate themselves, and social distancing is emphasized and these recommendations apply even to countries with no reported cases (2). Separately, in JAMA, researchers report that SARS-CoV-2, the virus that causes COVID-19, was most often detected in respiratory samples from patients in China. However, live virus was also found in feces. They conclude: “Transmission of the virus by respiratory and extrarespiratory routes may help explain the rapid spread of disease.”(3). COVID-19 is a novel disease with an incompletely described clinical course, especially for children. In a recente report W. Liu et al described that the virus causing Covid-19 was detected early in the epidemic in 6 (1.6%) out of 366 children (≤16 years of age) hospitalized because of respiratory infections at Tongji Hospital, around Wuhan. All these six children had previously been completely healthy and their clinical characteristics at admission included high fever (>39°C) cough and vomiting (only in four). Four of the six patients had pneumonia, and only one required intensive care. All patients were treated with antiviral agents, antibiotic agents, and supportive therapies, and recovered after a median 7.5 days of hospitalization. (4). Risk factors for severe illness remain uncertain (although older age and comorbidity have emerged as likely important factors), the safety of supportive care strategies such as oxygen by high-flow nasal cannula and noninvasive ventilation are unclear, and the risk of mortality, even among critically ill patients, is uncertain. There are no proven effective specific treatment strategies, and the risk-benefit ratio for commonly used treatments such as corticosteroids is unclear (3,5). Septic shock and specific organ dysfunction such as acute kidney injury appear to occur in a significant proportion of patients with COVID-19–related critical illness and are associated with increasing mortality, with management recommendations following available evidence-based guidelines (3). Novel COVID-19 “can often present as a common cold-like illness,” wrote Roman Wöelfel et al. (6). They report data from a study concerning nine young- to middle-aged adults in Germany who developed COVID-19 after close contact with a known case. All had generally mild clinical courses; seven had upper respiratory tract disease, and two had limited involvement of the lower respiratory tract. Pharyngeal virus shedding was high during the first week of symptoms, peaking on day 4. Additionally, sputum viral shedding persisted after symptom resolution. The German researchers say the current case definition for COVID-19, which emphasizes lower respiratory tract disease, may need to be adjusted(6). But they considered only young and “normal” subjecta whereas the story is different in frail comorbid older patients, in whom COVID 19 may precipitate an insterstitial pneumonia, with severe respiratory failure and death (3). High level of attention should be paid to comorbidities in the treatment of COVID-19. In the literature, COVID-19 is characterised by the symptoms of viral pneumonia such as fever, fatigue, dry cough, and lymphopenia. Many of the older patients who become severely ill have evidence of underlying illness such as cardiovascular disease, liver disease, kidney disease, or malignant tumours. These patients often die of their original comorbidities. They die “with COVID”, but were extremely frail and we therefore need to accurately evaluate all original comorbidities. In addition to the risk of group transmission of an infectious disease, we should pay full attention to the treatment of the original comorbidities of the individual while treating pneumonia, especially in older patients with serious comorbid conditions and polipharmacy. Not only capable of causing pneumonia, COVID-19 may also cause damage to other organs such as the heart, the liver, and the kidneys, as well as to organ systems such as the blood and the immune system. Patients die of multiple organ failure, shock, acute respiratory distress syndrome, heart failure, arrhythmias, and renal failure (5,6). What we know about COVID 19? In December 2019, a cluster of severe pneumonia cases of unknown cause was reported in Wuhan, Hubei province, China. The initial cluster was epidemiologically linked to a seafood wholesale market in Wuhan, although many of the initial 41 cases were later reported to have no known exposure to the market (7). A novel strain of coronavirus belonging to the same family of viruses that cause severe acute respiratory syndrome (SARS) and Middle East respiratory syndrome (MERS), as well as the 4 human coronaviruses associated with the common cold, was subsequently isolated from lower respiratory tract samples of 4 cases on 7 January 2020. On 30 January 2020, the WHO declared that the SARS-CoV-2 outbreak constituted a Public Health Emergency of International Concern, and more than 80, 000 confirmed cases had been reported worldwide as of 28 February 2020 (8). On 31 January 2020, the U.S. Centers for Disease Control and Prevention announced that all citizens returning from Hubei province, China, would be subject to mandatory quarantine for up to 14 days. But from China COVID 19 arrived to many other countries. Rothe C et al reported a case of a 33-year-old otherwise healthy German businessman :she became ill with a sore throat, chills, and myalgias on January 24, 2020 (9). The following day, a fever of 39.1°C developed, along with a productive cough. By the evening of the next day, he started feeling better and went back to work on January 27. Before the onset of symptoms, he had attended meetings with a Chinese business partner at his company near Munich on January 20 and 21. The business partner, a Shanghai resident, had visited Germany between January 19 and 22. During her stay, she had been well with no signs or symptoms of infection but had become ill on her flight back to China, where she tested positive for 2019-nCoV on January 26. This case of 2019-nCoV infection was diagnosed in Germany and transmitted outside Asia. However, it is notable that the infection appears to have been transmitted during the incubation period of the index patient, in whom the illness was brief and nonspecific. The fact that asymptomatic persons are potential sources of 2019-nCoV infection may warrant a reassessment of transmission dynamics of the current outbreak (9). Our current understanding of the incubation period for COVID-19 is limited. An early analysis based on 88 confirmed cases in Chinese provinces outside Wuhan, using data on known travel to and from Wuhan to estimate the exposure interval, indicated a mean incubation period of 6.4 days (95% CI, 5.6 to 7.7 days), with a range of 2.1 to 11.1 days. Another analysis based on 158 confirmed cases outside Wuhan estimated a median incubation period of 5.0 days (CI, 4.4 to 5.6 days), with a range of 2 to 14 days. These estimates are generally consistent with estimates from 10 confirmed cases in China (mean incubation period, 5.2 days [CI, 4.1 to 7.0 days] and from clinical reports of a familial cluster of COVID-19 in which symptom onset occurred 3 to 6 days after assumed exposure in Wuhan (10-12). The incubation period can inform several important public health activities for infectious diseases, including active monitoring, surveillance, control, and modeling. Active monitoring requires potentially exposed persons to contact local health authorities to report their health status every day. Understanding the length of active monitoring needed to limit the risk for missing infections is necessary for health departments to effectively use resources. A recent paper provides additional evidence for a median incubation period for COVID-19 of approximately 5 days (13). Lauer et al suggest that 101 out of every 10 000 cases will develop symptoms after 14 days of active monitoring or quarantinen (13). Whether this rate is acceptable depends on the expected risk for infection in the population being monitored and considered judgment about the cost of missing cases. Combining these judgments with the estimates presented here can help public health officials to set rational and evidence-based COVID-19 control policies. Note that the proportion of mild cases detected has increased as surveillance and monitoring systems have been strengthened. The incubation period for these severe cases may differ from that of less severe or subclinical infections and is not typically an applicable measure for those with asymptomatic infections In conclusion, in a very short period health care systems and society have been severely challenged by yet another emerging virus. Preventing transmission and slowing the rate of new infections are the primary goals; however, the concern of COVID-19 causing critical illness and death is at the core of public anxiety. The critical care community has enormous experience in treating severe acute respiratory infections every year, often from uncertain causes. The care of severely ill patients, in particular older persons with COVID-19 must be grounded in this evidence base and, in parallel, ensure that learning from each patient could be of great importance to care all population,
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            Initial Public Health Response and Interim Clinical Guidance for the 2019 Novel Coronavirus Outbreak — United States, December 31, 2019–February 4, 2020

            On December 31, 2019, Chinese health officials reported a cluster of cases of acute respiratory illness in persons associated with the Hunan seafood and animal market in the city of Wuhan, Hubei Province, in central China. On January 7, 2020, Chinese health officials confirmed that a novel coronavirus (2019-nCoV) was associated with this initial cluster ( 1 ). As of February 4, 2020, a total of 20,471 confirmed cases, including 2,788 (13.6%) with severe illness,* and 425 deaths (2.1%) had been reported by the National Health Commission of China ( 2 ). Cases have also been reported in 26 locations outside of mainland China, including documentation of some person-to-person transmission and one death ( 2 ). As of February 4, 11 cases had been reported in the United States. On January 30, the World Health Organization (WHO) Director-General declared that the 2019-nCoV outbreak constitutes a Public Health Emergency of International Concern. † On January 31, the U.S. Department of Health and Human Services (HHS) Secretary declared a U.S. public health emergency to respond to 2019-nCoV. § Also on January 31, the president of the United States signed a “Proclamation on Suspension of Entry as Immigrants and Nonimmigrants of Persons who Pose a Risk of Transmitting 2019 Novel Coronavirus,” which limits entry into the United States of persons who traveled to mainland China to U.S. citizens and lawful permanent residents and their families ( 3 ). CDC, multiple other federal agencies, state and local health departments, and other partners are implementing aggressive measures to slow transmission of 2019-nCoV in the United States ( 4 , 5 ). These measures require the identification of cases and their contacts in the United States and the appropriate assessment and care of travelers arriving from mainland China to the United States. These measures are being implemented in anticipation of additional 2019-nCoV cases in the United States. Although these measures might not prevent the eventual establishment of ongoing, widespread transmission of the virus in the United States, they are being implemented to 1) slow the spread of illness; 2) provide time to better prepare health care systems and the general public to be ready if widespread transmission with substantial associated illness occurs; and 3) better characterize 2019-nCoV infection to guide public health recommendations and the development of medical countermeasures including diagnostics, therapeutics, and vaccines. Public health authorities are monitoring the situation closely. As more is learned about this novel virus and this outbreak, CDC will rapidly incorporate new knowledge into guidance for action by CDC and state and local health departments. Some coronaviruses, such as Middle East Respiratory Syndrome (MERS) and Severe Acute Respiratory Syndrome (SARS), are the result of human-animal interactions. Preliminary investigation of 2019-nCoV also suggests a zoonotic origin ( 6 ), but the exact origin has not yet been determined. Person-to-person spread is evident ( 7 ); however, how easily the virus is transmitted between persons is currently unclear. 2019-nCoV is similar to coronaviruses that cause MERS and SARS, which are transmitted mainly by respiratory droplets. Signs and symptoms of patients with confirmed 2019-nCoV infection include fever, cough, and shortness of breath ( 8 ). Based on the incubation period of illness from MERS and SARS coronaviruses, CDC believes that symptoms of 2019-nCoV infection occur within 2 to 14 days following infection. Preliminary information suggests that older adults and persons with underlying health conditions or compromised immune systems might be at higher risk for severe illness from this virus ( 9 ); however, many characteristics of this novel coronavirus and how it might affect individual persons and potentially vulnerable population subgroups, such as the elderly or those with chronic health conditions, remain unclear. Epidemiology of First U.S. Cases On January 21, 2020, the first person in the United States with diagnosed 2019-nCoV infection was reported. As of February 4, a total of 293 persons from 36 states, the District of Columbia, and the U.S. Virgin Islands were under investigation based on current patient under investigation (PUI) definitions, ¶ and also included those being evaluated because they are close contacts. Of these PUIs, 11 patients have confirmed 2019-nCoV infection using a real-time reverse transcription–polymerase chain reaction (RT-PCR) assay developed by CDC. These 11 cases were diagnosed in the following states: Arizona (one), California (six), Illinois (two), Massachusetts (one), and Washington (one) (Table). Nine cases were in travelers from Wuhan. Eight of these nine cases were identified as a result of patients seeking clinical care for symptoms and clinicians connecting with the appropriate public health systems. Two cases (one each in California and Illinois) occurred in close contacts of two confirmed cases and were diagnosed as part of routine monitoring of case contacts. All patients are being monitored closely for progressing illness. No deaths have been reported in the United States. TABLE Characteristics of initial 2019 novel coronavirus cases (N = 11) — United States, January 21–February 4, 2020 Case State Approximate age (yrs) Sex Place of exposure Date laboratory confirmation announced 1 Washington 30s M Wuhan 1/21/2020 2 Illinois 60s F Wuhan 1/24/2020 3 Arizona 20s M Wuhan 1/26/2020 4 California 30s M Wuhan 1/27/2020 5 California 50s M Wuhan 1/27/2020 6 Illinois 60s M Household Illinois 1/30/2020 7 California 40s M Wuhan 1/31/2020 8 Massachusetts 20s M Wuhan 2/01/2020 9 California 50s F Wuhan 2/02/2020 10 California 50s M Wuhan 2/02/2020 11 California 50s F Household California 2/02/2020 Abbreviations: F = female; M = male. Public Health Response CDC established a 2019-nCoV Incident Management Structure on January 7, 2020. On January 21, CDC activated its Emergency Operations Center to optimize coordination for domestic and international 2019-nCoV response efforts. To date, CDC has deployed teams to the U.S. jurisdictions with cases to assist with epidemiologic investigation and to work closely with state and local partners to identify and monitor close contacts and better understand the spectrum of illness, transmission, and virulence associated with this novel virus. Information learned from these investigations will help inform response actions. CDC has closely monitored the global impact of this virus with staff members positioned in CDC offices around the world, including mainland China, and in coordination with other countries and WHO. This coordination has included deploying CDC staff members to work with WHO and providing active support to CDC offices in affected countries. In addition, CDC in response to the escalating risks of travel from China has issued a series of Travelers’ Health Notices for both Wuhan and the rest of China regarding the 2019-nCoV outbreak. On January 27, CDC issued a Level 3 travel notice for travelers to avoid all nonessential travel to mainland China.** U.S. quarantine stations, located at 18 major U.S. ports of entry, are part of a comprehensive regulatory system authorized under section 361 of the Public Health Service Act (42 U.S. Code Section 264), that limits the introduction of infectious diseases into the United States to prevent their spread. On January 17, consistent with existing communicable disease response protocols, CDC Quarantine staff members instituted enhanced entry screening of travelers on direct and connecting flights from Wuhan, China, arriving at three major U.S. airports: Los Angeles (LAX), New York City (JFK), and San Francisco (SFO), †† which then expanded to include travelers arriving in Atlanta (ATL) and Chicago (ORD). These five airports together receive approximately 85% of all air travelers from Wuhan, China, to the United States. U.S. Customs and Border Protection officers identified travelers arriving from Wuhan and referred them to CDC for health screening. §§ Any traveler from Wuhan with signs or symptoms of illness (e.g., fever, cough, or difficulty breathing) received a more comprehensive public health assessment performed by CDC public health and medical officers. ¶¶ All travelers from Wuhan were also provided CDC’s Travel Health Alert Notice (T-HAN)*** that advised them to monitor their health for 14 days and described recommended actions to take if relevant symptoms develop. As of February 1, 2020, a total of 3,099 persons on 437 flights were screened; five symptomatic travelers were referred by CDC to local health care providers for further medical evaluation, and one of these persons tested positive for 2019-nCoV. On January 24, 2020, travel bans began to be instituted by the Chinese government, resulting in restricted travel in and out of Hubei Province, including the city of Wuhan, and fewer travelers undergoing entry screening in the United States. In response to the escalating risks associated with travel from mainland China, on January 31, 2020, the Presidential Proclamation further refined the border health strategy to temporarily suspend entry, undergo additional screening, or possible quarantine for individuals that have visited China (excluding Hong Kong, Macau, and Taiwan) in the past 14 days. These enhanced entry screening efforts are taking place at 11 airports at which all air travelers from China are being directed. Laboratory and Diagnostic Support Chinese health officials posted the full 2019-nCoV genome sequence on January 10, 2020, to inform the development of specific diagnostic tests for this emergent coronavirus ( 1 ). Within a week, CDC developed a Clinical Laboratory Improvement Amendments–approved real-time RT-PCR test that can diagnose 2019-nCoV respiratory samples from clinical specimens. On January 24, CDC publicly posted the assay protocol for this test (https://www.cdc.gov/coronavirus/2019-nCoV/lab/index.html). On January 4, 2020, the Food and Drug Administration issued an Emergency Use Authorization to enable emergency use of CDC’s 2019-nCoV Real-Time RT-PCR Diagnostic Panel. To date, this test has been limited to use at CDC laboratories. This authorization allows the use of the test at any CDC-qualified lab across the country. CDC is working closely with FDA and public health partners, including the American Public Health Laboratories, to rapidly share these tests domestically and internationally through CDC’s International Reagent Resource (https://www.internationalreagentresource.org/). In addition, CDC uploaded the genome of the virus from the first reported cases in the United States to GenBank, the National Institutes of Health genetic sequence database of publicly available DNA sequences (https://www.ncbi.nlm.nih.gov/genbank/). CDC also is growing the virus in cell culture, which is necessary for further studies, including for additional genetic characterization. Once isolated, the virus will be made available through BEI Resources (https://www.beiresources.org/) to assist research efforts. Clinical and Infection Control Guidance Additional information about 2019-nCoV is needed to better understand transmission, disease severity, and risk to the general population. Although CDC and partners are actively learning about 2019-nCoV, initial CDC guidance is based on guidance for management and prevention of respiratory illnesses including influenza, MERS, and SARS. No vaccine or specific treatment for 2019-nCoV infection is currently available. At present, medical care for patients with 2019-nCoV is supportive. On January 31, CDC published its third Health Advisory with interim guidance for clinicians and public health practitioners. ††† In addition, CDC issued a Clinical Action Alert through its Clinician Outreach and Communication Activity network on January 31. §§§ Interim guidance for health care professionals is available at https://www.cdc.gov/coronavirus/2019-nCoV/hcp/clinical-criteria.html. Health care providers should identify patients who might have been exposed and who have signs or symptoms related to 2019-nCoV infection, isolate these patients, and inform public health departments. This includes obtaining a detailed travel history for patients being evaluated with fever and lower respiratory tract illness. Criteria to guide evaluation and testing of PUIs for 2019-nCoV include 1) fever or signs or symptoms of lower respiratory tract illness (e.g., cough or shortness of breath) in any person, including health care workers, who has had close contact ¶¶¶ with a patient with laboratory-confirmed 2019-nCoV infection within 14 days of symptom onset; 2) fever and signs or symptoms of lower respiratory tract illness (e.g., cough or shortness of breath) in any person with a history of travel from Hubei Province, China, within 14 days of symptom onset; or 3) fever and signs or symptoms of lower respiratory tract illness (e.g., cough or shortness of breath) requiring hospitalization in any person with a history of travel from mainland China within 14 days of symptom onset. Additional nonhospitalized PUIs may be tested based on consultation with state and local public health officials. Clinicians should evaluate PUIs for other possible causes of illness (e.g., influenza and respiratory syncytial virus) as clinically indicated. CDC currently recommends a cautious approach to the examination of PUIs. These patients should be asked to wear a surgical mask as soon as they are identified, and directed to a separate area, if possible, separated by at least 6 ft (2 m) from other persons. Patients should be evaluated in a private room with the door closed, ideally an airborne infection isolation room, if available. Health care personnel entering the room should use standard precautions, contact precautions, airborne precautions, and eye protection (e.g., goggles or a face shield). Clinicians should immediately notify the health care facility’s infection control personnel and local health department. The health department will determine whether the patient needs to be considered a PUI for 2019-nCoV and be tested for infection. If directed by the health department, to increase the likelihood of detecting 2019-nCoV infection, CDC recommends collecting and testing both upper and lower respiratory tract specimens.**** Additional specimen types (e.g., stool or urine) may be collected and stored. Specimens should be collected as soon as possible once a PUI is identified regardless of time since symptom onset. For persons who might have 2019-nCoV infection and their close contacts, information and guidance on how to reduce the risk for transmitting and acquiring infection is available at https://www.cdc.gov/coronavirus/2019-ncov/hcp/guidance-prevent-spread.html. Close contacts should immediately call their health care providers if they develop symptoms. In addition, CDC is working closely with state and local health partners to develop and disseminate information to the public on general prevention of respiratory illness, including the 2019-nCoV. This includes everyday preventive actions such as washing your hands, covering your cough, and staying home when you are ill. Additional information and resources for this outbreak are available on the CDC website (https://www.cdc.gov/coronavirus/2019-ncov/index.html). Discussion The 2019-nCoV has impacted multiple countries, caused severe illness, and sustained person-to-person transmission making it a concerning and serious public health threat. It is unclear how this virus will impact the U.S. over time. For the general population, who are unlikely to be exposed to this virus at the current time, the immediate health risk from 2019-nCoV is considered low. CDC, multiple other federal agencies, state and local health departments, and other partners are implementing aggressive measures to slow U.S. transmission of 2019-nCoV ( 4 , 5 ). These measures require the identification of cases and contacts in the United States and the effective management of the estimated 14,000 travelers arriving from mainland China to the United States each day ( 3 ). These measures are being implemented based on the assumption that there will be more U.S. 2019-nCoV cases occurring with potential chains of transmission, with the understanding that these measures might not prevent the eventual establishment of ongoing, widespread transmission of the virus in the United States. It is important for public health agencies, health care providers, and the public to be aware of this new 2019-nCoV so that coordinated, timely, and effective actions can help prevent additional cases or poor health outcomes. The critical role that the U.S. health care system plays in halting or significantly slowing U.S. transmission of 2019-nCoV is already evident: eight of the first 11 U.S. cases were detected by clinicians collaborating with public health to test persons at risk. The early recognition of cases in the United States reduces transmission risk and increases understanding of the virus, including its transmission and severity, to inform national and global response actions. 2019-nCoV symptoms are similar to those of influenza (e.g., fever, cough, or sore throat), and the outbreak is occurring during a time of year when respiratory illnesses from influenza, respiratory syncytial virus, and other respiratory viruses are highly prevalent. To prevent influenza, all persons aged ≥6 months should receive an annual influenza vaccine, and vaccination is still available and effective in helping to prevent influenza ( 10 ). Reducing the number of persons in the United States with seasonal influenza will reduce possible confusion with 2019-nCoV infection and possible additional risk to patients with seasonal influenza. Public health authorities are monitoring the situation closely. As more is learned about this novel virus and this outbreak, CDC will rapidly incorporate new knowledge into guidance for action. Summary What is already known about this topic? In December 2019, an outbreak of acute respiratory illness caused by a novel coronavirus (2019-nCoV) was detected in mainland China. Cases have been reported in 26 additional locations, including the United States. What is added by this report? Nine of the first 11 U.S. 2019-nCoV patients were exposed in Wuhan, China. CDC expects more U.S. cases. What are the implications for public health practice? CDC, multiple other federal agencies, state and local health departments, and other partners are implementing aggressive measures to substantially slow U.S. transmission of 2019-nCoV, including identification of U.S. cases and contacts and managing travelers arriving from mainland China to the United States. Interim guidance is available at https://www.cdc.gov/coronavirus/index.html and will be updated as more information becomes available.
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              WHO International Health Regulations Emergency Committee for the COVID-19 outbreak

              To discuss whether the coronavirus disease 2019 (COVID-19) outbreak constitutes a Public Health Emergency of International Concern (PHEIC), World Health Organization (WHO) organized the 15-member International Health Regulations Emergency Committee (EC). On January 22-23 and January 30, 2020, EC convened and discussed whether the situation in China and other countries would constitute PHEIC and issued recommendations for WHO, China and the international community. Based on the recommendations of EC, WHO declared the COVID-19 outbreak a PHEIC. One of the purposes of the declaration of PHEIC was to alarm countries with weak public health infrastructures to prepare promptly for emerging infectious diseases (EID) and provide WHO with a framework for proactively supporting those countries. On February 3, 2020, WHO proposed the 2019 COVID-19 Strategic Preparedness and Response Plan, which includes accelerating research and development (R&D) processes as one of three major strategies. On February 11-12, 2020, WHO held the Global Research and Innovation Forum: Towards a Research Roadmap for COVID-19. The fact that a COVID-19 R&D forum was the first meeting convened after the PHEIC declaration testifies to the importance of R&D in response to EID. Korea has demonstrated a remarkable capacity in its laboratory response by conducting high-throughput COVID-19 testing and utilizing innovative drive-through samplings. These measures for early detection and screening of cases should be followed by full efforts to produce research-based evidence by thoroughly analyzing epidemiological, clinical and immunological data, which will facilitate the development of vaccines and therapeutics for COVID-19. It is expected that Korea plays a global partner for COVID-19 research by actively participating in immediate and mid/long-term priorities jointly led by WHO and global partners.

                Author and article information

                J Glob Health
                J Glob Health
                Journal of Global Health
                International Society of Global Health
                December 2020
                26 October 2020
                : 10
                : 2
                : 020399
                [1 ]Nigeria Centre for Disease Control, Abuja, Nigeria
                [2 ]African Field Epidemiology Network, Abuja, Nigeria
                [3 ]Department of Community Medicine, Alex Ekwueme Federal University Teaching Hospital Abakaliki, Ebonyi State, Nigeria
                [4 ]Center for Global Health, Centers for Disease Control and Prevention, FCT Abuja, Nigeria
                [5 ]School of Public Health, University of the Western Cape, Cape Town, South Africa
                [6 ]World Health Organisation, Abuja, Nigeria
                [7 ]Resolve to Save Lives Resolve to Save Lives (Vital Strategies), Abuja, Nigeria
                [8 ]World Bank, Nigeria Country Office, Abuja, Nigeria
                [9 ]Tony Blair Institute, Tony Blair Institute for Global Change, London, UK
                [10 ]George Town University Center for Global Health Practice and Impact, Abuja, Nigeria
                [11 ]Public Health England International Health Regulations (IHR) Strengthening Project, British High Commission, Abuja, Nigeria
                [12 ]Nigeria Port Health Services, Federal Ministry of Health Abuja, Nigeria
                [13 ]ECOWAS Regional Center for Disease Surveillance and Control, Abuja-Nigeria
                [14 ]Africa Centers for Disease Control and Prevention, African Union Commission, Addis Ababa Ethiopia
                [15 ]Department of Hospital Services, Federal Ministry of Health Abuja, Federal Secretariat Abuja, Nigeria
                [16 ]Lagos State Ministry of Health Ikeja, Lagos, Nigeria
                [17 ]College of Medicine, University of Lagos Teaching Hospital Lagos, Nigeria
                [18 ]Health and Human Services Secretariat Federal, Capital Territory Administration, Abuja, Nigeria
                [19 ]Kano State Ministry of Health, Kano, Nigeria
                [20 ]Ogun State Ministry of Health Abeokuta, Nigeria
                [21 ]Federal Ministry of Agriculture and Rural Development, Federal Secretariat Abuja, Nigeria
                [22 ]National Veterinary Research Institute Vom, Plateau State, Nigeria
                [23 ]Nigerian Institute of Medical Research, Lagos, Nigeria
                [24 ]Institute of Global Health, University College London, London, UK
                [25 ]Department of Infectious Diseases, Cambridge University Hospitals, Cambridge, UK
                Author notes
                Correspondence to:
Chioma Cindy Dan-Nwafor
Nigeria Centre for Disease Control
Plot 801 Ebitu Ukiwe Street
 chioma.dannwafor@ 123456ncdc.gov.ng
                Copyright © 2020 by the Journal of Global Health. All rights reserved.

                This work is licensed under a Creative Commons Attribution 4.0 International License.

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                Figures: 3, Tables: 1, Equations: 0, References: 18, Pages: 9

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