Severe Acute Respiratory Syndrome – novel Coronavirus 2 (SARS-nCoV-2), was first reported in Wuhan, China, in December, 2019. Since the outbreak, the virus has infected more than 9,866,685 individuals, 4,983,029 treated and discharged and 495,692 deaths globally. The first Coronavirus Disease 2019 (COVID-19) in Nigeria was imported in February, 2020 and since then community transmission has been prevalent. As at the time of writing this report, Nigeria has reported about 23,298 cases of COVID-19, 8,253 treated and discharged and 554 deaths, giving a case mortality ratio of 2.4%. While responsible government agencies and international partners have been working hard to curtail the spread of the disease, we present in this report, some matters arising from managing COVID-19 pandemic in Nigeria; and proffered suggestions which could help not only in managing the current COVID-19 pandemic, but also for winning future outbreaks of public health significance with a view to curtailing global health security.
Severe Acute Respiratory Syndrome – novel Coronavirus 2 (SARS-nCoV-2) was first reported in Wuhan, China, in December, 2019 . World Health Organization (WHO) renamed it Coronavirus Disease-19 (COVID-19). The pandemic has posed serious threats to food security, socioeconomic stability, public health and fragile health systems especially in developing countries .
As at the time of writing this report, the virus has infected more than 9,866,685 individuals, 4,983,029 treated and discharged and 495,692 deaths globally. Health systems, human resources and supply chain have been stretched thereby posing challenges in managing the outbreak .
Locally, COVID-19 cases in Nigeria as at the time of writing this report stood at 23,298 cases, 8,253 treated and discharged and 554 deaths . While the disease has spread to 35 States of the Federation including the Federal Capital Territory (FCT), major economic and capital cities such as Lagos, FCT, Rivers and Kano have the largest burden of the disease (Figure 1).
The burden of COVID-19 across different geopolitical zones of the country is shown in Figure 2. The highest burden of COVID-19 is seen in the South West region, with Lagos contributing over 80% of the total disease burden. Lagos is the commercial capital and economic hub of the country; and considering the high economic activities on-going within the city, community transmission of the disease will have been prevalent. This could account for the increased number of COVID-19 cases reported in the city.
As a risk management strategy to limit the spread of COVID-19 with its associated mortality and morbidity, different countries have adopted diverse stringent measures. In Nigeria, restrictions on local and international flights have been effected. Schools at all levels have been shut; and inter and intra states movement restricted including compulsory wearing of face masks .
In an effort to manage, provide information regarding coronavirus infection and ensure that COVID-19 outbreak is curtailed, the Nigeria Center for Disease Control (NCDC), an agency under the Federal Ministry of Health has been at the epicenter of coordinating all activities including surveillance, contact tracing and testing. Other local and international partners such as the USCDC Nigeria have also been playing some major roles all targeted towards limiting the impact of the disease within the country. In spite of all efforts targeted towards ensuring that the health and economic consequences associated with COVID-19 are limited, several issues seem to be limiting the war against the disease.
Nigeria has a population of over 200 million spread across its six geopolitical zones. With this huge population, laboratory testing is very crucial for quick identification of populations at risk. This helps in initiating appropriate treatment and implementing suitable management strategies. Although the laboratory testing capacity needed for prompt identification of cases has been perceived to be low, not just in Nigeria alone, but within countries in sub-Saharan Africa , , but the NCDC has been making consistent efforts to increase the number of laboratories across the country .
The Nigeria Center for Disease Control as at the time of writing this reported has tested about 108,548 individuals using real time polymerase chain reaction (RT-PCR) . This represents only about 0.05% of the country’s population. This low testing capacity in Nigeria could be limiting the efforts targeted towards curtailing the spread of the virus especially delays in identifying individuals who have they virus, but are asymptomatic. Prompt identification of populations at risk through effective testing strategy enables quick isolation of positive cases and initiation of pharmacological treatments with a view to improving prognosis.
Real time polymerase chain reaction (rtPCR) is the current gold standard for diagnosing COVID-19 infection. Due to the total testing processes (TTP) involved with the use of PCR, the turnaround time (TAT) for completing an analysis could be high. However, more delays could be encountered when pre-analytical or analytical errors or delays are encountered in the testing process. While this has been observed as one of the challenges limiting the quick release of results , , the NCDC has been engaged in acquiring high throughput PCR systems that could complete testing within shorter turnaround time (TAT). Till date, the agency has tested about 108,548 individuals; and in the process have recorded 18,480 positive cases . While several individuals still consider this to be inadequate considering the huge population of the country, the agency asserts it is committed to scaling up testing with a view to identifying populations at risk .
Diagnostic Laboratory Networks in Nigeria seem to be poorly coordinated. Many laboratories exist in isolation and with limited capacities to handle different sample volumes. Movement of samples for testing from one location to another due to poor road network could be very challenging. In order for result(s) emanating from any sample to be credible, such sample should be collected, handled and transported using approved standard procedures. In countries with excellent laboratory networks, it is easier to transport samples from one location to another without any serious limitations. However, in Nigeria where there are often poor road network, incessant delays or cancellation of local flights, lack of adequate training of operators handling and transporting biological samples could pose as big challenges when moving samples across testing laboratories. This could become exaggerated when community outbreak of COVID-19 becomes more prevalent among populations living either in hard to reach (HTR) or far to reach (FTR) locations. Use of mobile laboratories is therefore recommended and could be very helpful in limiting these challenges and addressing the pandemic in such locations.
Individuals who have been diagnosed positive and are managed for COVID-19 require constant testing and retesting of their blood chemistry to help determine prognostic markers for the disease. Lippi and Plebani  reported that all COVID-19 patients require constant laboratory testing in order to ensure adequate staging, prognosis, therapeutic monitoring and epidemiological surveillance. Findings have shown that patients suffering from COVID-19 had decreased level of total white blood cells (TWBC), increased levels of C reactive protein (CRP), lactate dehydrogenase (LDH), erythrocyte sedimentation rate (ESR) and D-dimer; with decreased level of serum albumin . On the other hand, increased values of LDH, aspartate aminotransferase (AST), alanine aminotransferase (ALT), total bilirubin, creatinine, cardiac troponins, D-dimer, prothrombin time (PT), procalcitonin, CRP and decreased values of serum albumin have been reported to be useful for prognostic assessment of individuals managed for COVID-19 , , . Furthermore, a novel biomarker called monocyte volume distribution width (MDW) have been reported to be useful for identifying COVID-19 individuals with poor clinical conditions . From the forgoing, the role of robust medical laboratory services in diagnosing, treating, managing and determining treatment and prognostic outcomes become very critical. The critical question is how many secondary and tertiary hospital based laboratories in Nigeria have capacity to accurately measure these parameters? While some healthcare diagnostic laboratories currently receiving COVID-19 patients do have some capacity to measure these parameters with good precision, not all secondary and tertiary hospital laboratories are adequately equipped to perform these prognostic parameters needed for effective management of COVID-19 patients. Strengthening capacities of diagnostic laboratories to enable them play their diagnostic, treatment and prognostic roles required to effectively manage any epidemic remains very critical.
Another issue in the fight against COVID-19 in the country is centered on the use of rapid diagnostic test kits (RDTs). Rapid diagnostic test kits could either be antigen or antibody based. They are often used as point of care (POC) testing devices considering the challenges and increased TAT often associated with wet chemistries and molecular techniques such as PCR. Few RDT kits which importers presented to the Medical Laboratory Science Council of Nigeria, an agency of the Federal Ministry of Health (FMoH) for validation did not meet national expectations specified for population use, but showed varying levels of specificity, sensitivity and accuracy (Table 1) . Based on this, the Federal Ministry of Health as at the time of writing this report has not approved any COVID-19 RDTs for national use. However, some States within the country have commenced using RDTs for COVID-19 testing. The argument here is that health issues are on the concurrent list (constitutional issues which both the state and federal governments can legislate upon, example health issues),but not on exclusive list (constitutional issues which only the federal government can legislate upon, example security). Currently, RDTs which could detect either viral antigen or antibody within the shortest TAT are available globally, but none has been approved for national use due to the poor performance following validation report .
|Rapid test kits||Characteristics||Observed performance, %||Generally acceptable minimum (95% CI)|
|Product Aa||Sensitivity||29.0 (22.6–37.8)||≥95%|
|Product Ba||Sensitivity||51.4 (41.5–61.3)||≥95%|
|Product Ca||Sensitivity||22.1 (13.2–32.6)||≥95%|
|Product Da||Sensitivity||37.7 (26.9–49.4)||≥95%|
aA, B, C and D not real name of products, but are blinded to avoid product bias. CI, confidence interval. Numbers in parentheses are minium and maximum values obtained for each validation parameter.
While RDTs could allow for more rapid, easy and faster testing of the population, State governments using non-validated and non-approved RDTs for population testing should be cautious. Use of scientifically validated COVID-19 RDTs ensures that RDTs with good predictive value, accuracy, sensitivity and specificity are deployed for testing. Use of unvalidated RDTs poses a great danger to curtailing the spread of coronavirus and has the tendency of increasing types 1 and 2 error .
Furthermore, in Nigeria, where everyone including non-health professionals uses RDT for testing without going through licensed healthcare professionals, there could either be over diagnosis or under diagnosis of those who either are infected or not infected with the virus due to individual’s poor skill and training to handle and interpret result emanating from the testing process. In order to avoid such situations adherence to regulatory provisions in the use of COVID-19 RDTs is advised.
The World Health Organization (WHO) has ranked Nigeria as number 143 out of 195 WHO member countries with the worst health systems . While concerted efforts have been made to improve on the identified gaps, more resources are still needed to achieve the desired goal . Inadequate preparedness of healthcare institutions puts them in an emergency situation.
Based on 2016 Global Burden of Disease (GBD) report , huge investment is needed to improve the country’s health systems. With limited resources and a monoeconomy currently affected by the economic impact of COVID-19 pandemic, it becomes increasingly difficult to harness resources to prepare the healthcare institutions to manage the current pandemic. Preparedness of healthcare institutions to manage any outbreak of public health significance is a measure of several factors – adequate space for isolation of infected patients, capacity for clinical staff to manage the infection, training on biosafety issues, institutional diagnostic capacity, availability of personal protective equipment (PPE), motivation of the healthcare workers and many more. While everyone acknowledges that COVID-19 is a novel disease; and considering its high rate of infection with associated mortality, no country can be adjudged to have been fully prepared for the pandemic. However, in a country like Nigeria where her political leaders prefer going for treatment abroad to investing and strengthening the available health systems and capacities, COVID-19 has taught everyone a great lesson and has again emphasized the need to develop available health systems in readiness for emergencies.
Nigeria is a country that depends largely on imported products including medical supplies. Countries with increased burden of the disease have had challenges with medical supplies. Excessive demands on medical supplies have put increased pressure on companies manufacturing different kinds of medical products required to manage COVID-19 pandemic. Supply of medical and laboratory items in most hospitals within the country have been plagued with limited funds and bureaucracies leading often to out-of-stock syndromes with its attendant effect on organizational operations. Restrictions currently placed on both international and local flights and human mobility could distort the supply of health items needed to fight the outbreak. Pressures mounted on manufacturers of different medical products required to manage patients with COVID-19 from different countries could increase the period required to deliver ordered medical products to specific countries. Nigeria is not alone in this situation. Other countries in sub Saharan Africa have been affected by limited medical supplies needed to curtail the pandemic . Due to global shortage in commodities precipitated by high demand across countries, the Africa continent has been placed in a position where it has money to purchase medical products, but cannot see it to buy . Distortions in global supply of medical commodities catalyzed by COVID-19 pandemic have shown that the country can no longer depend solely on importation of essential medical items needed to curtail diseases of public health significance as well those posing significant threats to global health security. Premised on these, the need for government to begin to empower, strengthen and encourage local manufactures becomes very imperative.
Many emerging and remerging infectious diseases of public health significance do emerge unannounced. Adequate preparation for handling such pathogens which could have significant potential effects on global health security is key to curtailing their impacts. No nation is immune to disease outbreak. With increase in human mobility occasioned by excessive economic activities, diseases can be imported and exported from one country to another.
Improving laboratory diagnostic capacity and networks within the country are key to curtailing and handling disease outbreaks. There is an urgent need to improve laboratory networks within the country. In any outbreak of public health significance, movement of samples for testing becomes very critical. Appropriate initiation of treatment is premised on testing output. Delay in testing could result in avoidable mortalities and morbidities. Laboratories with different or same capacities can be identified and linked together using technology. In HTR and FTR locations, provision of mobile laboratories for quick testing and identification of causative agent(s) should be considered. These mobile laboratories could also be deployed to rural communities where social amenities such as electricity and water are lacking
While it might be difficult to predict or forecast the number of individuals who might be infected during any disease outbreak, there is need for the government, through the Federal Ministry of Health to domicile one public health laboratory (PHL) in each state. This will allow for ease of movement and testing of samples collected from individuals who are living within such zones. Different States could upgrade the Epidemiology Unit domiciled within the State Ministry of Health (SMoH) to a full-fledged State Center for Disease Control (SCDC). The SCDC should be equipped with full capacity to detect, diagnose and manage disease outbreaks at the state level; thereby augmenting the structures put in place by the government at the center to curtail epidemics.
While acknowledging the importance of RDTs as an acceptable point of care (POC) testing device, users should be aware of possible errors inherent in such testing methods. To this end, all stakeholders should ensure that they are properly validated prior to public use. With various emerging and remerging infectious disease challenging the country, there is need for the government to partner with biotechnology companies either within or outside the country to help research and develop RDTs for quick detection of infectious diseases when outbreak occurs.
We recommend more resources for health care institutions especially clinical laboratories. Priority should be given to strengthen laboratory systems in readiness to handle outbreak. Laboratory emergency plans should be established and implemented when the need arises. Proper planning of medical supplies should be determined; and arrangement should be put in place for contingency supply of medical items. Continuous capacity building to expand the number of trained medical laboratory professionals and improve the quality of testing are also very critical if the war against infectious diseases must be successful.
We appreciate Dadik Jelpe from United States Center for Disease Control (USCDC), Nigeria for his useful comments which helped in improving the quality of this manuscript.
Research funding: None declared.
Author contributions: All authors have accepted responsibility for the entire content of this manuscript and approved its submission.
Competing interests: Authors state no conflict of interest.
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