Nigeria Country

Office
Diphtheria Outbreak
Situation Report No.2

©UNICEF/2023/U. Thage
Reporting Period: Volunteer Community Mobilizer Sadiya Yahuza is sensitizing the
16 September 2023 – household of Zakiyya Suleman and Aisha Ya'u about Diphtheria
and prevention measures in Filin Kuka, Tudun Fulani, Ungoggo
LGAs in Kano State in Northwest Nigeria.
18 October 2023

Highlights Situation in Numbers

• 14,482 suspected cumulative cases since the 14 million children in need

beginning of the outbreak, of which 9,486 confirmed. of vaccination against diphteria
• 72 % (6,847 children) of the confirmed cases aged 1-
14 years. Some 562 cumulative deaths (cumulative 14,482 suspected cases
case fatality (CFR) 5.9 per cent).
• Cases reported from 19 states and 128 LGAs, with 95 (72% children 1-14 years),
per cent of cases from Northwest (Kano, Katsina), and 562 (98% children) deaths
Northeast (Yobe, Bauchi and Borno) states.
• 2,560,820 children aged 6 months to 4 years were 7,504,981 children
vaccinated against diphtheria during the first round of
the reactive vaccination with Pentavalent vaccines, children vaccinated against
while a total of 4,944,161 children aged from 5 to 14 diphtheria in phase 1 and 2 of
years were reached with Tetanus-Diphtheria (Td) first round of immunization
vaccines in 56 high-risk Local Government Areas campaigns.
(LGAs) in 7 states.
• A national Knowledge, Attitudes and Practices (KAP) Funding gap of
study led by NCDC and supported by UNICEF and
partners was finalised and is informing the adjustment US$3.85 M to respond to
of the response. the outbreak in 7 states
• Funding gap of $3,85M (while $3,95M mobilised) to
respond to the outbreak in 7 high-priority states over Data as of 12 October 2023
the next 6 months.

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Situation Overview

• Since December 2022, Nigeria has been experiencing a large diphtheria outbreak, which escalated
in July 2023. As of 12 October 2023, there are 14,482 suspected cumulative cases of which 9,486
confirmed have been reported by the Nigeria Centre for Disease Control and Prevention (NCDC)
since January 2023.
• The outbreak has claimed 562 lives (CFR 5.9%), with 95% of deaths under 14 years. Improvement
in case management and increased availability of Diphtheria Antitoxin (DAT) have resulted in
improved case fatality, with weekly case fatality reduced to less than 1 per cent.
• Kano State in northwestern Nigeria represents the outbreak's epicentre, recording 71 per cent of
confirmed cases. In total, 95 per cent of the cases are reported from five states of Northwest (Kano,
Yobe, Katsina, Bauchi and Borno).
• Initially localized in Kano, the outbreak has spread to 19 states and 128 LGAs, mostly in the
Northeast, with suspected cross-border transmissions with the Republic of Niger under
investigation.
• The highest burden of the outbreak is borne by children between the ages of 1 and 14 years,
accounting for a substantial 72 per cent (6,847 children) of the confirmed cases.
• Analysis of vaccination status highlighted that over 60 per cent of all suspected cases have not
been vaccinated.
• Phase 1 and 2 of the first round of the reactive vaccination campaign, targeting 6.7 million children
(6 weeks -14 years), with two doses Penta or Td vaccine, in seven states and 56 high-risk LGAs is
completed. 829,181 and 1,731,639 children 6 weeks – 4 years were reached with two doses of
Penta, while 1,668,964 and 3,275,197 children 4-14 years received two doses of Td vaccine in
Phase 1 and 2 respectively.

Summary Analysis of Programme Response

UNICEF's response to the outbreak extends from the national level through active participation in the
government-led Diphtheria Emergency Task Team, as well as state and LGAs levels. The risk of the
outbreak spreading beyond its current focal point in the North to the rest of the country remains
significant, primarily because of low immunization coverage. UNICEF's response continues to prioritize
addressing existing immunity gaps through reactive vaccination, enhancing awareness about the
disease and communities’ trust and empowerment through Risk Communication and Community
Engagement (RCCE), and preventing transmission and reducing deaths through active involvement in
Case Management and Infection Prevention and Control (IPC).

I. Coordination and Leadership

UNICEF actively participates in the National Diphtheria Emergency Task Team, which was activated on
14 September to respond to the outbreak, and determined the strategic focus on 56 LGAs in 7 states
(Kano, Katsina, Jigawa, Kaduna, Bauchi, Borno, and Yobe). UNICEF further participates in state-level
government coordination fora in all the 7 states. UNICEF supports the response pillars of RCCE, case
management/ IPC, and the reactive vaccination response.
Additionally, UNICEF participates in the national-level inter-agency coordination platform, led by the
WHO and activated to enhance collaboration on shared technical support and advocacy interventions.

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 II. Case Management and Infection Prevention and Control

Over the reporting period, UNICEF:

• Supported the procurement of 6 biosafety cabinets for the NCDC ($ 456,381)

• supported the procurement of personal protective equipment (PPEs) for healthcare workers in
diphtheria treatment centres ($120,000)
• Supported the procurement and dispatch to 3 States of 30,00 doses of antibiotics (Azithromycin,
Erythromycin) and 20 high performance tents for diphtheria case management.
• Provided technical support in developing and finalizing the National Diphtheria Response
Guidelines.

III. Risk Communication and Community Engagement (RCCE)

UNICEF supports the RCCE pillar coordination platforms at both federal and state levels. During the
reporting period, the following activities were conducted with UNICEF support.

• A national Knowledge, Attitudes and Practices (KAP) study led by NCDC and supported by
UNICEF and partners was finalized. The study, conducted in 8 States with 2672 responses from
100 LGAs, concluded that only 36 per cent recognized diphtheria as a bacterial disease, and about
30 per cent of respondents don’t know anything about it. Nevertheless, most respondents correctly
identified the symptoms of the disease. For all states except one, radio has been the main source of
information on diphtheria, as it’s also the most trusted channel of communication in seven of the
eight states.
• The KAP study also collected frequent rumours around the disease, namely related to alternative
treatments, spiritual beliefs, and misconceptions about the vaccines. These results will inform the
response interventions.
• Almost 3800 Volunteer Community Mobilizers (VCMs) who conduct house-to-house dialogues on
the signs and symptoms of diphtheria, early reporting, and preventive measures, continue to be
supported by UNICEF in Kano, Borno, and Yobe states.
• The VCM network has been crucial in community-based surveillance as well as in collecting and
tracking rumours that are then channelled to and addressed by RCCE partners in the respective
States.
• 400 cholera mobilizers engaged in hard-to-reach areas and cholera hot spots have been trained to
sensitize households on diphtheria in Borno and Yobe States.
• 235 traditional leaders and at least 290 religious leaders were engaged and trained, especially on
case finding and alerts notifications in the most affected States.
• 700 teachers of primary, junior, and secondary schools from the three highest-burden LGAs in
Kano State were briefed by Health, Education and SBC teams.
• 45 National Orientation officers and 48 Health Educators were trained in Borno and Yobe States on
signs and symptoms of diphtheria.
• Sensitization sessions with 60 local barbers, who many people still refer to when the first diphtheria
symptoms appear, believing they are experiencing another type of health issue (tonsilitis), were
organized in Kano State. Around 60 nomads were also engaged and part of an awareness session.

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• 40 members of civil society organizations and selected governmental staff were trained on
diphtheria and equipped to lead the sensitization of other actors in six selected LGAs in Katsina
State.
• Two media training courses and briefings were conducted, involving 80 professionals from five
states.
• Sessions with and engagement of the Federation of Muslim Women Associations of Nigeria
(FOMWAN), Nomadic for Health members, Jumaat Mosque Imams, Patent Medicine Vendors
Association, and social media activists were organized in the northern states.
• Development of key messages, printing of IEC materials (Frequently Asked Question pamphlets,
banners, etc.), and the production of radio jingles and video spots, including one by an UNICEF
champion were concluded.
• Audio materials have been broadcast in five different languages in a total of 15 radio stations from
seven States and Federal level. Live and interactive radio programmes on diphtheria are also being
supported, which have been crucial for the roll out of the vaccination campaigns.

IV. Reactive Vaccination

• Three rounds of reactive vaccination campaigns against diphtheria, a minimum four weeks apart,
are planned, targeting 56 high-priority LGAS in seven states.
• Round 1, staggered in phase 1 and phase 2 implemented in 34 LGAs across five states targeting
1,432,810 (6 weeks – 4 years) children with Pentavalent vaccine and 2,892,585 children Td (4-14
years) with Td vaccine is completed, with the outcome included in the table below.
• Round 2 of the campaigns is planned for November, with states commencing on different dates
based on when they completed Round 1.

Round 1 – Phase 1
Penta (6 weeks – 4 years) Td (4 – 14 years) LQAS* results
State LGAs Target Reached (%) Target Reached (%)
Katsina 9 296,959 331,615 112 474,322 421,045 89 Pending
Bauchi 5 275,369 162,840 59 586,270 257,075 44 Pending
Kaduna 5 242,613 184,016 76 516,531 279,039 54 Pending
Yobe 7 142,715 82,601 58 303,846 207,418 68 Pending
Kano 8 475,153 68,109 14 1,011,616 504,387 50 Pending
1,668,96
Total 34 1,432,810 829,181 2,892,584 4
Round 1 – Phase 2
Penta (6 weeks – 4 years) Td (4 – 14 years)
State LGAS Target Reached % Target Reached % LQAS4 results
Katsina 9 296,959 255,075 86 474,322 403,252 85 Pending
Bauchi 5 275,369 243,399 88 586,270 338,208 58 Pending
Kaduna 5 242,613 251,126 104 516,531 502,657 97 Pending
NA, campaign
Yobe1 8 194,922 205,392 105 414,994 437,138 105 not completed
Kano 14 511,406 557,433 109 1,089,647 1,231,301 113 43
NA, campaign
Kano2 8 475,153 - 1,011,616 - - not completed
Jigawa 3 183,161 178,487 97 281,092 267,350 95 Pending

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 NA, campaign
Borno3 4 71,926 40,728 57 153,132 95,291 62 not completed
Total 56 2,251,508 1,731,639 4,527,604 3,275,197
1Commenced 12 October (data as at day 6), 2Planned for Round 2; 3 Commenced on 16 October (as at day 3);
4 Proportion of LGAs who passed Lot quality assurance surveys (LQAS).

V. Supply

• In support of the Government of Nigeria, a variety of funding channels were utilized to secure
access to the global market of Td and Penta vaccines.
o UNICEF Nigeria Health Section budget
o Gavi Alliance funding
o The Government of Nigeria’s World Bank Loan
o UNICEF Supply Division’s Vaccine Independence Initiative, with risk-sharing provided by the
World Bank and UNICEF Nigeria
• 15.5 million doses of Td and 20 million doses of Penta have been procured with full delivery
expected by January 2024.
• 7.5 million doses of Td and 7 million doses of Penta have already been delivered to Nigeria (as of
19 October).
• An additional 13 million doses of Td and 8.3 million doses of Penta are in the funding pipeline to
arrive in country by December 2023 and January 2024.
• Procured quantities will support an increased outbreak response or routine immunization needs
going into 2024, subject to the dynamic situation on-the-ground.

VI. Human resources

In addition to CO and sub-office staff engaged in the response, four staff from HQ were deployed to
support the response in the areas of coordination and leadership (1), immunization (2), RCCE (1), and
information/data management (1)

VII. Human interest stories and external media

Informative messages on diphtheria vaccination and call-to-action were shared on UNICEF Nigeria
Social Media pages. Some links below

• https://www.instagram.com/p/CxdpPyRtAJV/
• https://www.instagram.com/p/CxnAR-hMbxT/
• https://www.instagram.com/p/CxphPuGsfvZ/ https://www.instagram.com/p/CxurMGFMYA1/
• https://twitter.com/UNICEF_Nigeria/status/1707316630282178645
• https://twitter.com/UNICEF_Nigeria/status/1706237230220476482
• https://www.facebook.com/UNICEFNigeria/posts/
• https://www.facebook.com/UNICEFNigeria/posts/

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Funding Overview and Partnership
With the generous support from partners - notably the Alwaleed Foundation, and the US Fund
for UNICEF - as well as reprogramming of internal resources, funds in the amount of $1.75m
have been made available thus far (89% for vaccines, 8.6% for case management, including
community management, and 2.4% for WASH in schools). Additionally, commitments have
been received for vaccines in the amount of $2.2m. To conduct the diphtheria outbreak
response in 56 LGAs across 7 states, another $3.85 m is required to undertake the following
activities: procurement and shipment of vaccines, operational support to campaign
implementaton, procurement of supplies for case management, IPC, RCCEs and community-
based activities.

Funds needed Funds available (and Funding gap

7,800,000 committed): 3,950,000 3,850,000

For further information, please contact UNICEF Nigeria

Cristian Munduate Eduardo Celades Christina Valderrama- Linda Clare Wangeci

Representative Chief of Health Alfirev Resource Mobilization
cmunduate@unicef.org ecelades@unicef.org Emergency Manager Specialist
cvalderamma@unicef.org lclare@unicef.org