1. 1170Investigation of COVID-19 outbreak in a South West State of Nigeria: Preliminary findings.
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Adejugbagbe, Adewale Moses, Isere, Elvis Efe, Fagbemi, Aderonke Tolulope, Fagbemi, Stephen, Famokun, Adekunle Gboyega, Omoju, Temitope Olajumoke, and Adegbenro, Wahab
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MEDICAL personnel , *COVID-19 pandemic , *COVID-19 , *COUGH , *SYMPTOMS , *PUBLIC health , *RESPIRATORY diseases - Abstract
Background The COVID-19 outbreak is increasing and spreading rapidly globally, with over 20 million cases and 800, 000 thousand deaths reported in 216 countries as of 28th August 2020. Since the report of the index case in Nigeria in February 2020 by the Nigeria Center for Disease Control (NCDC), daily records of confirmed cases have been reported in all states in the country. On 3rd April 2020, an outbreak of Coronavirus disease-2019 (COVID-19) was confirmed in Ondo State, Southwest Nigeria. Field investigations were conducted by the State Ministry of Health (MoH) to identify and confirm additional cases. This paper provides the outcome of the epidemiological investigation of the outbreak to further guide outbreak response activities. Methods Outbreak settings Ondo State is in the South-West Zone of Nigeria with her capital at Akure. The State is situated between longitudes 40 151E and 60 001E of the Greenwich median and latitudes 50 451N and 70 451 N, which are to the North of the equator in the Southwestern geopolitical zones of the country. Field Investigation The investigation was conducted as part of outbreak control and response measures hence permission to conduct the study was obtained from the Ondo State Ministry of Health (OSMoH). Following an alert from clinicians at a government-owned Hospital, Akure, Ondo State on 30 March 2020, the index case of COVID-19, a 34-year-old male with recent travel history to India was investigated. He arrived at Ondo State on 21st March 2020 and presented at the hospital with cough, sore throat and running nose with the onset of symptoms on 23rd March 2020. The State public health emergency Rapid Response Team (RRT) comprising of Commissioner for Health, State Epidemiologist, State and LGA surveillance officers, and health development partners in the state visited the hospital to investigate and implement public health response. Nasopharygeal and oropharyngeal samples were collected and tested for COVID-19, and returned positive from the national reference laboratory on the 3rd of April 2020. Operational definitions During the onset of the outbreak, three categories of case definitions for COVID-19 were used to guide the outbreak investigations according to the Nigeria Center for Diseases Control (NCDC) guidelines. Suspect case: (1) This is a patient with acute respiratory illness (fever and at least one sign/ symptom of respiratory disease (e.g. cough, shortness of breath) and a history of travel to or residence in a country/area or territory reporting local transmission of COVID-19 disease during the 14 days prior to symptom onset; (2) or a patient/health care worker with any acute respiratory illness and has been in contact with a confirmed COVID-19 case in the last 14 days prior to the onset of symptoms; (3) or a patient with a severe acute respiratory infection (fever and at least one sign/symptom of respiratory disease (e.g. cough, shortness of breath) and requiring hospitalization and with no other aetiology that fully explains the clinical presentation; (4) or a case for whom testing for COVID-19 is inconclusive. Confirmed case: A person with laboratory confirmation of COVID-19 infection, irrespective of clinical signs and symptoms. Probable case: Any suspected case for whom testing for COVID-19 is indeterminate test result or for whom testing was positive on a pan-coronavirus assay Data analysis The State COVID-19 line-list and case investigation forms of all COVID-19 cases from 19th March to 9th August 2020 were retrieved from the state disease surveillance unit, information on key variables were extracted and exported into SPSS version 20 and analyzed. Descriptive statistics such as frequency table, mean (standard deviation) and charts were used to describe key variables including LGA, age, sex, occupation and education and clinical conditions of cases. The week of report of cases and outcomes were used to generate the epidemic curve. The Chi-square test was used to compare categorical variables including the socio-demographic characteristics, clinical condition and outcome of cases. Two-sided P-values <0.05 were considered statistically significant. Results Socio-demographic characteristics of cases A total of 4353 suspected cases were reported and tested for COVID-19, of which 1316 COVID-19 cases were confirmed, with a case fatality rate of 2.2% recorded in 7 of the 17 Local Government Areas that reported at least a confirmed case (Figure 1). Most of the confirmed cases (1169; 88.8%), resides in urban areas (LGAs) (Table 1). Majority [1110 (84.3%)] were within the age group 20 to 59 years, with a mean age of 37.8 ±14.8 years. Males (713; 54.2%) were more affected compare to females (603; 45.8). More than three quarters (1009; 76.7%) of the cases had a tertiary level of education. Health care workers (404; 30.7%) were most affected compared to other professionals as shown in Table 1. 1170 Figure 1: Open in new tab Download slide Distribution of suspected and confirmed COVID-19 cases in Ondo state, March to August 2020 1170 Figure 1: Open in new tab Download slide Distribution of suspected and confirmed COVID-19 cases in Ondo state, March to August 2020 1170 Table 1: Socio-demographic characteristics of respondents N = 1316 Variable. Frequency. Percentage. Age in years <5 18 1.4 5-19 84 6.4 20-39 666 50.6 40-59 444 33.7 60-79 96 7.3 ≥80 8 0.6 Gender Male 713 54.2 Female 603 45.8 Location of cases Rural 147 11.2 Urban 1169 88.8 Type of Education None 15 1.1 Nursery 8 0.6 Primary 80 6.1 Secondary 204 15.5 Tertiary 1009 76.7 Occupation Health workers 404 30.7 Businessman and woman 225 17.1 Civil servant 168 12.8 Others 182 13.8 Pupil/Student 129 9.8 Political office Holders 77 5.9 Engineer 48 3.6 Religious/traditional leader 24 1.8 Banker 24 1.8 Security officer 35 2.7 Variable. Frequency. Percentage. Age in years <5 18 1.4 5-19 84 6.4 20-39 666 50.6 40-59 444 33.7 60-79 96 7.3 ≥80 8 0.6 Gender Male 713 54.2 Female 603 45.8 Location of cases Rural 147 11.2 Urban 1169 88.8 Type of Education None 15 1.1 Nursery 8 0.6 Primary 80 6.1 Secondary 204 15.5 Tertiary 1009 76.7 Occupation Health workers 404 30.7 Businessman and woman 225 17.1 Civil servant 168 12.8 Others 182 13.8 Pupil/Student 129 9.8 Political office Holders 77 5.9 Engineer 48 3.6 Religious/traditional leader 24 1.8 Banker 24 1.8 Security officer 35 2.7 Open in new tab 1170 Table 1: Socio-demographic characteristics of respondents N = 1316 Variable. Frequency. Percentage. Age in years <5 18 1.4 5-19 84 6.4 20-39 666 50.6 40-59 444 33.7 60-79 96 7.3 ≥80 8 0.6 Gender Male 713 54.2 Female 603 45.8 Location of cases Rural 147 11.2 Urban 1169 88.8 Type of Education None 15 1.1 Nursery 8 0.6 Primary 80 6.1 Secondary 204 15.5 Tertiary 1009 76.7 Occupation Health workers 404 30.7 Businessman and woman 225 17.1 Civil servant 168 12.8 Others 182 13.8 Pupil/Student 129 9.8 Political office Holders 77 5.9 Engineer 48 3.6 Religious/traditional leader 24 1.8 Banker 24 1.8 Security officer 35 2.7 Variable. Frequency. Percentage. Age in years <5 18 1.4 5-19 84 6.4 20-39 666 50.6 40-59 444 33.7 60-79 96 7.3 ≥80 8 0.6 Gender Male 713 54.2 Female 603 45.8 Location of cases Rural 147 11.2 Urban 1169 88.8 Type of Education None 15 1.1 Nursery 8 0.6 Primary 80 6.1 Secondary 204 15.5 Tertiary 1009 76.7 Occupation Health workers 404 30.7 Businessman and woman 225 17.1 Civil servant 168 12.8 Others 182 13.8 Pupil/Student 129 9.8 Political office Holders 77 5.9 Engineer 48 3.6 Religious/traditional leader 24 1.8 Banker 24 1.8 Security officer 35 2.7 Open in new tab Admission and clinical conditions of confirmed cases From Table 2 , 88 (6.7%) of the confirmed cases were admitted as inpatient during investigation, while 325 (24.7%) were symptomatic. The first symptom reported by cases were as follows; cough (98; 30.2%), fever (74; 22.8%), headache (30; 9.2%), runny nose (39; 12.0%), sore throat (24; 7.4%) and difficulty in breathing (15; 4.6%). 1170 Table 2: Admission and clinical conditions of confirmed cases. Frequency. Percentage. Admitted as inpatient before lab testing Yes 88 6.7 No 1228 93.3 Symptomatic Yes 325 24.7 No 991 75.3 First symptom reported by respondents (n = 325) Cough 98 30.2 Fever 74 22.8 Headache 30 9.2 Runny nose 39 12.0 Sore throat/pharyngitis 24 7.4 Difficulty breathing 15 4.6 New loss of taste 9 2.7 New loss of smell 8 2.5 Chest pain 7 2.2 General Body weakness 6 1.8 Others 15 4.6 Outcome Alive 1287 97.8 Dead 29 2.2 . Frequency. Percentage. Admitted as inpatient before lab testing Yes 88 6.7 No 1228 93.3 Symptomatic Yes 325 24.7 No 991 75.3 First symptom reported by respondents (n = 325) Cough 98 30.2 Fever 74 22.8 Headache 30 9.2 Runny nose 39 12.0 Sore throat/pharyngitis 24 7.4 Difficulty breathing 15 4.6 New loss of taste 9 2.7 New loss of smell 8 2.5 Chest pain 7 2.2 General Body weakness 6 1.8 Others 15 4.6 Outcome Alive 1287 97.8 Dead 29 2.2 Others= abdominal pain; chills/sweats; joint pain; inability to walk; Nausea Open in new tab 1170 Table 2: Admission and clinical conditions of confirmed cases. Frequency. Percentage. Admitted as inpatient before lab testing Yes 88 6.7 No 1228 93.3 Symptomatic Yes 325 24.7 No 991 75.3 First symptom reported by respondents (n = 325) Cough 98 30.2 Fever 74 22.8 Headache 30 9.2 Runny nose 39 12.0 Sore throat/pharyngitis 24 7.4 Difficulty breathing 15 4.6 New loss of taste 9 2.7 New loss of smell 8 2.5 Chest pain 7 2.2 General Body weakness 6 1.8 Others 15 4.6 Outcome Alive 1287 97.8 Dead 29 2.2 . Frequency. Percentage. Admitted as inpatient before lab testing Yes 88 6.7 No 1228 93.3 Symptomatic Yes 325 24.7 No 991 75.3 First symptom reported by respondents (n = 325) Cough 98 30.2 Fever 74 22.8 Headache 30 9.2 Runny nose 39 12.0 Sore throat/pharyngitis 24 7.4 Difficulty breathing 15 4.6 New loss of taste 9 2.7 New loss of smell 8 2.5 Chest pain 7 2.2 General Body weakness 6 1.8 Others 15 4.6 Outcome Alive 1287 97.8 Dead 29 2.2 Others= abdominal pain; chills/sweats; joint pain; inability to walk; Nausea Open in new tab Figure 2 described the epidemic curve of the outbreak from March to August 2020. The index case was confirmed on April 4, 2020. Thereafter, there was a surge in the number of confirmed COVID-19 cases with the outbreak reaching its peak on July 2, 2020. Afterwards, fluctuations in the number of cases were observed before a steady decline was recorded between August 3, 2020 and August 9, 2020. 1170 Figure 2 Open in new tab Download slide Epi-Curve of confirmed cases of COVID-19 in Ondo State, March to August 2020 1170 Figure 2 Open in new tab Download slide Epi-Curve of confirmed cases of COVID-19 in Ondo State, March to August 2020 Association between socio-demographic characteristics, clinical conditions and outcomes of cases In Table 3 , significant proportion of death occurred among cases within the age group 60 years and above (14; 13.5%) compared to other age groups (p < 0.001). Death occurred more among males (26; 3.6%) compared to the females (3; 0.5%) (p < 0.001). Furthermore, symptomatic cases had higher proportion (27; 8.3%) of deaths compared to asymptomatic cases (2; 0.2%) (P < 0.001). Among the symptomatic cases, a high proportion of death was found among those with difficulty in breathing (3; 20%), fever (11; 14.9%), new loss of taste (1; 11.1%), cough (9; 9.2%) and sore throat (2; 8.3%) (P < 0.001) 1170 Table 3: Association between socio-demographic characteristics and outcomes of cases Variable. Outcome. . Total. P-value. Dead. Alive. Age in years <5 0 (0.0) 18 (100.0) 18 <0.001 5-19 0 (0.0) 84 (100.0) 84 20-39 2 (0.3) 664 (99.7) 666 40-59 13 (2.9) 431 (97.1) 444 ≥60 14 (13.5) 90 (86.5) 104 Gender Male 26 (3.6) 687 (96.4) 713 <0.001 Female 3 (0.5) 600 (99.5) 603 Location of cases Rural 5 (3.4) 142 (96.6) 147 0.294 Urban 24 (2.1) 1145 (97.9) 1169 Type of Education None 1 (6.7) 14 (93.3) 15 0.630 Nursery 0 (0.0) 8 (100.0) 8 Primary 3 (3.8) 77 (96.2) 80 Secondary 4 (2.0) 200 (98.0) 204 Tertiary 21 (2.1) 988 (97.9) 1009 Occupation Health workers 2 (0.5) 402 (99.5) 24 Businessman and woman 14 (6.2) 211 (93.8) 225 Civil servant 1 (0.6) 167 (99.4) 168 <0.001 Others 10 (5.5) 172 (94.5) 182 Pupil/Student 0 (0.0) 129 (100.0) 129 Politician 0 (0.0) 77 (100.0) 77 Engineer 0 (0.0) 48 (100.0) 48 Religious/traditional ruler 2 (8.3) 22 (91.7) 24 Banker 0 (0.0) 24 (100.0) 24 Security officer 0 (0.0) 35 (100.0) 35 Symptomatic Yes 27 (8.3) 298 (91.7) 325 <0.001 No 2 (0.2) 989 (99.8) 991 First symptom N = 325 Cough 9 (9.2) 89 (90.8) 98 Fever 11 (14.9) 63 (85.1) 74 <0.001 Headache 1 (3.3) 29 (96.7) 30 Running nose 0 (0.0) 39 (100.0) 39 Sore throat 2 (8.3) 22 (91.7) 24 New loss of taste 1 (11.1) 8 (88.9) 9 Difficulty in breathing 3 (20.0) 12 (80.0) 15 New loss of smell 0 (0.0) 5 (100.0) 5 Others 0 (0.0) 31 (100.0) 31 Variable. Outcome. . Total. P-value. Dead. Alive. Age in years <5 0 (0.0) 18 (100.0) 18 <0.001 5-19 0 (0.0) 84 (100.0) 84 20-39 2 (0.3) 664 (99.7) 666 40-59 13 (2.9) 431 (97.1) 444 ≥60 14 (13.5) 90 (86.5) 104 Gender Male 26 (3.6) 687 (96.4) 713 <0.001 Female 3 (0.5) 600 (99.5) 603 Location of cases Rural 5 (3.4) 142 (96.6) 147 0.294 Urban 24 (2.1) 1145 (97.9) 1169 Type of Education None 1 (6.7) 14 (93.3) 15 0.630 Nursery 0 (0.0) 8 (100.0) 8 Primary 3 (3.8) 77 (96.2) 80 Secondary 4 (2.0) 200 (98.0) 204 Tertiary 21 (2.1) 988 (97.9) 1009 Occupation Health workers 2 (0.5) 402 (99.5) 24 Businessman and woman 14 (6.2) 211 (93.8) 225 Civil servant 1 (0.6) 167 (99.4) 168 <0.001 Others 10 (5.5) 172 (94.5) 182 Pupil/Student 0 (0.0) 129 (100.0) 129 Politician 0 (0.0) 77 (100.0) 77 Engineer 0 (0.0) 48 (100.0) 48 Religious/traditional ruler 2 (8.3) 22 (91.7) 24 Banker 0 (0.0) 24 (100.0) 24 Security officer 0 (0.0) 35 (100.0) 35 Symptomatic Yes 27 (8.3) 298 (91.7) 325 <0.001 No 2 (0.2) 989 (99.8) 991 First symptom N = 325 Cough 9 (9.2) 89 (90.8) 98 Fever 11 (14.9) 63 (85.1) 74 <0.001 Headache 1 (3.3) 29 (96.7) 30 Running nose 0 (0.0) 39 (100.0) 39 Sore throat 2 (8.3) 22 (91.7) 24 New loss of taste 1 (11.1) 8 (88.9) 9 Difficulty in breathing 3 (20.0) 12 (80.0) 15 New loss of smell 0 (0.0) 5 (100.0) 5 Others 0 (0.0) 31 (100.0) 31 Others = chest pain, diarrhea, fatigue, joint pain, malaise, nausea, vomiting Open in new tab 1170 Table 3: Association between socio-demographic characteristics and outcomes of cases Variable. Outcome. . Total. P-value. Dead. Alive. Age in years <5 0 (0.0) 18 (100.0) 18 <0.001 5-19 0 (0.0) 84 (100.0) 84 20-39 2 (0.3) 664 (99.7) 666 40-59 13 (2.9) 431 (97.1) 444 ≥60 14 (13.5) 90 (86.5) 104 Gender Male 26 (3.6) 687 (96.4) 713 <0.001 Female 3 (0.5) 600 (99.5) 603 Location of cases Rural 5 (3.4) 142 (96.6) 147 0.294 Urban 24 (2.1) 1145 (97.9) 1169 Type of Education None 1 (6.7) 14 (93.3) 15 0.630 Nursery 0 (0.0) 8 (100.0) 8 Primary 3 (3.8) 77 (96.2) 80 Secondary 4 (2.0) 200 (98.0) 204 Tertiary 21 (2.1) 988 (97.9) 1009 Occupation Health workers 2 (0.5) 402 (99.5) 24 Businessman and woman 14 (6.2) 211 (93.8) 225 Civil servant 1 (0.6) 167 (99.4) 168 <0.001 Others 10 (5.5) 172 (94.5) 182 Pupil/Student 0 (0.0) 129 (100.0) 129 Politician 0 (0.0) 77 (100.0) 77 Engineer 0 (0.0) 48 (100.0) 48 Religious/traditional ruler 2 (8.3) 22 (91.7) 24 Banker 0 (0.0) 24 (100.0) 24 Security officer 0 (0.0) 35 (100.0) 35 Symptomatic Yes 27 (8.3) 298 (91.7) 325 <0.001 No 2 (0.2) 989 (99.8) 991 First symptom N = 325 Cough 9 (9.2) 89 (90.8) 98 Fever 11 (14.9) 63 (85.1) 74 <0.001 Headache 1 (3.3) 29 (96.7) 30 Running nose 0 (0.0) 39 (100.0) 39 Sore throat 2 (8.3) 22 (91.7) 24 New loss of taste 1 (11.1) 8 (88.9) 9 Difficulty in breathing 3 (20.0) 12 (80.0) 15 New loss of smell 0 (0.0) 5 (100.0) 5 Others 0 (0.0) 31 (100.0) 31 Variable. Outcome. . Total. P-value. Dead. Alive. Age in years <5 0 (0.0) 18 (100.0) 18 <0.001 5-19 0 (0.0) 84 (100.0) 84 20-39 2 (0.3) 664 (99.7) 666 40-59 13 (2.9) 431 (97.1) 444 ≥60 14 (13.5) 90 (86.5) 104 Gender Male 26 (3.6) 687 (96.4) 713 <0.001 Female 3 (0.5) 600 (99.5) 603 Location of cases Rural 5 (3.4) 142 (96.6) 147 0.294 Urban 24 (2.1) 1145 (97.9) 1169 Type of Education None 1 (6.7) 14 (93.3) 15 0.630 Nursery 0 (0.0) 8 (100.0) 8 Primary 3 (3.8) 77 (96.2) 80 Secondary 4 (2.0) 200 (98.0) 204 Tertiary 21 (2.1) 988 (97.9) 1009 Occupation Health workers 2 (0.5) 402 (99.5) 24 Businessman and woman 14 (6.2) 211 (93.8) 225 Civil servant 1 (0.6) 167 (99.4) 168 <0.001 Others 10 (5.5) 172 (94.5) 182 Pupil/Student 0 (0.0) 129 (100.0) 129 Politician 0 (0.0) 77 (100.0) 77 Engineer 0 (0.0) 48 (100.0) 48 Religious/traditional ruler 2 (8.3) 22 (91.7) 24 Banker 0 (0.0) 24 (100.0) 24 Security officer 0 (0.0) 35 (100.0) 35 Symptomatic Yes 27 (8.3) 298 (91.7) 325 <0.001 No 2 (0.2) 989 (99.8) 991 First symptom N = 325 Cough 9 (9.2) 89 (90.8) 98 Fever 11 (14.9) 63 (85.1) 74 <0.001 Headache 1 (3.3) 29 (96.7) 30 Running nose 0 (0.0) 39 (100.0) 39 Sore throat 2 (8.3) 22 (91.7) 24 New loss of taste 1 (11.1) 8 (88.9) 9 Difficulty in breathing 3 (20.0) 12 (80.0) 15 New loss of smell 0 (0.0) 5 (100.0) 5 Others 0 (0.0) 31 (100.0) 31 Others = chest pain, diarrhea, fatigue, joint pain, malaise, nausea, vomiting Open in new tab Conclusions The outcome of this investigation indicating high transmission among urban residence and health care workers are key public health concerns in the response to the COVID-19 outbreak in Ondo State, Nigeria. Furthermore, high case mortality among the older age groups requires public health intervention. Thus, we recommend intensified risk communication, enhanced surveillance activities, and use of community structures such as community and religious leaders, market and commercial vehicles associations, Ward Development Committee (WDC) and Village Development Committee (VDC) to ensure compliance with public health COVID-19 preventive measures particularly in the urban areas and among those facing a high risk of death. Furthermore, there is a need to prioritize public health interventions including training and vaccination among the vulnerable groups including health care workers who serve as front liners during case investigation, testing and case management. Key messages Enforcement of public health preventive measures particularly in urban settings, and supporting government to strengthen and monitor Infection Prevention and Control practices in hospital settings. [ABSTRACT FROM AUTHOR]
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- 2021
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