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The origin and hazardous potential of human mpox is obscured by a lack of genomic data between the 2018, when exportations from Nigeria were recorded, and 2022 when the global outbreak started. Here, 18 genomes from patients across southern Nigeria in 2019/20 reveal multiple lineages of Monkeypox virus have achieved sustained human-to-human transmission, co-existing in humans for several years and accumulating mutations consistent with APOBEC3 activity suggesting the virus in humans is now segregated from its natural reservoir. Remarkably, three genomes have disruptions in the A46R gene, which contributes to innate immune modulation. The data demonstrates that the A.2 lineage, multiply exported to North America since 2021 independently of the global outbreak, has persisted in Nigeria for more than two years prior to its latest exportation.One-Sentence SummaryMpox is now a human diseae evolving in humans with multiple variants taking separate paths towards adaptation, some analogous to those ofVariola

The introduction of effective vaccines in December 2020 marked a significant step forward in the global response to COVID-19. Given concerns with access, acceptability, and hesitancy across Africa, there is a need to describe the current status of vaccine uptake in the continent. An exploratory study was undertaken to investigate these aspects, current challenges, and lessons learnt across Africa to provide future direction. Senior personnel across 14 African countries completed a self-administered questionnaire, with a descriptive analysis of the data. Vaccine roll-out commenced in March 2021 in most countries. COVID-19 vaccination coverage varied from low in Cameroon and Tanzania and up to 39.85% full coverage in Botswana at the end of 2021; that is, all doses advocated by initial protocols versus the total population, with rates increasing to 58.4% in Botswana by the end of June 2022. The greatest increase in people being fully vaccinated was observed in Uganda (20.4% increase), Botswana (18.5% increase), and Zambia (17.9% increase). Most vaccines were obtained through WHO-COVAX agreements. Initially, vaccination was prioritised for healthcare workers (HCWs), the elderly, adults with co-morbidities, and other at-risk groups, with countries now commencing vaccination among children and administering booster doses. Challenges included irregular supply and considerable hesitancy arising from misinformation fuelled by social media activities. Overall, there was fair to reasonable access to vaccination across countries, enhanced by government initiatives. Vaccine hesitancy must be addressed with context-specific interventions, including proactive programmes among HCWs, medical journalists, and the public.

Background: Human monkeypox (HMPX) is currently spreading outside endemic countries in Africa and the majority of those affected are gay and bisexual men within interconnected sexual networks. We investigated the sexual history of HMPX cases seen at a tertiary hospital in Bayelsa State during the 2017–2018 outbreak in Nigeria. Method: A cross-sectional study was conducted between 20 October 2017 and 2 January 2019 among adult confirmed/probable HMPX cases. A questionnaire was used to collect data on the sexual history of participants, including sexual contact in relation to the first symptom, and high-risk behaviours (HRB) such as a history of condomless casual sex, multiple sexual partners, and transactional sex. Results: Of 21 patients, 16 (76.2%) gave consent to participate in the study: age range of 22–43 years, 75% males, three (18.8%) HIV-1 positive, and 13 (81.2%) with genital ulcers. Nine (56.2%) of participants reported HRB, and all were male heterosexuals. Eight of the 16 participants (50%) reported having sex within a month before their first symptom, and five (62.5%) of this number reported HRB. There were two cases of sex with a partner with a non-genital rash, and a spouse who developed a vulval ulcer four days after sex with her husband. Conclusion: Our results support the role of sexual contact in the transmission of monkeypox among some confirmed cases from Nigeria. However, future elaborate studies are required to confirm if sexual behaviour and sexual transmission are associated with HMPX in Nigeria.

BACKGROUND: Population-level health and mortality data are crucial for evidence-informed policy but scarce in Nigeria. To fill this gap, we undertook a comprehensive assessment of the burden of disease in Nigeria and compared outcomes to other west African countries. METHODS: In this systematic analysis, using data and results of the Global Burden of Diseases, Injuries, and Risk Factors Study 2019, we analysed patterns of mortality, years of life lost (YLLs), years lived with disability (YLDs), life expectancy, healthy life expectancy (HALE), and health system coverage for Nigeria and 15 other west African countries by gender in 1998 and 2019. Estimates of all-age and age-standardised disability-adjusted life-years for 369 diseases and injuries and 87 risk factors are presented for Nigeria. Health expenditure per person and gross domestic product were extracted from the World Bank repository. FINDINGS: Between 1998 and 2019, life expectancy and HALE increased in Nigeria by 18% to 64·3 years (95% uncertainty interval [UI] 62·2-66·6), mortality reduced for all age groups for both male and female individuals, and health expenditure per person increased from the 11th to third highest in west Africa by 2018 (US$18·6 in 2001 to $83·75 in 2018). Nonetheless, relative outcomes remained poor; Nigeria ranked sixth in west Africa for age-standardised mortality, seventh for HALE, tenth for YLLs, 12th for health system coverage, and 14th for YLDs in 2019. Malaria (5176·3 YLLs per 100 000 people, 95% UI 2464·0-9591·1) and neonatal disorders (4818·8 YLLs per 100 000, 3865·9-6064·2) were the leading causes of YLLs in Nigeria in 2019. Nigeria had the fourth-highest under-five mortality rate for male individuals (2491·8 deaths per 100 000, 95% UI 1986·1-3140·1) and female individuals (2117·7 deaths per 100 000, 1756·7-2569·1), but among the lowest mortality for men older than 55 years. There was evidence of a growing non-communicable disease burden facing older Nigerians. INTERPRETATION: Health outcomes remain poor in Nigeria despite higher expenditure since 2001. Better outcomes in countries with equivalent or lower health expenditure suggest health system strengthening and targeted intervention to address unsafe water sources, poor sanitation, malnutrition, and exposure to air pollution could substantially improve population health. FUNDING: The Bill & Melinda Gates Foundation.

Funder: Wellcome Trust, Health is central to the development of any country. Nigeria’s gross domestic product is the largest in Africa, but its per capita income of about ₦770 000 (US$2000) is low with a highly inequitable distribution of income, wealth, and therefore, health. It is a picture of poverty amidst plenty. Nigeria is both a wealthy country and a very poor one. About 40% of Nigerians live in poverty, in social conditions that create ill health, and with the ever-present risk of catastrophic expenditures from high out-of-pocket spending for health. Even compared with countries of similar income levels in Africa, Nigeria’s population health outcomes are poor, with national statistics masking drastic differences between rich and poor, urban and rural populations, and different regions.

In a retrospective review of hospital records of 40 human monkeypox cases from Nigeria, the majority developed fever and self-limiting vesiculopustular skin eruptions. Five deaths were reported. Compared to human immunodeficiency virus (HIV)–negative cases, HIV type 1–coinfected cases had more prolonged illness, larger lesions, and higher rates of both secondary bacterial skin infections and genital ulcers.

Recently, concern has been raised about the emergence of human monkeypox virus and the occasionally severe clinical presentation bearing resemblance to that of smallpox. In 2018 3 patients in the UK were diagnosed with monkeypox, and the frequency and geographic distribution of cases across West and Central Africa have increased in recent years. In Nigeria, most monkeypox patients are aged

Objectives: The understanding of antimicrobial utilization patterns is pertinent to successful implementation of the National Action Plans on Antimicrobial Resistance (AMR). There is, however, limited information on antibiotics utilization in Nigeria. This study was undertaken to build on existing information and provide direction for appropriate interventions including Antibiotics Stewardship Programs (ASP). Method: A Point Prevalence Study (PPS) was conducted in two public urban health facilities in Lagos, Nigeria using a design adapted from the European Center for Disease Prevention and Control (ECDC) and Global-PPS surveys. Results: The prevalence of antibiotics use was 80.6% administered mostly parenterally (83.1% of total prescriptions) with concerns with extended surgical antibiotics prophylaxis. The mostly used antibiotics in the secondary hospital were parenteral metronidazole (32.4%), ceftriaxone (27.5%), and amoxicillin + clavulanate (8.2%) while the mostly used in the tertiary hospital were ceftriaxone (25.3%), parenteral metronidazole (19.1%), and amoxicillin + clavulanate (9.3%). There was an appreciable lack of specific functional capacities, policies, and processes to promote appropriate antimicrobial use in both hospitals. Conclusions: There is high rate of antibiotics utilization in these facilities with lack of institutional frameworks and processes for ensuring appropriate antibiotic use. The study provides the information needed to improve future antimicrobial use in hospitals and reduce AMR.

Background The largest West African monkeypox outbreak began September 2017, in Nigeria. Four individuals traveling from Nigeria to the United Kingdom (n = 2), Israel (n = 1), and Singapore (n = 1) became the first human monkeypox cases exported from Africa, and a related nosocomial transmission event in the United Kingdom became the first confirmed human-to-human monkeypox transmission event outside of Africa. Methods Epidemiological and molecular data for exported and Nigerian cases were analyzed jointly to better understand the exportations in the temporal and geographic context of the outbreak. Results Isolates from all travelers and a Bayelsa case shared a most recent common ancestor and traveled to Bayelsa, Delta, or Rivers states. Genetic variation for this cluster was lower than would be expected from a random sampling of genomes from this outbreak, but data did not support direct links between travelers. Conclusions Monophyly of exportation cases and the Bayelsa sample, along with the intermediate levels of genetic variation, suggest a small pool of related isolates is the likely source for the exported infections. This may be the result of the level of genetic variation present in monkeypox isolates circulating within the contiguous region of Bayelsa, Delta, and Rivers states, or another more restricted, yet unidentified source pool.

Monkeypox research was mostly of academic interest until the 1980s when with the global waning of smallpox, monkeypox emerged as the most important Orthopoxvirus of public health importance [1,2]. ...

Smallpox eradication, coordinated by the WHO and certified just 40 years ago, led to the cessation of routine smallpox vaccination in most countries. It is estimated that over 70% of the world’s population is no longer protected against smallpox, and through cross-immunity, to closely related orthopox viruses such as monkeypox. Monkeypox is endemic in as yet unconfirmed animal reservoirs in sub-Saharan Africa, while its human epidemiology appears to be changing. Monkeypox in small animals imported from Ghana as exotic pets was at the origin of an outbreak of human monkeypox in the USA in 2003. Travellers infected in Nigeria were at the origin of monkeypox cases in the UK in 2018 and 2019, Israel in 2018 and Singapore in 2019. Together with sporadic reports of human infections with other orthopox viruses, these facts invite speculation that emergent or re-emergent human monkeypox might fill the epidemiological niche vacated by smallpox. An ad-hoc and unofficial group of interested experts met to consider these issues at Chatham House, London in June 2019, in order to review available data and identify monkeypox-related research gaps. Gaps identified by the experts included: understanding of zoonotic hosts, reservoirs and vectors risks associated with transmission, and full description of the clinical spectrum and the natural history of infection including an estimation of the prevalence of monkeypox specific antibodies in humans living in areas of emergence. The experts further agreed on the need for a better understanding of the genomic evolution and changing epidemiology of orthopox viruses, the usefulness of in-field genomic diagnostics, and the best disease control strategies, including the possibility of vaccination with new generation non-replicating smallpox vaccines and treatment with recently developed antivirals. Funding Statement: Chatham House provided a seminar venue and logistic support. Bavarian Nordic provided support for international travel. Declaration of Interests: Authors Elsgaard, Hochrein, Maclennan and Powell are employees of Bavarian Nordic, manufacturer of a vaccine registered as Jynneos for smallpox and monkeypox indications in the USA. Simpson works as a consultant for Bavarian Nordic. Ethics Approval Statement: Not required.

In Nigeria, before 2017 the most recent case of human monkeypox had been reported in 1978. By mid-November 2017, a large outbreak caused by the West African clade resulted in 146 suspected cases and 42 laboratory-confirmed cases from 14 states. Although the source is unknown, multiple sources are suspected.

Summary box In October 2017, the first confirmed case of a monkeypox outbreak was reported in Bayelsa State, Nigeria, although suspected cases started to be reported in September 2017. 1 It continues to this day, with exported cases reaching the UK, Israel and Singapore.2 3 Prior to this outbreak, the disease was last reported in Nigeria in 1978.4 Monkeypox is an orthopox virus, closely related to smallpox, that produces vesicopapular lesions on the skin. Symptoms are usually self-limiting and most people recover within weeks. Severe illness and death usually only occurs among immunosuppressed individuals.5 When the first cases were announced in Nigeria, media reports exaggerated the symptoms and impact of the outbreak. The outbreak generated front page headlines, with one title describing it as a ‘new airborne Ebola’.6 A European headline (from the Voice of Europe) was ‘ Horrible Nigerian disease called monkeypox spreads in the United Kingdom for the first time’ . The media used unverified pictures of people with skin rashes, to amplify their messages.7 There may be substantial discrepancies between what the National Public Health Institute …

Recently, concern has been raised about the emergence of human monkeypox virus and the occasionally severe clinical presentation bearing resemblance to that of smallpox. In 2018 3 patients in the UK were diagnosed with monkeypox, and the frequency and geographic distribution of cases across West and Central Africa have increased in recent years. In Nigeria, most monkeypox patients are aged40 years and lack cross-protective immunity because they were born after discontinuation of the smallpox eradication campaign. This article reviews the epidemiology, clinical features, and management of monkeypox and discusses its growing public health threat in this context.

Process mapping is a systems thinking approach used to understand, analyse and optimise processes within complex systems. We aim to demonstrate how this methodology can be applied during disease outbreaks to strengthen response and health systems. Process mapping exercises were conducted during three unique emerging disease outbreak contexts with different: mode of transmission, size, and health system infrastructure. System functioning improved considerably in each country. In Sierra Leone, laboratory testing was accelerated from 6 days to within 24 hours. In the Democratic Republic of Congo, time to suspected case notification reduced from 7 to 3 days. In Nigeria, key data reached the national level in 48 hours instead of 5 days. Our research shows that despite the chaos and complexities associated with emerging pathogen outbreaks, the implementation of a process mapping exercise can address immediate response priorities while simultaneously strengthening components of a health system.

Introduction : lassa fever is an endemic Viral Hemorrhagic Fever (VHF) in Nigeria. Improvements in case detection and treatment outcome could be achieved by understanding the transmission dynamics better and applying the lessons from previous outbreaks considering the resource constrained setting. This study assessed age-sex disparities in treatment outcome using data from 2016/2017 lassa fever outbreak surveillance in Nigeria. Methods : lassa fever surveillance and outcome data from December 2016 to May 2017 from 14 States was extracted from the VHF platform. Univariate and bivariate analysis were carried out using Epi info 7 for socio-demographics and treatment outcome. Possible association between treatment outcome and selected variables (age, sex) were analyzed using Chi square at 0.05 level of significance. Results : there were 168 confirmed cases of Lassa fever during the study period, data was complete for 139 (82.7%). More men were affected (56%), as 61 of the 139 patients (46%) were female. The median age for all the patients treated was 32 years (IQR 25 - 44). Symptoms at presentation prior to treatment included fever (67%), nausea and vomiting (34.5%), diarrhea (14.4%), and intense fatigue (39%) while only 10.8% experienced unexplained bleeding. A total of 75 (54%) patients were treated and discharged alive, while 64 (46%) died. No significant association was found between gender and treatment outcome (p value = 0.976). Although survival was higher among patients aged 15 to 24 years (72%) and lowest among patients who were 45 years and above (35%), age of the patient was not significantly associated with the adverse treatment outcome (p-value = 0.06). Conclusion : for the 2016/2017 lassa fever outbreak in Nigeria, age and sex did not influence the treatment outcome of the recorded cases. There is a need for further analysis and more large scale studies on Lassa fever treatment outcomes.