Monkeypox and more, from public trust to preparedness – an interview with Chikwe Ihekweazu

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In this interview we speak to Chikwe Ihekweazu, current Director of the Nigeria Centre for Disease Control, about monkeypox, public trust, surveillance and the factors that influence preparedness following his presentations at the European Congress of Clinical Microbiology and Infectious Disease (ECCMID; 11–16 April, Amsterdam, the Netherlands).

First, could you introduce yourself and give a brief summary your career to date?

My name is Chikwe Ihekweazu and I am an infectious disease epidemiologist. I have worked mostly in national public health institutes; the Robert Koch Institute (Berlin, Germany), the Health Protection Agency (London, UK) and the National Institute for Communicable Disease (South Africa). I now lead the Nigeria Centre for Disease Control as the Director General.

Could you outline the research you’re presenting here?

The major piece of work that I am presenting is on monkeypox. A couple of years ago, we had a re-emergence of a disease in the south of Nigeria. I previously hadn’t seen monkeypox in my clinical experience. At the time it re-emerged in 2017, we hadn’t seen any in Nigeria for the past 30 years. Monkeypox is a very interesting disease. It has a very challenging clinical presentation, including a rash and fever, and its re-emergence caused a lot of anxiety in the country. The outbreak took us a while to get on top of, to get the diagnostics right and to set up a new approach to surveillance and control of this disease.

Regarding the UK cases reported in 2018, two of the three cases had a travel history linked to Nigeria. The key lesson for all of us in that is how interconnected the world is and how we must work together to deal with this challenge, or any challenge.

Many emerging diseases are zoonotic, such as monkeypox and Lassa fever – what challenges does this present?

Zoonoses present a huge challenge in many ways. In Nigeria, and I think the same goes for many African countries, the animal health side of things has very limited support, compared with the resources that we have in the human health side to deal with these diseases.

In addition, the science around the control of infection in animals is not as clear cut as in humans – we haven’t really paid enough attention to the animal–human interface and there’s a lot of work needed to improve this.

For monkeypox, we still have gaps in our knowledge of the host animal or reservoir. We think it is rodents, but our experience has shown it could also be in other animals – we just don’t know enough. The first challenge is the scientific challenge of getting to know more about the animal side of zoonotic diseases and putting more resources behind this research. The second challenge is the resource challenge – once we know a little bit more, we need to invest more resources in controlling these infections in animals, as well as controlling the transmission of the infections from animals to humans.

How important is regional surveillance in reacting to emerging diseases?

Surveillance has been a long neglected but critical part of the work we do in infectious diseases. We have paid a lot of emphasis, at least in Africa, in strengthening a vertical disease control program; TB control, malaria control, HIV control etc. However, this has been done with limited focus on a holistic approach to effectively establish a broad-based surveillance architecture.

For us, the biggest challenge with surveillance is not necessarily the identification of a disease, it is the laboratory confirmation. For laboratory confirmation we need strong public health laboratories with the capacity, human resources and specialist equipment to make this diagnosis.

We haven’t done enough in terms of thinking about how we can design a system, especially in a federal republic like Nigeria, where laboratories serve a broad surveillance purpose. We are doing that now, but we have lost many years.

So, at the heart of my work at the moment is making sure that the capacity required to establish a surveillance system is put in place. Sometimes this is as obvious as building laboratories, but there are other things. For example, how to get samples from a rural village to a lab in an urban area, which requires a very complex sample transportation system that needs to be paid for. These are not easy problems to solve and a lot of our work at the moment is getting those systems in place. We are building a system where the laboratory equipment is available and in addition, a strong sample transportation network to ensure samples actually get to the laboratory, the result gets back to the patient quickly and to the public health authorities.

With increasing globalization, how can more networks be built to ensure preparedness?

We say this a lot, that infections don’t recognize borders, but we don’t really operationalize that phrase. For the work that we do, we really have to ensure that professionals have the access and confidence to speak to each other routinely – because it is only when I have a routine relationship for example with a colleague in the UK,  or in Cote d’Ivoire or in South Africa, that I will have the confidence to go to them when there is a crisis. If we wait for a crisis before using the formal IHR mechanisms to go to our colleagues in other countries to discuss incidents that may or may not be a problem, then perhaps these discussions will never happen or they will happen much too late to have a real impact.

I strongly believe that we have to normalize the interaction between people involved in infectious disease control, speaking regularly and exchanging information. No outbreak starts as a huge outbreak, each outbreak starts with a single case with a set level of uncertainty about the diagnosis and that’s when the conversations need to happen, not when you have a cluster of a hundred cases – if we wait for that cluster of a hundred, then we have lost an opportunity to respond. This is really an area where we should minimize the hurdles we need to go through in order to communicate and ensure that will build trust across countries for our mutual benefits.

Do you think new technologies will help with this?

I think new technologies are helping, but there’s still almost a mental barrier to get over. Technology has moved on both in terms of communication, in terms of laboratory equipment and ability to communicate. I think technology does help but ultimately it is really a question of building more trust.

Have you faced any issues with public trust – like we’ve seen in the Democratic Republic of Congo (DRC) regarding Ebola vaccination, or vaccine hesitancy across Europe?

Yes, there’s always the challenge of public trust. One of our biggest responsibilities is informing the public about the work that we do and the need to work together. One of the biggest challenges with the Ebola outbreak in DRC at the moment is something called community resistance. Now this is the most normal thing to happen if you think about it – if you have neglected communities for years and not provided the care they needed when they had a child dying of malaria or a mortality in childbirth, they have absolutely no reason to trust the health system. Then there is a big problem when you want communities to come forward because it feels as if you’re saying that Ebola is important, but their child dying during childbirth is not important. I think if we are to learn any lessons from this outbreak it is to come down from our pedestals and really find out what it takes to build trust and confidence in the people that we serve.

I think the challenges with measles and vaccination in the West are a little bit different, but it also has similarities in that we really have to think about communication to the public as a science and an area of further development. It’s not enough just saying to people, “Do this, it is the right thing to do.”, we need to understand where the anxieties are coming from and respond to them at that level.

Do you have any other comments you would like to add?

The reason I am at this conference is to share some of the work we are doing and also to learn from the work going on across the world. When I walk around this conference venue and the exhibition space, it is obvious that there is a large gap between what is possible in terms of diagnostics for an individual living in western Europe, where I worked for 10 years of my career, and what is possible where Nigeria is at the moment. We really need to get that gap closer together for the interest of all of us.

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