Finally, some good news to report on the Ebola front: Nigeria and Senegal are now completely free of the disease. Here's how they contained the outbreak — and why the world needs to take notice.
Top image: A Nigerian health official uses a thermometer on a worker to check for fever at the arrivals hall of Murtala Muhammed International Airport in Lagos (Associated Press).
Earlier today, the World Health Organization announced that no new case of Ebola has emerged in Nigeria in 42 days. That's the standard length of time required for declaring the end to an outbreak, since it's twice the maximum 21-day incubation period for the virus. It's an incredible achievement — one that should assuage fears and show that Ebola can be contained. Moreover, it's proof that developing nations, with sufficient support from the international community, are fully capable of dealing with the epidemic.
Thwarting an "Apocalyptic Urban Outbreak"
Things looked bleak back in July when the virus was detected in Lagos, Africa's largest city. Nigeria, with its 166 million inhabitants, is Africa's most populous country and its newest economic powerhouse. Lagos boasts a population of 21 million, making it nearly as large as the populations of Guinea, Liberia, and Sierra Leone combined. With its airport and large population living in often crowded and unsanitary conditions, news of Ebola was met with a palpable sense of dread.
"The last thing anyone in the world wants to hear is the two words, 'Ebola' and 'Lagos' in the same sentence," noted Jeffrey Hawkins, the U.S. Consul General in Nigeria, at the time. The juxtaposition of the two conjured images of an "apocalyptic urban outbreak."
In the end, Nigeria confirmed a total of 19 Ebola cases, of whom seven died and 12 survived. It's a far cry from the situation in other parts of West Africa — but that's not an accident. Here's how Nigeria did it and the "best practices" that should now be employed elsewhere:
Effective Leadership and Public-Health Institutions
The WHO credits Nigeria for its strong leadership and effective coordination of the response:
The most critical factor is leadership and engagement from the head of state and the Minister of Health. Generous allocation of government funds and their quick disbursement helped as well. Partnership with the private sector was yet another asset that brought in substantial resources to help scale up control measures that would eventually stop the Ebola virus dead in its tracks.
The response was greatly aided by the rapid utilization of a national public institution (NCDC) and the prompt establishment of an Emergency Operations Centre, which was supported by the Disease Prevention and Control Cluster within the WHO country office. Nigeria also features a first-rate virology lab affiliated with the Lagos University Teaching Hospital. It was staffed and equipped to quickly and reliably diagnose Ebola, ensuring that containment measures could be employed with the shortest possible delay.
Rapid Response to the Initial Case
Nigeria's first Ebola patient, Patrick Sawyer, was initially thought to have malaria. But once that was ruled out, doctors immediately began treating him as a possible Ebola patient. He was kept in isolation, officials were notified, and a blood sample was rushed to a testing lab. Just three days later, Nigeria's health ministry set up an Ebola Incident Management Center, which eventually turned into an Emergency Operations Center that co-ordinated the response and decision-making.
Sufficient Access to Resources
As noted, federal and state governments in Nigeria were able to provide ample financial and material resources, including well-trained and experienced national staff. Isolation wards were immediately constructed, as were designated Ebola treatment facilities (though more slowly). Other resources included vehicles and mobile phones equipped with specially adapted apps allowing healthcare workers to engage in real-time reporting as the investigations moved forward. Many of these efforts were supported by social mobilization experts from UNICEF, CDC and Médecins sans Frontières.
High Quality Contact-Tracing
Nigerian health officials, working with assistance from WHO, the US CDC and others, managed to reach 100% of known contacts in Lagos and 99.8% at the second outbreak site in Port Harcourt, Nigeria's oil hub. High-quality contact tracing was performed by experienced epidemiologists who expedited the early detection of cases and their rapid movement to isolation wards. And unlike the tragic situation in Guinea, Liberia, and Sierra Leone, all identified contacts were physically monitored on a daily basis for 21 days. Some contacts tried to escape during the monitoring process, but they were all tracked by special investigation teams and returned to observation to complete the requisite monitoring period of 21 days.
Applying Lessons From Previous Outbreaks
Nigeria has been combating another blight, polio, for quite some time now and with great success. Among their many tactics, health officials use the very latest satellite-based GPS technologies to ensure that no child missed out on polio vaccinations. When Ebola first appeared in July, they immediately repurposed these technologies and infrastructure to conduct Ebola case-finding, contact-tracing, and daily mapping of links between identified chains of transmission. Nigerian health officials also adapted the learnings from their efforts to eradicate guinea-worm disease.
A Rigorous Public Education Campaign
Communication with the public was also key. Nigerian health and government officials rallied communities to support containment measures. This involved house-to-house information campaigns — spoken in local dialects — that explained the level of risk, effective personal measures, and the actions being taken for control. All the while, Nigeria's president, Goodluck Jonathan, reassured his population on nationally televised newscasts. Traditional and religious community leaders were engaged early on and asked to play a role in sensitizing the public.Finally, the full range of media opportunities were exploited, including social media and televised facts about the disease delivered by Nigerian celebrities.
Screening At Borders — And A Refusal To Stop Air Travel
Instead of panicking and banning air travel, Nigerian health officials screened all arriving and departing travellers by air and by sea in Lagos and Rivers State. The average number of travellers screened each day reached a peak of more than 16,000.
Moving Forward With Vigilance
Clearly, this story isn't over yet. Vigilance remains high and Nigeria's surveillance systems remains on a high level of alert. It's quite possible that, given the country's success, people from neighbouring countries may try to (illicitly) enter in.
As a final note, and as noted by WHO Director-General Margaret Chan: "If a country like Nigeria, hampered by serious security problems, can do this – that is, make significant progress towards interrupting polio transmission, eradicate guinea-worm disease and contain Ebola, all at the same time – any country in the world experiencing an imported case can hold onward transmission to just a handful of cases."