Nigeria is the most populous country in Africa and a growing economic powerhouse. The former capital, Lagos, is home to some 21 million people – almost as many as live in Guinea, Liberia and Sierra Leone combined. When news broke on July 23rd that a case of Ebola had been confirmed in Lagos, the world held its breath. But Nigeria has successfully prevented the feared “apocalyptic urban outbreak.”
In a situation assessment released on Monday, October 20th, the World Health Organization (WHO) declare Nigeria “free of Ebola virus transmission.” The chains of transmission have been broken, it says, because it has been exactly 42 days – double the maximum incubation period for Ebola virus disease – since the last infectious contact with a confirmed or probable case occurred.
Such a “spectacular success story” of how Ebola can be contained is worth telling in detail, says the UN health agency.
Many other developing countries are very worried about the prospect of Ebola cases crossing their borders and want to know how best to prepare themselves. Many wealthy countries may also learn a few things from the Nigerian story, despite their more advanced health systems.
The success follows another remarkable achievement in Nigeria, when earlier this year WHO confirmed the country had eradicated Guinea worm disease. When the eradication campaign started in 1986, Nigeria had 650,000 of the estimated 3.5 million Guinea worm cases worldwide, more than any other country. In January 2014, the campaign estimated there remained only 148 cases of Guinea worm disease worldwide.
A Liberian air traveler infected with Ebola entered Lagos on July 20th and died 5 days later. He had vomited in the flight and in the car that drove him to a private hospital. There, he told staff he had malaria and denied having had any contact with people infected with Ebola – later it was discovered he had.
As malaria does not transmit from person to person, the hospital staff attending the index patient did not protect themselves. Nine became infected and four of them died, as did the man who had escorted the patient to the hospital.
There was a second outbreak at Port Harcourt, Nigeria’s oil hub, when on August 1st, a close contact of the Lagos index patient arrived by plane and sought help from a private doctor. The doctor developed symptoms 9 days later and died of Ebola on August 23rd.
When the Nigerian authorities, with help from WHO, studied the contacts involved, they discovered an alarming number of high and very high-risk exposures for hundreds of people.
It was clear that all required resources had to be mobilized immediately to stop the outbreak.
One of the challenges was to trace all the people who had come into contact with infected Ebola patients.
Lagos is the largest city in Africa. It has a large population living in crowded, unsanitary conditions, many in slums. Also, for work and to sell their goods, thousands of people travel in and out of the city every day.
“How can contact tracing be done under such conditions?” was a main concern, voiced right at the beginning, when the first case was confirmed. Jeffrey Hawkins, the United States Consul General in Nigeria, said the prospect of Ebola in Lagos conjured up images of an “apocalyptic urban outbreak.”
But such an appalling prospect was averted. With help from WHO, the US Centers for Disease Control and Prevention (CDC) and other organizations, the Nigerian authorities reached 100% of known contacts in Lagos and 99.8% in Port Harcourt.
Another important feature of Nigeria’s success was that federal and state governments very quickly provided financial and material resources, and well-trained and experienced staff.
They immediately set about constructing isolation wards and then designated Ebola treatment centers. Vehicles and specially adapted mobile communications systems were made available and greatly assisted real-time reporting of the changing situation.
Unlike in Guinea, Liberia and Sierra Leone, in Nigeria, all identified contacts were monitored on a daily basis for the maximum incubation period of Ebola – 21 days. A few contacts did try to escape during the surveillance period, but they were tracked and special intervention teams returned them to complete the required monitoring.
WHO suggest the most critical factor in Nigeria’s successful response to the Ebola outbreak was “leadership and engagement from the head of state and the Minister of Health,” followed by generous allocation and quick disbursement of government funds.
Another big factor, say WHO, was strong partnership with the private sector, as was rapid involvement of the Nigerian Centre for Disease Control (NCDC) and the prompt establishment of an Emergency Operations Centre, supported by local WHO officials.
Nigeria also has a first-rate virology laboratory that is affiliated to the Lagos University Teaching Hospital. The lab was quickly staffed and equipped to reliably diagnose Ebola cases so containment could proceed promptly.
Coupled with high-quality contact tracing by experienced epidemiologists, these factors ensured cases were detected early and quickly isolated, greatly reducing the chance of further transmission.
The Nigerian authorities were quick to put out messages to the general public, the idea being that this would get communities to support the containment measures.
Various initiatives put out messages and key facts about Ebola on different media.
House-to-house and local radio campaigns – using local dialects – explained the risks, how to take personal preventive measures and what was being done to control virus spread.
President Goodluck Jonathan also appeared on television newscasts to reassure Nigeria’s vast and diverse population. Also, messages were put out on social media, and well-known “Nollywood” movie stars were enlisted to give out Ebola facts on television.
Drawing on the success of Nigeria’s polio eradication program, traditional, religious and community leaders were engaged early on and played a critical role in raising public awareness.
Nigeria is implementing one of the world’s most innovative polio eradication programs. Re-purposing the infrastructure of the program also helped the country avoid an Ebola disaster.
Nigeria’s polio eradication program makes use of cutting-edge GPS technology to ensure no child misses out on polio vaccination. During the high transmission season, only one case of polio was detected. WHO say the country is on track to interrupt wild poliovirus transmission from its borders before the close of 2014.
When Nigeria’s first Ebola case was confirmed in Lagos in July, the authorities immediately re-purposed the polio eradication infrastructure and technology to trace Ebola cases and contacts.
Using the latest GPS technology, the Nigerians, with help from WHO, were able to quickly trace contacts and map links between identified chains of transmission.
Eventually, every single one of the country’s 19 confirmed cases was linked back to direct or indirect contact with the air traveler who brought Ebola to Lagos from Liberia on July 20th.
WHO Director-General, Dr. Margaret Chan, says Nigeria’s achievements have a very clear message:
“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.”