An Ebola Outbreak Contained: What U.S. And Other Nations Can Learn From Nigeria

Today, the country of Nigeria is free of active Ebola virus transmission.

The World Health Organization and the Nigerian Federal Minister of Health, Professor Onyebuchi Chukwu, MD, declared this morning that 42 days have passed since the last diagnosed incidence of Ebola Virus Disease (EVD), or two, 21-day disease incubation periods, a milestone that signals the end of the country’s first Ebola outbreak.

In an official public statement, Minister Chukwu cited the leadership of President Goodluck Jonathan, his Ministry of Health staff, and the cooperation of diverse domestic and international agencies in containing Nigeria’s first Ebola outbreak: “The Nigeria Centre for Disease Control and the Port Health Service, the State Ministries of Health of Lagos, Enugu and Rivers, the WHO, UNICEF, the US Centres for Disease Control and Prevention, MSF and other partners who were part of the team under the leadership of the Minister of Health.”

In a follow-up email response to us, Minister Chukwu cited two other components of the response that were critical to their success, “The second component is coordination among leadership. In this situation, that means coordinating within federal government, local governments, security services, AND international organizations active on the ground. So many players need to be involved for this to work, but the efforts must be organized and managed under one central leadership structure.”

Three days after the arrival of Patrick Sawyer to Lagos, where the Liberian-American index patient exposed 72 people at the airport and upon hospital admission, an incident management center was set up in Lagos by the Federal Ministry of Health and the Nigerian Centre for Disease Control (NCDC). The resulting Emergency Operations Center centralized surveillance and responses across organizations and jurisdictions, enabled by a structure in place since a 2010 lead poisoning outbreak and a 2012 polio eradication campaign funded, in part, by the Bill and Melinda Gates Foundation.

Responsibility of the media

Most striking, and perhaps most unlike the United States, is that the government considered the media part of its response management. In fact, the media is depicted as an arm in the organizational chart reproduced below from a paper published by Faisal Shuaib, DrPH, and colleagues in the October 3 issue of the U.S. Centers for Disease Control and Prevention’s Morbidity and Mortality Weekly Report (MMWR).

Minister Chukwu elaborated on what he viewed as a civic responsibility of the media. “Thirdly, the media is very important. And we are seeing the media play a major role in the U.S. outbreak. Media has an important role to play. Reporters, editors and publishers need to understand that this is a major public health danger and that the media needs to be a part of the effort. It needs to collaborate with the government, it must act responsibly and not publish information that has not been verified by officials.”

                         

The organizational chart of the Nigeria Ebola Response Incident Management Center, July-September 2014. Credit: Centers for Disease Control and Prevention, Shuaib, et al. available at http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6339a5.htm

Today in Nigeria, the press is regulated under a parastatal organization called the Nigerian Press Council, comprised of representatives from press associations, the Federal Ministry of Information, and journalism training institutions. The Council considers itself a buffer between the media, government, and the public. While the Council fields media complaints, requires journalist registration, and holds journalists to a code of conduct, it’s far removed from the sometime lethal oppression of the press by military dictatorships that preceded the current democratic government.

Minister Chukwu didn’t feel that the press should be controlled as much as it should be reporting responsibly. “As I said, this is a major public health danger, but spreading panic and choosing sensational headlines will only add to the problem. The media has the power to help protect the public by educating them and equipping them with the right knowledge to protect themselves and others. Sensationalizing the situation will only make matters worse. This is the time for everyone to act responsibly,” said Chukwu.

In the U.S., of course, the media’s responsibility is to hold the government accountable and we have seen justifiable criticism of our national response. But, several news outlets and individual reporters have done exemplary work in placing U.S. Ebola cases into context and providing useful, fact-based guidance. Moreover, large organizations such as the Associated Press have begun to establish standards such as no longer reporting on “suspected Ebola cases” because of their almost exclusive propensity for not leading to diagnosed disease.

“Potentially enormous” threat to Nigeria

Much like the first diagnosed Ebola virus disease case in the U.S., Nigeria experienced their first ever introduction of Ebola via the inbound traveler, Patrick Sawyer, who had been infected with the virus. The circumstances of Sawyer’s case had the potential for more broad disease transmission than that of Thomas Eric Duncan traveling to Dallas.

First, Sawyer was visibly ill even before getting on the plane at Monrovia’s James Spriggs Payne Airport. Airport footage showed that he was lying on the floor “in excruciating pain,” according to Liberia’s New Dawn newspaper, and keeping his distance from other passengers.

Sawyer was so sick – and contagious – that he infected several dozen people who greeted or treated him before dying in Lagos on July 25. Duncan, in contrast, didn’t become ill until four days after his arrival in the United States. Today marks the end of the 21-day quarantine of the family members he visited, none of whom contracted Ebola.

Finally, Sawyer’s final conference destination was to have been the Nigerian city of Calbar. But he first flew to Accra, Ghana, then Lomé, Togo, before traveling into Lagos, the largest city in Nigeria – and the African continent – with a population estimated at 21 million people.

Dallas is certainly large, of course, with a city population of 1.3 million. (The Dallas-Fort Worth metropolitan area is the fourth-largest in the U.S., with combined population of 6.5 million people). But Dallas and Lagos each cover the exact same area: 386 square miles.

Despite this population density and a nation that was facing its first Ebola outbreak, Nigeria experienced a total of 20 cases of Ebola infection and eight deaths. On one hand, this magnitude of suffering and loss was due to one man. But, on the other, containing the losses to eight deaths is an achievement considering that one contact in Lagos fled to the petroleum hub of Port Harcourt, a seven-hour drive, and caused the death of the doctor who treated him.

Lessons from Uganda

When I spoke with Professor Chukwu in late September, he also cited the value of the WHO sending to Nigeria a group of physicians from Uganda and the Democratic Republic of Congo to quickly guide Nigerian doctors and other health care workers through patient treatment and infection control measures.

At the time, Chukwu said, “We only knew about Ebola virus through our medical books. We’ve never seen a single case of Ebola virus until this year. So we needed someone with practical experience who had seen the virus to come and train our doctors what to do and the rest, and then we took over.”

One unfortunate advantage that other African nations have over the U.S. and other developed countries is that they have seen and managed Ebola outbreaks before.

Uganda, for example, has had three Ebola outbreaks since 2000 and is currently containing a small outbreak of Marburg virus, a member of the same family to which Ebola belongs (filoviruses). The Central African country is about the size of Oregon and has 32 million people. Previous outbreaks have primarily been linked to bat colonies in caves and mining shafts in the western part of the country.

Dr. Jane Ruth Aceng, Uganda’s Director-General for Health Services in the Uganda Ministry of Health, told us that the 2000 outbreak was a defining moment for the country as almost half of 428 victims died.

“That alone was a big lesson to Uganda,” said Dr. Aceng. “The population are highly sensitized to hemorrhagic fever and they are very willing to divulge information and to report themselves if they have had contact.”

Dr. Aceng also said that Uganda has deep gratitude to the CDC for supporting them over the years for strengthening their systems and getting Ugandans as a team to become self-reliant in managing outbreaks.

Perhaps due to having seen multiple outbreaks that have been contained, the public tends to have more confidence in their political and health care system than in other countries. Dr. Aceng said, “Political support is extremely high. Immediately upon an outbreak, our president speaks to the people himself, educates them about the outbreak, appeals to follow the information given to them, stresses infection control. Ministers take it upon themselves to visit the isolation facilities and show solidarity by even dressing up in the personal protective equipment and going into the isolation facilities themselves.”

Would issues be different here in the U.S. if Governor Rick Perry or CDC Director Tom Frieden had gowned up as Texas Health Presbyterian Hospital workers did in the initial days of Mr. Duncan’s hospitalization?

“If you do not have political support and support from the public, it becomes a difficult situation,” said Dr. Aceng.

With regard to the Ugandan press, Dr. Aceng’s comments bear striking similarity to those of Nigeria’s Chukwu, some of which again fly against the U.S media landscape.

Dr. Aceng said, “We work very closely with the press. They are our [the Ministry of Health] mouthpiece to the people. They don’t go outside the messages we are giving and, if they hear something, they always clarify with the Ministry of Health.”

“The press understand that Ebola is a deadly thing. It’s a matter of life and death. But we also keep them informed of the developments on a daily basis,” said Dr. Aceng. ”We don’t stop them from reporting from the districts, showing images, as long as they talk about them in the context of public health to protect the population.”

I asked Dr. Aceng if she had any advice for the United States.

She said, “The most important thing during an outbreak is to keep calm. If people get excited and agitated, they begin to run away or they begin to harass the people who are infected. It’s also best to let the people handling the outbreak figure out what to do and not have too many players in the field. One of the challenges we are having in West Africa is that everyone comes in with their ideas.”