In the wake of the ebola outbreak in Western Africa, the fact that Nigeria reported cases of ebola for only 42 days has largely gone unnoticed. The first case was reported on 20 July 2014, and the last case reported on 31 August 2014, leading to the World Health Organisation (WHO) declaring Nigeria Ebola-free on 20 October 2014. With the successful, albeit challenging, handling of their Ebola outbreak, this “spectacular success story”, in the words of the WHO’s director for Nigeria, Rui Gama Vaz, provides a great learning tool for public health and the developed world.

Background

With a population of almost 200 million (a conservative estimate to many), Nigeria was seen as a nightmare setting for Ebola. A Liberian-American, Patrick Sawyer, serving as the vector and patient zero, arriving in Lagos from Monrovia, Liberia. Collapsing at the airport he was suspected of having malaria, and was taken to a private hospital. Going undetected, the Ebola virus spread to 11 hospital staff before further tests confirmed that Mr. Sawyer was carrying the highly infectious virus that led to his death.

Lacking adequate resources and facilities, controlling this huge emergency seemed impossible. Disaster loomed as many acknowledged Nigeria’s initial unpreparedness. However, the nation’s lengthy history of combating global epidemics proved to be its greatest ally. A polio-endemic country, Nigeria had already built a strong surveillance and response team in association with international partners. With polio on the verge of eradication, reassigning these epidemiology-trained physicians became top priority. Following the deaths of four of the infected patients, Nigeria faced a crossroads: going the way of its West African counterparts, or aiming for the kill. Winning this war against Ebola would involve an imperfect mix of skill, innovation, and basic surveillance principles.

Initial Challenges

Despite being aware of the ongoing outbreak in other West African countries, Nigeria initially had no isolation wards. Many healthcare professionals had a poor understanding of Ebola. Fear was widespread among the public. On the global stage, creating a new disease management blueprint remained the primary goal. Racing against time, Nigeria spent two weeks building a proper isolation ward in Lagos.

In a city with poor water access, even providing chlorinated water to the facility was not an easy feat. Medics treating the sick patients needed full protective gear and this equipment was not on standby. With the mortality rate increasing, the clock was ticking. Given the complexity and dense population of Lagos the number of trained health workers conducting door-to-door surveillance would end up being almost 2,000.

Lessons Learned

Early Recognition and Identification of Symptoms

When Mr. Sawyer was taken to the private First Consultant Hospital in the wealthy area of Lagos known as Ikoyi, fate was on the side of Nigeria. Known for providing excellent healthcare services for over three decades, this hospital boasted highly knowledgeable and trained health staff. The hospital’s Medical Director, the late Dr. Stella Adadevoh, quickly decided that Mr Sawyer’s lack of response to malaria treatment, coupled with his place of origin, suggested Ebola, and this swift decision made all the difference. Isolation methods were quickly put in place at the hospital, firmly preventing the patient from leaving even when he wanted to, in addition to informing the government authorities for further confirmation.

Dr. Adadevoh’s recognition of this case being a great public health hazard ultimately resulted in the loss of her own life. With no proper protective gear available while treating the patient, Dr. Adadevoh and some of her colleagues were exposed to the virus, leading to their deaths. Early recognition of Ebola is vital; something which the USA was ill-prepared for even after the situation played out in Nigeria. The early signs and symptoms of an Ebola patient, Mr Duncan, were ignored and he was allowed to leave the hospital after his initial visit. Sadly, without the use of adequate full protective gear when treating this patient in Dallas, nurses were also exposed to the perils of Ebola.

Collaboration

In this global melting pot, it is essential to be able to combine resources and skills. Nigeria knew it was not equipped to handle this on its own. A quick response meant engaging the help of others, including local authorities such as the State governments, Nigerian health ministry, the World Health Organisation, UNICEF, the US Centers for Disease Control and Prevention, Médecins sans Frontières and the International Committee of the Red Cross. Furthermore, large donations from wealthy individuals and businesses in Nigeria also provided the vital funds needed. This helped with the purchasing of essential tools and services, such as contact tracing.

Contact Tracing

In a disease outbreak, the key to proper surveillance is being able to answer the “who, what, where, how” accurately. To carry this out effectively it was of paramount importance to come up with an extensive list of primary and secondary contacts for each patient, together with anyone living in close proximity or working with them. In a country with poorly maintained road networks, door-to-door contact tracing allowed people who had been exposed to the virus to be detected and located, even in faraway Nigerian cities like Enugu and Port Harcourt.

Sticking to the Basics

According to a personal account by Dr. Ada Igonoh, an Ebola survivor involved in the care of Mr Sawyer, no high-tech health care was in sight. There was no Intensive Care Unit (ICU) or organ monitoring devices. No experimental drugs were provided and electrolyte imbalances were not checked. Dr Ada’s treatment consisted mainly of managing her infections with antibiotics, her fever and pain with Paracetamol (Acetaminophen) and, most importantly, drinking huge amounts of oral rehydration salts fluids. Knowing that dehydration could result in her going into shock, she drank as much as 4.5 litres a day.

Educating the Public

The Nigerian government set up an emergency Ebola phone hotline. Additionally, websites created by private organisations helped educate the public about Ebola. Social media proved useful in disseminating the information, and video and audio messages were created in local languages and the popular pidgin English dialect. With hand sanitisers flying off the shelves, Nigerians even stopped shaking hands. Moving any corpse around the country now required a letter from the Ministry of Health to certify that the death was not related to Ebola. Airport officials wore gloves and infrared thermometers were commonly used in public places, such as airports and banks, prior to allowing people to enter.

Current Status

Almost six months have passed since the WHO declared Nigeria Ebola-free, and to date no new cases have been reported. However, new cases are still developing in the other West African countries of Liberia, Sierra Leone and Guinea. Nigeria has provided one of the most comprehensive examples of effective disease management in recent times. Their ability to handle this outbreak so effectively and decisively despite the many challenges endemic to a developing nation is truly remarkable.

Cover image courtesy of CDC Global, licensed under Creative Commons 2.0.