Nigeria’s hard-earned lesson for quashing Ebola

Rapid reaction and co-operation key to controlling outbreak

When Liberian development consultant Patrick Sawyer collapsed in the arrivals hall of Lagos airport with the symptoms of Ebola in July, the initial reaction, both inside and outside Nigeria, was close to panic.

The fear was that Nigeria’s rickety, overstretched health service would be unable to contain the deadly virus. In a sign of the strains the system was under, Nigerian doctors were on strike for higher pay when Mr Sawyer entered the country.

Against the odds, however, public health officials say one of the world’s more chaotic nations has provided an object lesson in how to deal with Ebola. It is a lesson that could prove salutary for western governments scrambling to come up with their own response.

For public-health experts, the idea of Ebola gaining a grip in Nigeria – Africa’s most populous nation and largest economy – is a nightmare scenario. There are 170m Nigerians, eight times the combined population of Guinea, Sierra Leone and Liberia, where the disease is raging. The country’s peripatetic elites and prolific traders have connections across the globe.

Yet Nigeria has quashed its outbreak – and is now just a week short of being clear of a live case for 42 days, the period required by the World Health Organisation before it can be officially declared Ebola free.

Dr Simon Mardel, a global specialist in emerging pathogens, describes the effects of the disease as a series of vicious circles. These attack the individual first and then the surrounding society, he says. On both counts Nigeria appears to have broken the cycle.

That outcome, far from assured at the outset, is the result of a rare national effort that saw the Lagos state government, federal institutions, the private sector and global non-governmental organisations all pulling in the same direction to defeat the disease.

Together they have provided hope at a time when public confidence in the state has been knocked by large-scale corruption scandals and the poor performance of the army in combating Islamist insurgents in the country’s north.

“President [Bill] Clinton, when he came here 14 years ago, said that from what he could see there is no problem Nigerians can’t fix if they get together,” says Dr Benjamin Ohiaeri, director at the First Consultants clinic where Sawyer was taken on July 20 and later died.

Like the current case in Texas, Nigeria’s outbreak was the result of a lone traveller entering from Liberia. Dr Ohiaeri’s clinic bore the brunt of the tragedy that subsequently unfolded and it was partly thanks to the courage of his staff in preventing Sawyer from leaving the premises that the disease did not spread further.

Eleven of his staff and their family members contracted Ebola, many in the 48 hours between Sawyer’s admission and the positive result of the laboratory tests. Four of them later died. But Nigeria got its act together quickly after that.

An emergency presidential decree enabled officials to access mobile phone records and empowered them to lean on law-enforcement agencies where necessary to track down people at risk. Thereafter, a strict system to monitor potential cases was put in place by the Lagos state government.

“They were very organised. They put resources into tracking down every contact. In the US the wife [of the first Ebola victim in Texas] was left for five days with contaminated material. Here they disinfected houses immediately,” says Dr Eilish Cleary, a public health expert on contract to WHO who has been debriefing the Nigerian survivors.

Senegal, which borders Guinea, where the current outbreak of Ebola took root, has been even more successful in containing an initial scare to just one case.

In total 20 Nigerians became infected, of whom eight died. Teams of state officials and volunteers tracked down more than 800 people who had primary or secondary contact with the Sawyer case. These included the congregations of two churches in the city of Port Harcourt where an infected man had worshipped, according to Dr Tochi Okwor, who runs the public awareness campaign in Lagos state.

In addition, hundreds of private clinics have been trained in identifying Ebola patients and keeping them away from the community until they are evacuated to isolation wards. A social media campaign set up in the wake of the first case by volunteer technology experts, manning twitter handles, web sites and helplines, complemented these efforts.

In the process, according to Dr Cleary and other top World Health Organisation officials, Nigeria has shown the importance of logistics and public information awareness on top of medical care in containing the disease.

Nigeria was fortunate that Mr Sawyer entered the country through the airport, into the commercial capital and straight to a top private clinic. The country could be far more vulnerable, according to Dr Mardel, if another case arrives by land, and ends up in a remote public hospital.

But if Ebola strikes again, the country will be better prepared. “People are determined that they don’t want Ebola in Nigeria. We could have had much higher casualty figures. But within weeks we would still have got it right,” says Dr Okwor.

Treatment: Rehydration seen as key for patients
No one would guess that Dr Ada Igonoh recently emerged from two weeks battling Ebola in an isolation ward in Lagos.

Dr Ada Igonoh

Radiating good health, the doctor, who was infected at her Lagos clinic by Patrick Sawyer, the Liberian who brought Ebola to Nigeria, insists there is no magic formula or miracle cure to thank for her recovery. She credits plenty of water and her own determination to survive for her ability to defeat the deadly virus.

Her experience is consistent with other survivors of the disease in Nigeria – all of whom engaged in an endurance test of rehydration as soon as they were diagnosed, drinking up to five litres of a solution of water combined with rehydration solution each day.

“The disease knocks every system slightly. But when it comes to dehydration it is shocking. It takes you by surprise every time,” says Dr Simon Mardel. “Behind every survivor there is a heroic tale of rehydration.”

Dr Mardel, who has examined more Ebola patients than anyone, believes there are important public health lessons to be learnt from Nigeria’s survivors. He argues the case, in a forthcoming article for the Lancet magazine, that far more attention needs to be given to providing rehydration than is currently practised in the worst affected countries.

This means ensuring that patients are drinking a rehydration solution consistently during the early stages of the disease. Later it becomes much more difficult.

“With Ebola things multiply – they don’t add up,” he says, adding that if you miss a day of water, you have to make up for it the next with twice as much. “Changing this from an epidemic of fear to a disease that is treatable is central to defeating this outbreak,” he says.

The psychology of patients is key. In Nigeria, according to World Health Organisation officials, those victims who believed that only medicine from the west could save them, mostly died. Those who lived, would not have done so without simple H2O combined with the rehydration solution.

“All of them decided to survive. Because they wanted to survive they forced themselves to take more oral rehydration solution. The mind has huge power over the body. That’s not talked about enough,” says Dr Eilish Cleary, the Ebola expert.

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