How Outbreaks shaped Africa, Before & After: Nigeria

By Morayo Akinrogunde, a Clinical Pharmacist

Despite the coronavirus not taking hold of Africa at similar rates to Europe, a significant amount of hot spots are beginning to emerge on the continent (1). One of these hotspots is Kano, Nigeria. Official data released from Kano State Ministry of Health shows an unusually high number of deaths, even though officials initially denied any correlation with COVID-19. Kano just as other various parts of Nigeria suffers from poor healthcare infrastructure. Furthermore, insufficient testing combined with a lack of public awareness caused by misinformation and ignorance about the existence oattlef COVID-19 in Kano is causing an exponential increase in cases (2).

Another alarming factor that plays into this, is Nigeria being seemingly unprepared to contain the virus. Nigeria has a population of 206.6 million, however, only 450 ventilators and 350 ICU beds available for the entire country (3). Moreover, the government’s current measures to contain COVID-19 (e.g. domestic and international travel bans, school closures) have been unsuccessful in flattening Nigeria’s curve (3). In the past, Nigeria has shown its incredible capacity by its ability to swiftly eradicate Ebola virus disease (EVD). What approaches were taken then and what lessons can be utilised to fight its current pandemic?

Outbreak

The initial outbreak of Ebola started in Guinea in December 2013 and subsequently spread to neighbouring countries such as Liberia and Sierra Leone (4). Nigeria was introduced to its index case on the 20th of July 2014 by a 40-year old Liberian-American man, an air traveller who arrived in Lagos from Liberia (5,6). Between July and September Nigeria had 19 additional Ebola cases affecting two major cities: Lagos and Port Hartcourt (7). Nigeria was declared free of Ebola October by the World Health Organization (WHO) after no new cases were confirmed for 42 consecutive days (8). During the outbreak, the Director General of the WHO had raised a Public Health Emergency of International Concern (PHEIC) declaration. This was mainly initiated due to a growing concern of overburdened infrastructures in Lagos potentially contributing to a rapid spread (9).

Response

As dense populations and poor infrastructures were likely catalysts to a nation-wide spread. Nigeria’s main priority was to employ all available public health resources to implement a quick response. The Nigerian Centre for Disease Control (NCDC) of the federal ministry of health, in partnership with the Lagos and Rivers States Ministry of Health, private sector organisations and international partners led the Ebola response whereby the following actions were taken:

1. Laboratory investigations of suspected Ebola case samples
2. Establishment of a response team to ensure functional coordination of response.
3. Establishment of Ebola Treatment Centres for patient care managed by international organisations and Nigerian healthcare workers
4. Pro-active distribution of information to increase public awareness (10,11).

Photo by National Cancer Institute on Unsplash

In addition to these measures, it was the strong coordination of contact tracing that mainly led to Nigeria’s success of beating Ebola within a short time period. A team of epidemiologists from Lagos and Rivers States Ministry of Health, resident of the Nigeria Field Epidemiology and Laboratory Training Program (NFELTP) and WHO surveillance workers compiled a list. This list consisted of all those who had made contact with the index case as well as all subsequent cases (alive or dead). In-person and house-to-house visits took place in a particular radius from each Ebola contact. By using innovative tools such as mobile applications, data such as daily temperature were collated in order to gauge any potential new cases arising over a 21 day period (10,12). Furthermore, contacts were given advice on social distancing and additional teams mobilised to track non-compliant contacts (10). Nigeria did have some luck on its side as the first case was a diplomat. His diplomatic status provided him access to a private room and restricted a rapid initial spread as his contact with the general public was limited (12).

Lessons Learned

Coronavirus on the other hand is not as easily identifiable as Ebola, because an asymptomatic presentation is not uncommon. However, Nigeria can certainly carry out similar approaches and apply lessons learned from 2014 to combat its current pandemic. According to Dr. Chikwe Ihekweazu (Epidemiologist and CEO of NCDC) Nigeria has seen the importance of building facilities to aid in the event of future outbreaks. For example, the National Reference Laboratory capacity has improved by providing molecular diagnosis for all epidemic prone pathogenes, which includes the Ebola virus (13,14,15).

“We also used lessons from the Ebola outbreak to strengthen our risk communications capacity. We recognise the critical importance of ensuring members of the public are equipped with the right information. In the last week, Nigeria Centre for Disease Control has issued a public health advisory to Nigerians informing them of our preparedness and how to stay protected from coronavirus.

In December 2019, we completed the training of rapid response teams in all states in Nigeria. All 36 states have a team ready to be deployed in the event of an outbreak (14).”

Another lesson that can be taken from this response is the essential role played by the community. Having an engaged community and encouraging collaborative partnership with healthcare workers in order to educate others and promote positive behaviours (e.g. social distancing, frequent hand-washing etc.) decreases the risk of resistance from the public to comply with health professionals out of fear (10,16).

Unfortunately, examples such as Kano have proven that despite these measures and efforts derived from past experiences, there seems to be an apparent difficulty to execute a good response. As Nigeria continues its ongoing battle with COVID-19, I hope that it does not forget the incredible results achieved with past outbreaks and realises pivoting from current plans will be vital to contain COVID-19 from causing further harm.

References:

1. https://www.nytimes.com/2020/05/17/world/africa/coronavirus-kano-nigeria-hotspot.html
2. https://www.hrw.org/news/2020/05/04/fears-covid-19-outbreak-nigerias-kano-state
3. Dixit S, Kofoworola Ogundeji Y K, Onwujekwe O. How well has Nigeria responded to COVID-19? 2020 Jul 2 [cited 2020 Jul 11]. In: Brookings. FUTURE DEVELOPMENT [internet]. Available from: https://www.brookings.edu/blog/future-development/2020/07/02/how-well-has-nigeria-responded-to-covid-19/
4. World Health Organization (2016) Ebola situation report.
5. Chan M (2014) Ebola virus disease in West Africa-no early end to the outbreak. N Engl J Med 371: 1183–1185.
6. https://en.wikipedia.org/wiki/Ebola_in_Nigeria
7. Althaus C.L., Low N., Musa E.O., F. Shuaib, Gsteiger S. Ebola virus disease outbreak in Nigeria: Transmission dynamics and rapid control. Epidemics 11: 80–84.
8. World Health Organization. Nigeria is now free of Ebola virus transmission. 20 October 2014.
9. Musa E, Abdulsalam N, Shuaib F, Nguku PM, Vaz RG, Nigeria’s Ebola Outbreak Response: Lessons for Future Epidemic Preparedness. Archives of Medicine. 2016.
10. Shuaib F, Gunnala R, Musa EO, Mahoney FJ, Oguntimehin O, Nguku SB et al. Ebola virus disease outbreak — Nigeria, July — September 2014. MMWR Morb. Mortal Wkly. Rep., 63 (2014), pp. 867–872.
11. Omosivie M, Osaretin O. Ethical challenges of containing Ebola: the Nigerian experience. J Med Ethics 2015;0:1–3.
12. https://theconversation.com/how-nigeria-beat-the-ebola-virus-in-three-months-41372
13. https://www.cfr.org/blog/nigeria-responds-first-coronavirus-case-learning-2014-ebola-response
14. https://qz.com/africa/1810161/coronavirus-how-nigeria-prepared-and-lessons-from-ebola/
15. Out A, Ameh S, Osifo-Dawodu E, Alade E, Ekuri S, Idris J. An account of the Ebola virus disease outbreak in Nigeria: implications and lessons learnt. BMC Public Health 2017 17:736.
16. Maduka O, Maleghemi S, Komakech W, Nwaduito I, Green P, et al. (2016) Effective risk communication and contact tracing for Ebola virus disease prevention and control-Experiences from Port Harcourt, Nigeria. Public Health 135: 140–143. 13. Ogoina D (2016) Behavioural and ĞmŽtiŽnĂů responses to the 2014 Ebola outbreak in Nigeria