This report is the 3rd in a continuing series on the Ebola epidemic affecting West Africa.  Previous reports can be found here: Report #1 and Report #2.

Large Number of People in the Crosshairs

With a population of more than 177 million people, Nigeria has a larger population than the next two most populous African countries combined (Ethiopia & Egypt).  Although the current Ebola crisis has focused on the more than 2,100 cases and 1,100 deaths in Liberia, Sierra Leone, and Guinea, the epidemic has now spread to Nigeria.

Sentinel Case: Air Travel brings Ebola to Nigeria

On July 23, 2014, Patrick Sawyer, a Liberian-American consultant for the Liberian Ministry of Finance, traveled on the African airline ASKY from Monrovia, Liberia to Lagos, Nigeria via a stop in Togo.  Sawyer was traveling to a meeting of the Economic Community for West African States (ECOWAS) in Calabar, Nigeria when he collapsed at the Lagos airport on July 20, 2014 and was taken to First Consultants Hospital in the Obalende section of Lagos.  Initially, Sawyer denied exposure to Ebola in Liberia and was tested for Malaria & HIV.  When those tests were negative, his blood sample was sent to the Nigerian national lab for Ebola testing since he had travelled from Liberia. Later Sawyer admitted he had cared for his sister who had died of Ebola on July 7th at the Catholic Hospital in Monrovia, Liberia.  Sawyer died from Ebola on July 25th at 6:50 AM local time.  Sawyer reportedly came in direct contact with 59 people, 44 were at the hospital he was treated, according to the Lagos State government.  All Ebola 12 cases and 4 deaths in Nigeria have been related to Patrick Sawyer’s illness, and currently, no other index cases have been reported in Nigeria.  On a positive note, the initial physician who treated Sawyer and contracted the disease was discharged from the hospital on August 16th with a reported full recovery per the Ministry of Health. There are still 189 persons under surveillance in Lagos and 6 persons under surveillance in Enugu.

Political Response

Nigeria’s President Goodluck Jonathan on August 8, 2014 declared the control of Ebola a National Emergency.  The President’s spokesman, Reuben Abati, stated the following measures would be taken:

• Federal ministry of health will work in collaboration with state ministries of health, National Centre for Disease Control (NCDC),and National Emergency Management Agency (NEMA)
• Special Intervention Plan enacted and immediate release of N1.9 billion ($11.7 million) in Ebola funding
• Deployment of isolation centers, case management, contact tracing, additional personnel, border screening, and the procurement of required medical supplies
• Reduction of social, political, and religious public gatherings

Medical Response

Since July 1, 2014 , a large number of Nigerian physicians affiliated with the Nigerian Medical Association working in government hospitals have been on strike demanding better pay and working conditions.  In the midst of the current Ebola crisis, President Jonathan fired 16,000 striking physicians on August 15, 2014.  In a country with limited healthcare personnel and with a contagious disease outbreak that has made healthcare providers reluctant to treat patients, the combined workforce stoppage and the subsequent terminations may have an enormous impact on Nigeria’s capacity to prevent the spread of the disease and to respond to new cases.

The Ebola patients were being treated in an Ebola isolation ward within the government-run Infectious Diseases Hospital (IDH) located in the Yaba district of Lagos, but they have recently all been moved to an expanded 40 bed facility nearby. The United States Centers for Diseases Control (CDC) has sent a 9-member team to Lagos to work with Nigerian public health officials on treatment and containment protocols. In addition, the Ebola patients are being treated by a 7-member team of Nigerian physicians who are being trained and guided by 8 individuals from the World Health Organization (WHO) and Doctors Without Borders. The country has three national labs that have the capability to diagnose the Ebola disease.  Private hospitals are no longer accepting patients with symptoms of Ebola, and these patients are being directed to the government facility.

Initially, the Ministry of Health was going to allow the use of Nano Silver as an Ebola treatment, even though it has never been used for this purpose.  The US Food and Drug Administration (FDA) has classified the product as a pesticide.  The Nigerian government decided that drug did not meet research criteria and was eventually not given as planned. The experimental drug ZMapp that was given to 2 US individuals with Ebola has been given to 3 doctors in Liberia but not to any infected individuals in Nigeria.  One of the doctors in Liberia, Dr. Aroh Cosmos Izchukwu, is originally from Nigeria.  The manufacturer of ZMapp, Mapp Biopharmaceuticals, has said the supply of the drug is “exhausted.”  The US FDA does not normally allow experimental drugs to leave the country.

Public Response: Dire Concerns

Although Nigeria’s Ebola cases and deaths can be connected to a single index patient, the public has concerns that Ebola may spread from Liberia, Sierra Leone or Guinea due to the ease of movement of people and commerce through the agreements in place via the Economic Community of West African States (ECOWAS).  Although the 3 countries initially affected by the epidemic have placed travel restrictions, flights and ground transportation are still operating in and out of the 3 countries.  In addition the WHO has recently stated that new evidence suggests that the current number of recored cases and deaths vastly “underestimates” the actual numbers.  These concerns have caused a severe shortage of hand sanitizer and gloves within Lagos and around the country.

One of the main issues public health officials are facing are the numerous myths and false claims of “preventing” Ebola. For example, rumors have spread that kola nuts, a caffeine-rich fruit used in Nigerian ceremonies, will protect individuals from Ebola. In addition, people have taken to unusual practices to ward off the disease:

Benedict Lukpata, a 30-year-old laundry worker living in the capital, Abuja, isn’t taking his chances. Last week he bathed in hot salted water, drank a glass of saline liquid and then called friends and family to recommend they do the same after he was told by a neighbor it would protect him from “the spirit” of Ebola.

One practice that may help limit further spread of the disease is the recent revival of Nigeria’s “revolutionary salute.”  The clenched fist sign upon meeting another individual means no contact necessary as would occur with a handshake.

Unified International Response

Public health experts and officials all agree a unified and coordinated response will be required to stop this current Ebola epidemic.  Sharing of epidemiological data, coordinating travel surveillance & restrictions, increasing availability of medical supplies, and amplifying evidence-based prevention messaging all will help combat this crisis.

Report written by Bobby Kapur, M.D., M.P.H.