Results: This study elucidated the public health response to the Ebola outbreak led by Lagos State Government in conjunction with the Federal Ministry of Health. The principal strategy was an incident management approach which saw them identify and successfully follow up contacts. The infected EVD cases were quarantined and treated. The Nigerian private sector and international organizations made significant contributions to the control efforts.
Public health enlightenment programmes using multimodal communication strategies were rapidly deployed. A total of contacts were identified, and approximately 18, face-to-face visits were conducted by contact tracers to assess Ebola symptom development.
Persons with suspected Ebola were transported to a suspected case isolation ward by the case management team, and persons who subsequently tested Ebola positive were moved to the confirmed case ward at the same facility in either Lagos or Port Harcourt.
The isolation and treatment wards were empty, and all but three contacts had successfully exited follow up. The remaining three contacts became ill but tested Ebola negative and were released from the isolation ward in Lagos.
As is standard practice, upon release, the patients who had been suspected cases started a new day follow-up as contacts because of the possibility that they were exposed in the ward. In this instance, no one was diagnosed with Ebola while these three contacts were in the ward, thus the likelihood of Ebola exposure was very low, and all three are due to exit follow-up on October 2.
Investigation of the index patient and all exposed contacts required coordination between multiple IMS response teams and across several cities in the course of the response. The three-generation spread of Ebola all 19 confirmed and probable cases to date can be traced to the index case through contact networks Figure 1.
Twelve of the 20 patients were exposed in two health facilities in Lagos. Four of the cases have been associated with a suspected case in a patient who traveled while ill via commercial aircraft from Lagos to Port Harcourt, Rivers State, and back Figure 1. No ill or deceased passengers were identified.
Overall, no new cases have occurred since August 18 in Lagos and August 31 in Port Harcourt, suggesting that the Ebola outbreak in Nigeria might have been contained Figure 1. The threat to Nigeria posed by the arrival in Lagos of a patient acutely ill with Ebola was potentially enormous. Lagos is Africa's largest city and is also a transit hub for the region with air, land, and sea ports of entry 1. The dense population and overburdened infrastructure create an environment where diseases can be easily transmitted and transmission sustained.
Suboptimal infection control practices in health centers lacking necessary equipment and supplies increase the risk for Ebola transmission to health care workers. Contact tracing efforts are burdened by the complex nature of transit, commercial, and public health notification and reporting mechanisms. The implementation of a rapid response that made use of the available public health assets was the highest priority at the onset of the outbreak, as was organizing the response using proven structures for the delivery of public health in Nigeria.
To effectively address Ebola in this complex environment, the response was mounted quickly and used an IMS; both actions are largely credited with helping contain the outbreak early. The EOC expanded its operations to Rivers State when cases emerged there, and oversaw the monitoring of contacts in Enugu State with state health officials as part of the early outbreak response.
There was a stated expectation that all partner organizations, donors, and response teams would work through the EOC structure, reporting to an Incident Manager IM. The IM, responsible for oversight of the response, was selected based on IMS experience and competency rather than rank in government or public service.
Nigeria's response benefited from the rapid use of its national public institution i. In October , responding to the declaration by the World Health Organization of polio eradication as a global public health emergency, and to improve its national response, the Government of Nigeria used the IMS to establish a national EOC as part of a new national emergency plan for the global polio eradication initiative 3. The use of IMS through the EOC changed the operational tempo, accountability measures, and programmatic success of the polio program.
Indicators and dashboards electronic displays of high level indicators for each response team monitored at the EOC were developed to increase accountability of the program staff and spending. Critical to demonstrating both national and state commitment, the Deputy IM was a senior member of the Lagos State Ministry of Health Ebola was imported to Lagos State , with access to human and financial resources within the state health system.
Immediately, the EOC developed a functional staff rhythm that facilitated information sharing, team accountability, and resource mobilization while attempting to minimize the distraction of teams from their highest priorities. An "Action Tracker" was developed that included specific tasks arising from each meeting, the person responsible, and the due date. Terms of reference and priority activities were developed by the strategy team to guide each operational team's work; operational teams developed their own staffing, lists of material and financial needs, and a goal-oriented operational plan.
The strategy group reviewed and approved all of the teams' work and needed resources. Technical partners assigned staff throughout the operational teams in technical advisory roles aimed at building the capacity of the local teams and ensuring quality work.
Early in the response, this team mobilized to identify and track the index patient's contacts in the airport and outside Nigeria. Port Health Service worked with airline and airport authorities and other stakeholders to gather information about contact passengers, decontaminate affected areas of the airport, and send a notice through the World Health Organization-International Health Regulations system to avoid possible spread of the disease.
The Point of Entry team also established entry and exit screening at ports, which is being rolled out at additional ports and will continue for the duration of the regional outbreak to minimize the likelihood of either further importation or exportation of Ebola.
In response, the team developed a staffing plan for Lagos that included over contact tracers, vehicles, telephones, and mobile data platforms that the contact tracers could use to administer their questionnaires and report contact responses.
Directly linked to the contact tracing was the Social Mobilization strategy. This included teams of three social mobilizers who were trained and deployed to conduct house-to-house, in-person visits within specific radii of the homes of the Ebola contacts.
For high-density areas, house-to-house teams covered a m radius, 1km in medium density areas and 2km for low density 7. As of September 24, approximately 26, households of persons living around Ebola contacts had been reached with house-to-house visits in Lagos and Rivers states. These contacts who did not manifest symptoms of EVD were followed up in their homes as they were deemed non contagious. It was safe to leave them at home as long as they were not manifesting symptoms.
Wide spread publicity, public awareness and fear of the contagion among the general populace contributed to the prevention of further spread of the disease. There were concerns by people living within the vicinity of hospital Y about potential contamination arising from cremation of the bodies of the EVD victims.
Community enlightenment activities were deployed to dispel these fears. The patients who were diagnosed with EVD were transferred to hospital Y. This facility was only hurriedly converted to an EVD treatment centre.
Although hospital Z was shut down during the EVD outbreak to prevent the spread of infection, the staff were still being paid salaries from funds provided to the hospital by the Lagos State Government.
The children of some patients who died from EVD were reportedly ejected from their homes due to stigma. Such children were provided new homes. The children of late X [who died from EVD] were driven out of their home as a result of stigma. The children now have a new home, and they are back in school. Survivors of the EVD were said to have been offered monetary incentives by the Lagos State government to compensate for job losses due to stigma.
The survivors and their families were also reported to have been offered counselling and psychosocial support. There was also employment for survivors as well as psychosocial and counselling support. Nigeria benefitted immensely from support from the international community and the EOC coordinated this. They were also in charge of the server used by the response team. The Lagos State Government initiated efforts to partner with the private healthcare practitioners. So it was easy to organise the private health sector during the outbreak through this group.
The foundation also provided 12 units of thermal scanning systems for the 4 international airports in Nigeria. The foundation also donated 3, sets of personal protective equipment costing NGN 25,, The Lagos State Government reportedly tried to dissuade two churches with large membership from hosting international conferences during the EVD outbreak.
Letters were written to warn them to suspend these. However, one of them, Church A had already begun. They assured the authorities that infection control measures had been put in place in the church. It involved all strategies to communicate with the people. Virtually all media houses came forward to get accurate information on Ebola from the Lagos State Ministry of Health.
Information on Ebola was rife. A contact of the index case was isolated at home after blood samples were taken for EVD testing. Unfortunately, the contact absconded to Rivers State and placed himself under the care of a doctor. This doctor decided to treat the contact in his hotel room and died in the process. Blood samples from the both the contact and the doctor finally tested positive for EVD. The doctor was in turn linked to a total of contacts in Port Harcourt [ 3 ].
Rivers State eventually managed 8 suspected EVD cases and 2 confirmed cases with 1 out of the 2 dying. Several difficulties were experienced during the EVD outbreak. The first few days proved to be very chaotic. A lack of infrastructure was reported to be one of the greatest challenges faced. The decision to convert hospital Y to an EVD treatment centre was made only after the index case was diagnosed. There were no quarantine centres; contacts were traced and monitored in their homes.
The industrial action by the doctors was eventually resolved following the intervention of Nigerian doctors in diaspora. The EVD outbreak is reported to have impacted negatively on the commercial activities of Lagos State [ 15 ]. The Lagos State hospitality industry reportedly lost over 8 billion Nigerian Naira between July and October due to plummeting hotel occupancy rates [ 3 ].
Key informants reported that the EVD outbreak revealed how unprepared and vulnerable the health system was. It was also reported that the health system was suited for curative rather than preventive medicine. The need for an emergency response framework was very evident during the EVD outbreak in Nigeria. The uncertainty of stakeholders with respect to their specific roles was eventually overcome.
A solid structure is now in place in Lagos State to facilitate her response to future emergencies. There are also plans to upgrade facilities in hospital Y to position it to respond efficiently to future infectious diseases outbreaks.
There is a plan underway to build up hospital Y to be able to quarantine and treat infectious disease cases. The EVD outbreak in West Africa has come and gone leaving in its wake devastated families and communities. The deaths recorded in this particular outbreak are said to surpass those recorded during the previous 25 Ebola epidemics combined [ 16 ].
The lack of infectious disease surveillance capacity in West Africa was identified as a major factor that contributed to the spread of EVD in this region which had never experienced an EVD outbreak [ 17 ]. In Nigeria, the rapid control of the EVD was facilitated by the rapid detection of the index case, the comprehensive contact tracing measures and the isolation and treatment of the secondary cases [ 3 , 19 ].
Amidst all the uncertainties that characterized the first few days of the EVD response in Nigeria, the Lagos State Government provided the vital leadership in conjunction with the Federal Ministry of Health.
Using the incident management approach which was coordinated by the EOC, the massive support provided by the private sector and international community was effectively harnessed. With respect to contact tracing, a total of contacts were identified and approximately 18, face-to-face visits were conducted to assess contacts for symptoms of EVD.
Flight manifests and phone records were reportedly used in the contact tracing exercise [ 20 ]. The isolation and treatment of secondary cases was initially challenging as there were no isolation facilities. Considering the relatively common occurrence of infectious disease outbreaks in African settings, the provision of such isolation facilities and training of healthcare personnel needs to be given priority.
This training might have positioned the country to provide a robust response the EVD outbreak [ 22 ]. The effectiveness of disseminating educational materials via electronic channels such as Twitter and Facebook has been reported severally [ 23 , 24 , 25 , 26 ] and the EVD outbreak in Nigeria mirrors this.
Given that the use of electronic communication devices has become commonplace even in resource poor settings, disease control strategies need to make full use of this resource to drive behaviour change during outbreaks. This was vital in the Nigerian outbreak as rumours were rife that Garcinia kola bitter kola and salt could cure EVD [ 27 , 28 ].
The EVD outbreak in Nigeria recorded significant gains from a public heath perspective as water and sanitary facilities were provided in many public schools in Lagos and other parts of the country. It is important that desirable habits such as hand washing should continue as this singular action can reduce the incidence of other infectious diseases such as diarrhoea.
As the African subcontinent recovers from the onslaught of EVD, it is time to reposition her health system to be able to effectively contain future disease outbreaks. The Nigeria EVD experience provides valuable insights to guide these vital reforms. Idris J. Presentation by Dr.
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