As the WHO Ebola Response Team published dire predictions of the West African outbreak in the New England Journal of Medicine, overnight – including an updated 70.8% fatality rate – the Health Minister of Nigeria reports that his country is completely free of active Ebola cases and have today released the final victim contacts from surveillance.
In a telephone interview last night where he was preparing for a United Nations General Assembly meeting in New York, Minister of Health Onyebuchi Chukwu, MD, said, “Presently, there is no single case of Ebola virus disease in Nigeria – none.”
Dr. Chukwu provided further details, saying, “No cases are under treatment, no suspected cases. There are no contacts in Lagos that are still under surveillance, having completed a minimum of 21 days of observation.”
In the process of tracing contacts of individuals infected with Ebola, anyone showing no symptoms after three weeks of last known contact with a victim is considered free of any potential for the disease.
Rivers State, whose capital city is Port Harcourt, had been home to over 400 contacts under medical surveillance. As of last night, only 25 contacts remained.
“None of them are showing any symptoms. Tonight [Mon 22 Sept] will mark the end of their 21 days of observation and the plan is to get them discharged from surveillance tomorrow [Tues 23 Sept].”
“Nigeria will be as clean as any other country as far as Ebola virus disease is concerned.”
Achievement in perspective
PBS TV reporter Fred de Sam Lazaro wrote yesterday from Port Harcourt, “The story of Ebola in Nigeria is an unusual and frankly rare one about things going right somewhere in Africa.”
“Nigeria’s achievement truly hits home for a television crew working “in the trenches” of a country the U.S. Central Intelligence Agency describes as “hobbled by … insecurity and pervasive corruption,” added Lazaro, who can be found on Twitter @newshourfred.
His team’s outstanding 8-minute report aired last night on PBS Newshour.
Indeed, the disease has now been contained in Lagos, a city of 21 million people, and Port Harcourt, population 1.4 million.
Nigeria is the most populous country on the African continent, with 177 million people, yet only suffered 21 Ebola cases and eight deaths. In contrast, Liberia has just 4.3 million people yet has experienced 2,710 reported cases, with 1,459 deaths (as of 18 September).
Ebola virus was brought to Nigeria when naturalized American and Liberian Ministry of Finance official, Patrick Sawyer, traveled to Lagos for a meeting of the Economic Commission of West African States (ECOWAS) in Calabar on July 23.
Sawyer had symptoms of the disease before leaving Liberia and became very ill on the flight, infecting others from ECOWAS who greeted him and at the hospital where he was treated and died two days later.
A contact under quarantine in Lagos for some reason took flight to Port Harcourt, about a seven-hour drive. There, he was treated in secret by Dr. Ikechukwu Enemuo. Both Dr. Enemuo later died.
[Update, 24 Sept: A Twitter follower and another reader have contacted me to stay that the diplomat treated by Dr. Enemuo, Olu-Ibukun Koye, survived and has returned to work at ECOWAS. We are attempting to confirm this independently.]
Enemuo infected others, including his wife and sister. Both were successfully treated and recovered. But authorities had to track 477 contacts in the Port Harcourt area.
The need for cautious communication
Dr. Chukwu told me, and has said publicly elsewhere, that one challenge in Nigeria has been preventing stigmatization of anyone under surveillance as well as Ebola survivors.
“Three terms became part of our lexicon: surveillance, quarantine, and isolation.” But these need to be clearly explained, said Dr. Chukwu.
“Surveillance is sort of like house arrest. You don’t criminalize them. The person is actually a victim, not a criminal. We monitor their movements, the rest of the family are counseled about what contact can and can’t be done. We have contact with them everyday. You can imagine what this effort must’ve been like when we had 300 in Lagos and over 400 in Port Harcourt.”
Only when those under surveillance show symptoms – a fever, whether it ends up being Ebola, yellow fever, or malaria – they are put under quarantine.
“That is the first time we are denying that individual the comfort of his own bed. We put him in separately from the isolation ward from those who are confirmed. If malaria, we discharge them to their doctor to be treated for malaria.”
Credit to WHO-assigned physicians
The Ebola survivors in Nigeria were not treated with any experimental drugs. Contract tracing and early identification of cases were managed by isolating the patients and replacing fluids and electrolytes. In some cases, blood transfusions were necessary.
Dr. Chukwu had high praise for WHO Director General, Margaret Chan, for sending physicians to Nigeria. “We only knew about Ebola virus through our medical books. We’ve never seen a single case of Ebola virus until this year. So we needed someone with practical experience who had seen the virus to come and train our doctors what to do and the rest, and then we took over.”
“It is important that we let the world know that WHO did well in sending us doctors with practical experience, said Dr. Chukwu. “But we also worked with the CDC, UNICEF, and MSF in managing the disease.”
Controlling the outbreak in Guinea, Liberia, and Sierra Leone
Dr. Chukwu said that a major challenge is that the three countries are contiguous and in need of independent, coordinated oversight. The case in Nigeria was different because once President Goodluck Jonathan declared a health emergency, he had the authority and resources to direct the entire national effort.
In an attempt to centralize the West African response, the current chairman of ECOWAS is the president of Ghana and convening a meeting of West African health ministers together with the director of the Nigerian Center for Disease Control.
In the rest of Africa, Dr. Chukwu suggested that Guinea, Liberia, Sierra Leone (as well as Senegal) could benefit from the expertise of doctors in Uganda and the DRC who have successfully treated Ebola patients. The rest of the world can certainly provide the aid that is starting to grow: emergency mobile hospitals, supplies such as IV fluids and personal protective equipment.
But people in these countries are also voicing a loss of confidence in their own governments as their economies fail and food and clean water are in short supply.
And, particularly with the killing of aid workers in Guinea last week, the international effort must bolster security to encourage volunteers that they can work safely in what are already extremely demanding conditions.