Wednesday, October 08, 2014

‘How Nigeria Contained Ebola Virus Disease’
Nigerian student in Lagos screened for fever.
Written by Chukwuma Muanya
Nigerian Guardian

• ‘Team did not use experimental drugs’

• Committee meets today, may adopt position on bitter kola cure

SO many questions have been asked since the country was last week declared Ebola Virus Disease (EVD)-free by the World Health Organisation (WHO) and the United States Centres for Disease Control and Prevention (CDC).

    Some are saying, ‘it was an act of God.’ To others, the Federal Ministry of Health and the Lagos State Ministry of Health have excellent disease surveillance and monitoring systems.

    What really happened? How was the country able to record far lower fatality ratio of 36.8 per cent with only seven deaths in 19 confirmed cases compared to the global average of 70 per cent set by the WHO?

   To the CDC, Nigeria’s success story was due to her strong emergency operations centres (EOC) and polio eradication experience.

   The EOC was established after the first case of EVD in the country on July 20, 2014, to contain the disease.

   Dr. Faisal Shuaib was immediately appointed the Incident Manager and Head of the EOC by the Health Minister, Prof. Onyebuchi Chukwu.

    Shuaib was  highly recommended for the job. Shuaib, who hails from Nasarawa State, studied medicine at the Ahmadu Bello University Zaria and was further trained at the University of Alabama at Birmingham, United States where he obtained a doctorate in public health. He was also once surveillance officer and state coordinator with the WHO in Nigeria before his current job at the Federal Ministry of Health where he is the Technical Assistant to the Minister of State for Health on Immunisation and Polio Eradication and Deputy Incident Manager of the National Polio Emergency Centre.

  Shuaib graduated from the doctoral programme in the U.S. with distinction, going home with the outstanding doctoral student and the dean’s prize as well as the best international student recognition.

   Shuiab in this online interview with The Guardian narrates how his team was able to contain the virus.

   He said the team did not use experimental drugs in the treatment of EVD during this outbreak but was able to achieve a relatively high survival rate using accepted, high quality standards of care.

   Shuiab said the lessons learnt are that we can defeat EVD and indeed manage any disease outbreak with adequate preparedness, effective coordination, rapid action and cohesive teamwork.

   Besides, a professor of pharmacy and member of the National Expert Committee on Ebola, Prof. Maurice Iwu, yesterday told The Guardian that contrary to some reports that the committee was to meet yesterday, it would be meeting today in Abuja.

   Iwu who is the pioneer researcher on bitter kola cure for EVD said the committee was set to announce a plan to support the continuation of the work on bitter kola cure for Ebola.

   Iwu is part of a six-man working group, inaugurated by the Federal Government in August to carry out research on the treatment of Ebola virus.

    The terms of reference of the committee, among others, are conducting research into the treatment of the Ebola virus and receiving and verifying claims relating to the treatment of the disease, including uncompleted researches carried out in 1999 in the U.S. by Iwu and his team.

   The Minister of Health had inaugurated the committee co-chaired by Prof. Karniyus Gamanie, Director-General, National Institute for Pharmaceutical Research and Development (NIPRID), Abuja.

   The other co-chair is the Director-General of Nigerian Institute for Medical Research, Prof. Innocent Ujah.

   Chukwu said researches were going on across laboratories worldwide on vaccines for the treatment of the virus.

    The team, he said, should collate and analyse related research findings worldwide, adding that the committee was free to collaborate with similar centres around the world in the discharge of its mandates.

   Reacting to what informed the decision of the Minister of Health to appoint him as the manager of the Emergency Operation Centre for the containment of Ebola outbreak in Nigeria, Shuaib said: “I believe this is because the Honourable Minister of Health knew that an outbreak of this magnitude requires someone with deep understanding and experience of incident management in Nigeria. The incident management system is used to stand up emergency operations anytime there is a public health emergency such as the Ebola Virus Disease outbreak. Given that I was involved in the conceptualisation, establishment and operations of the effective National Polio Emergency Operation Center (EOC), I was invited to lead the Ebola EOC. I also think my experience in working with both government and international development partners put me in a unique position to bring these varied proficiencies to bear on a very delicate system.”

   Nigeria has been hailed by the WHO, the United States and indeed the whole world for its efforts in containing the dreaded EVD  that has ravaged some parts of West Africa. Shuaib said Nigeria’s success stemmed from three important variables that may have been missing in other West African countries: Firstly, when the index (first) case was confirmed, there was rapid action on the part of the federal and Lagos State governments. There was an immediate declaration of the event as a public health emergency by President Goodluck Ebele Jonathan and mobilisation of human, financial and material resources to contain the outbreak.

   Secondly, the leadership provided by the Minister of Health, the Governor of Lagos State, Mr. Babatunde Fashola and the Project Director, Nigeria Center for Disease Control (NCDC) Prof. Abdulsalami Nasidi, were very critical towards ensuring the  setting  up of the Ebola EOC by providing it with protected authority and operational space to implement strategies required to contain the spread of the virus.

      Thirdly, the establishment of the EOC itself was a game changer; the EOC is an operational organ of the NCDC. It operates using a war-room approach with co-location of all actors within a designated facility. Under the leadership of government, international development agencies like the WHO, United Nations Children Fund (UNICEF), CDC, Medicine San Frontieres (MSF), and the Red Cross participate in joint strategising, agree on one plan and implement it in a way that accentuates efficiency and accountability.

    Shuaib further described the structure of the EOC, the component teams and their functions: “The Ebola EOC used a war-room approach to coordinate the outbreak response. The EOC is an assembly of public health experts working under the leadership of the Federal Government of Nigeria. So you have a situation whereby Government and staff of international development agencies are co-located in a designated facility, agree on the strategies, develop ONE plan and implement this plan together. Central to the success of the outbreak response is the harnessing of all available resources towards the implementation of this unified containment strategy.”

     According to him, the Ebola EOC’s architecture is made up of six important pillars: epidemiology/surveillance, case management, point of entry, communication and social mobilisation coordination, logistics and management/coordination.

  He  said : “The first four are directly involved in the technical aspect of the outbreak control so I will describe their roles briefly.

   “Epidemiology/surveillance: This unit analyses and maps chains of transmission with the objective of stopping them, they conduct a tracing exercise of everyone who comes in contact with a suspected/confirmed case, they also  list all contacts as indicated. The contact tracers who are largely residents of the Nigeria Field Epidemiology and Laboratory training programme, conduct daily assessments of each contact’s symptoms including temperature monitoring. The latter group also coordinates the management of rumours and alerts through proper investigation and triaging.

   “Case management team: This team is responsible for the  strict implementation of standard operating procedures for assessing, treating and caring for suspected and confirmed cases of EVD; they ensure management of other illnesses that are  present with  during the time of EVD clinical management; conduct decontamination of homes and other facilities from where cases are evacuated; ensure the collection of clinical specimens from suspected and confirmed patients; conduct counseling of all EVD suspects and confirmed cases.

  “Point of entry team: This team ensures screening of all arrivals/departures in and out of the country by land, air and sea to prevent importation/exportation of EVD. Screening includes temperature monitoring and analysis of the entrant’s contact with cases of EVD. They also ensure that capacity is available at all border points to properly manage passengers presenting with   symptoms of EVD including ability to isolate them.

   “Communication and social mobilisation team: The communication approach targets risky behaviours to contracting EVD. The team conducts house-to-house interpersonal communication; it also enables the implementation of community mobilisation strategies that uses the leadership and influence of religious, traditional, informal and professional bodies towards preventing the spread of EVD. They also develop and disseminate information, education and communication (IEC) materials that build awareness and knowledge around EVD. The team developed the social media platforms e.g. Facebook, Twitter and EbolaAlert website that were an integral part of the outbreak response.”

   The WHO puts the fatality rate at 70 per cent but in Nigeria it was less than 40 per cent. The public health expert explained: “Actually, the case fatality rate in the Nigeria outbreak was 40 per cent. This means that 40 per cent of those who developed the disease died in Nigeria. This proportion includes the index case that arrived  in  Nigeria with already advanced Ebola disease.

   “Clearly, the patients in Nigeria were given the best level of care possible. We had Ebola case management experts from  WHO working with our equally qualified Nigerian medical doctors, nurses and other health care workers. They provided the highest level of clinical care to EVD patients round the clock. As you are aware, treatment of EVD is mainly supportive. However, the quality of this supportive care does determine the trajectory of the disease.

   “Furthermore, the chances of survival from the disease improve when a patient is able to report early to a treatment centre. So once an individual knows they have been exposed to the disease and develop symptoms, they should seek urgent medical care by calling the Ebola help hotline (0800-EBOLA-HELP).”

   One of the survivors, a medical doctor, said the major thing that was used was the oral rehydration therapy (ORS) solutions.  But  according  to the EOC Incident Manager, the  treatment of EVD is mainly supportive. He further explained: “Among other symptoms, EVD presents with vomiting and diarrhea. Patients lose a lot of fluids and electrolytes from their body, which can be life-threatening. Giving oral rehydration solution (ORS) helps restore this balance once the patients are able to eat and drink on their own. Otherwise, fluid and electrolyte replacement is done using intravenous fluids (IVF).”

   The survivor also painted the picture that it was the Lagos State government that did the job not the Federal Ministry of Health. Shuaib, however, said the outbreak response in Nigeria was a collaborative effort involving the Federal Ministry of Health, the NCDC, and the Lagos and Rivers State Governments working together  with  international development partners. None would have been successful without the other.

     He explained: “This was an effort that saw seamless and consistent teamwork through the mechanism of the EOCs. We should celebrate our collective success as a country. Within the partnership, different team members had their strong suits, but being able to harness these resources towards such a goal is unprecedented. Team Nigeria stepped up to the challenge and did an outstanding work of containing the EVD outbreak. That is the message I think we should align on.”

   Some people are saying that Nigeria was lucky and that it was an act of God that saved her from possible Ebola epidemic. In this regard, Shuaib said : “There is always an element of luck in man’s endeavors; it could have been worse. However, the overarching theme is that the epidemic was contained due to exemplary leadership, teamwork and rapid action.”

   Some stakeholders say the success vindicates the WHO statement in March this year that Nigeria has one of the best disease surveillance systems in Africa. The public health expert said: “You are absolutely right. Nigeria has a very vibrant integrated disease surveillance and response network. The detection of the disease followed the linkages in our alert system, between the health facilities and our response teams. The surveillance system in Nigeria continues to enhance surveillance for EVD in our health facilities, ports of entry and communities. This is to ensure that any case of EVD is swiftly reported and investigated.”

   On the drugs that were used by Nigeria and how  it happened, Shuaib explained: “There are no specific drugs for treating EVD. The treatment given to individual patients depends on the presentation. Generally speaking, as afore-mentioned, supportive treatment was provided to the patients: fluids and electrolytes are replaced; drugs to prevent and control hemorrhagic events, pains, fever, etc. are administered. We did not use experimental drugs in the treatment of EVD during this outbreak but were able to achieve a relatively high survival rate using accepted, high quality standards of care.”

   On whether Nigeria has successfully eradicated or stopped Ebola,  Shuaib said: “We have managed to control this outbreak. However, from an epidemiological point of view, we have to wait until 42 days or two incubation periods after the last infectious case has been discharged before declaring an outbreak as over. There is a need to sound a note of caution though. Although the outbreak may be declared over within our Nigerian borders, we must remain steadfast in our vigilance. As long as the epidemic continues in Liberia, Sierra Leone and Guinea, there is always a threat to our public health system. We could find another individual who may enter our shores without disease but develop symptoms later. So we must maintain a high index of suspicion. We must continue our active surveillance, screening at all points of entry and increase public awareness around EVD.

    “Although we may declare Nigeria EVD free, our joy must be subdued because we continue to sympathise with the families, friends and colleagues of those who paid the ultimate price during this outbreak. While we acknowledge our success, we cannot celebrate because our neighbours, our brothers and sisters in Sierra Leone, Liberia and Guinea continue to witness an extraordinary level of death and human suffering. Now is the time for us to mobilise resources to support and comfort them.”

   On when Nigeria  could be certified Ebola free and whether people  were under surveillance,  he said the last EVD case became EVD negative and was discharged on September 7, 2014. “Forty-two days after this date means we declare Nigeria Ebola free by October 20, 2014”, he said.

   Shuaib explained: “I want to reiterate that the war against EVD is far from over. We must not let our guard down; we cannot afford to become complacent. The price to pay for losing sight of this would be heavy, because no country is free from the threat of Ebola until all countries in West Africa become Ebola free. The recent report of imported EVD from Liberia into Texas, USA, underscores this reality.

   “No, there are currently no contacts under surveillance in Nigeria.”

    On the lessons learnt from the Ebola scare and    the challenges,  Shuaib  said : “The lessons learned are that we can defeat EVD and indeed manage any disease outbreak with adequate preparedness, effective coordination, rapid action and cohesive teamwork.

   “The challenges related to the initial misconceptions and panic caused by misinformation. Once we got over this hurdle and the press provided correct information about the nature of the virus and the evolution of the outbreak, the situation became more manageable.”

   Asked what was next  after Ebola,  he said: “I am back to trenches fighting in the last frontiers of polio eradication. We are closer than ever to eradicating polio from Nigeria. I am going back to help ensure we finish the job of stopping transmission this year.”

      There is the fear that the attention being given to Ebola may shut down efforts to control other important diseases such as Human Immuno-deficiency Virus (HIV)/Acquired Immune Deficiency Syndrome (AIDS), tuberculosis (TB), malaria and polio. But Shuaib said this fear may have been justifiable early in the outbreak but this was no longer the case because the outbreak had been contained.

     He explained: “In places like Liberia, Sierra Leone and Guinea, where the outbreak has increased exponentially, their health systems are completely overwhelmed. Theirs is a story of working far behind the curve, too little resources, coming too late to help stave off the outbreak, let alone control these other diseases effectively.

    “Clearly, this is a time for us to use the experience of our successful outbreak response to strengthen the Nigeria Centre for Disease Control (NCDC) so that epidemic preparedness and response will consistently be comprehensive and institutionalised.

   “Credit must be given to the Minister of Health, Professor Onyebuchi Chukwu for his foresight in pushing for the establishment of the Nigeria Centre for Disease Control and to President Goodluck Jonathan for approving it as a full-fledged parastatal of the Federal Ministry of Health as recommended by the report of the Orosanye committee on the rationalisation of federal parastatals and agencies. In a way, this singular move prepared Nigeria for the successful containment of Ebola outbreak in the country.”

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