On October 20 2014, almost exactly one year ago, the World Health Organisation declared Nigeria Ebola free, 42 days after the last known case had occurred. At the time the world was in the grip of one of the largest and most terrifying public health disasters in generations.
While not completely over, there are signs that we are finally getting to the end of this outbreak which has had an unprecedented impact on the sub-continent. The Ebola outbreak claimed thousands of people, including hundreds of doctors and health care workers and it will be a tragedy of immense proportions if lessons are not learnt and history repeats itself. While we wait for our governments and schools of public health to engage with this process, we offer a starting point of the reflection that should be happening across the country and continent.
— Dr. FiF® (@officialdaddymo) October 20, 2014
Compared to the three most affected countries, Nigeria had a relatively small outbreak. As the outbreak escalated in Liberia, Guinea and Sierra Leone, there was significant anxiety on the consequences of the introduction of the virus to Lagos, with its estimated population of 15 million, living in densely populated neighbourhoods. In many ways Nigeria was lucky that its first case entered the country through the main airport and presented to one of the most recognised private hospitals in Lagos. Here, the astute clinical acumen and professionalism of the staff of First Consultants Hospital Group led to the rapid diagnosis of Ebola and the sheer determination of its excellent group of clinicians prevented the patient from leaving the hospital at his request, most probably saving the country from many more infections. This was done at great personal sacrifice, with many of the team paying the ultimate price with their lives.
Subsequently, the country experienced probably its finest hours in public health by rapidly mobilising the resources to mount a determined response. The rest is history, as the country managed to limit the number of cases to 19 with 10 deaths, confounding the predictions of doom that had spread around the world. Nigeria saved itself not only from a major public health crisis but also an economic one, as the consequences of exclusion from the global economy would have been a disastrous outcome for the country.
One year after the outbreak, it is important for the country to reflect both on what was achieved and how it was achieved, but most importantly we must ponder whether the lessons learnt have formed the basis for the prevention of future outbreaks and the preparation of a more robust response in the future. We hope that the Federal Ministry of Health and its National Centre for Disease Control has carried out a similar exercise, or if not, that this piece inspires them to do so. We propose these five areas below as those that enabled the successful response in Nigeria and therefore should be further developed.
- Central coordination through an “Emergency Operations Centre” (EOC)
Nigeria’s rapid response to the introduction of Ebola benefited from having an established EOC that was funded and set up by the Bill and Melinda Gates Foundation to support the response towards the elimination of polio in Nigeria. The deputy incident manager of the polio EOC was rapidly deployed to lead the Ebola EOC (watch a great interview with Dr Faisal Shuaib by Ebola Deeply). Nigerian authorities moved quickly to establish a co-ordinated response using EOC structures previously developed for its polio response and drew from its experience in setting up strict command and control structures to manage the response.
Among its activities, the team coordinated the follow up of thousands of contacts, developed a staffing plan that executed a social mobilization strategy that reached more than 26,000 households of people living around the contacts of Ebola patients, and ensured that resources required for the clinical management of cases were available. A number of partners from WHO, CDC, UNICEF and MSF were part of the EOC structure, however all reporting and communication was done through the incident manager appointed by the Ministry of Health for this purpose. After the Ebola response using EOCs in Lagos and Port Harcourt, its core structure was moved to Abuja to maintain contingency arrangements. This has since faded away quietly. It is not clear what proactive steps the country is taking to sustain an operational EOC, nor where this would be located.
- The public health function of the private hospitals
It is difficult to over state the critical role that a culture of strong clinical governance and an awareness of public health responsibility played in shaping the response of the First Consultants Hospital Group in Lagos to the Ebola outbreak, led by Dr Adadevoh and her team . Population health as proposed by Kindig et al is a concept of health that focuses on “the health outcomes of a group of individuals, including the distribution of such outcomes within the group,” and includes health outcomes, patterns of health determinants, and policies and interventions that link these two. Population health is primarily a goal—a goal of achieving measurable improvements in the health of a defined population. Therefore it is important not only for those responsible for the health of populations, but for all those working in hospitals and clinics with a responsibility to deliver care to understand concepts such as prevalence, incidence, risk, and disease determinants at a population level in order to practise to a high level. If Dr Adadevoh and her team were not acutely knowledgeable on this, Nigeria would have ended up with a completely different outbreak. Dr. Ada Ighonoh, a young doctor at the hospital who survived Ebola, gave a personal account of how she survived and how she is using her second chance at life to prepare herself to prevent similar incidents from happening in the future. Every doctor should listen, and learn.
- Communication matters more than ever during outbreaks
During the outbreak, the media was saturated with messages on Ebola. It was on every media, on television, radio, on newspapers on social media. Suddenly there were Ebola experts everywhere and people were rapidly educated on the risks of the disease, the symptoms and what to do if one had symptoms. But this was not the case in the beginning of the outbreak, when stories on remedies such as “salt water”, “bitter kola” and “Nano Silver” filled the airwaves as we clutched at straws, filled with anxiety. A completely volunteer group, EbolaAlert led by Dr Lawal Bakare rose out of Nigeria to be one of the most credible sources of information on Ebola. Led by young Nigerians, they quickly garnered over sixty thousand followers on twitter. At this time, there was virtually no usable information on the website of the Federal Ministry of Health and the Nigerian Centre for Disease Control did not and still does not have a website through which it can inform the population. The impact of poor communication was demonstrated acutely during the recent apparent Ebola “scare” in Calabar.
- Investing in training and development: The National Field Epidemiology Training Programme example.
A few years ago, with the support of the US CDC, the Field Epidemiology and Laboratory Training Program (FELTP) was set up in Nigeria. This is a two-year competency-based training and service program in applied epidemiology and public health that builds the capacity to strengthen the surveillance and response systems of a country. It is managed by the Federal Ministry of Health, the Federal Ministry of Agriculture, in partnership with the University of Ibadan and Ahmadu Bello University in Zaria. The programme trains medical epidemiology residents, public health laboratory residents, and veterinary epidemiology residents for leadership positions. The field epidemiology component is similar to programs that have been established in more than 30 countries. Itis modeled after the Centers for Disease Control and Prevention’s (CDC) two-year Epidemic Intelligence Service (EIS) training program and is composed of 25% course work and 75% field work. Current and past fellows of the programme who were already trained in most of the requisite skills formed the bedrock of the contact tracing and case investigation teams during the Nigerian response. Having this cohort of experts readily available is a testament to the importance of investing in developing skills for the future.
The leadership provided by the then Minister of Health, Professor Onyebuchi Chukwu, the then Governor of Lagos State, Babatunde Fashola, SAN, and his Commissioner for Health, Dr. Jide Idris were critical in controlling the outbreak. Despite some initial disagreements in approach, they maintained a collaborative framework in agreeing strategy and communication, recognising the lead responsibility of the Federal Government during major outbreak situations. They worked together to prevent the doomsday scenario of the rapid spread of the disease predicted in Nigeria. The function of leadership is not however limited to the public sector leaders but across the entire chain of command to the so-called “boots on the ground” that went house to house diligently following up on all the contacts.
Ironically, at the time of the outbreak, doctors working in public hospitals across Nigeria were on strike. This probably represents the biggest area of public sector leadership failure in the health sector over the last decade.
There are definitely many other lessons that the outbreak has taught us, here we have offered our top five. Evaluations are only consequential if their results lead to change and improvement. There has been a lot of chest beating on the successful Nigerian response, now it is time to prepare for the future.