DRC and its neighbors mobilize resources to tackle Ebola outbreak
At least 17 people have died in an outbreak of Ebola Virus Disease in the north west of the Democratic Republic of the Congo (DRC) in the town of Bikoro. Ebola is endemic to the country. But the number of deaths in a short period is cause for concern. The Conversation Africa’s health and medicine editor Candice Bailey spoke to Chikwe Ihekweazu in Nigeria.
What are the critical steps that the DRC needs to take now that the outbreak has been confirmed?
Health authorities have learnt many valuable lessons from previous Ebola outbreaks – particularly the outbreak in 2014 in West Africa where more than 11 000 people died.
Because the DRC has had so many outbreaks it’s developed the capacity to deal with new ones. But, as with every other disease that threatens global health security, it is critical for nearby countries to collaborate with it to ensure the outbreak stays under control.
Bringing the outbreak under control has two important phases. Firstly, health authorities in the country must define its scale. Secondly, they have to interrupt its chains of transmission as quickly as possible.
Our colleagues at the Centre for Disease Control in the DRC are currently evaluating the people who are infected. There are several pieces of information that they want to establish: when and where people were infected, where they they’ve been – or travelled to – since being infected. This will give them a better understanding of the extent of the person-to-person transmission.
Once this has been established, the government can respond. Several control activities will be initiated almost immediately covering both prevention as well as treatment. From a prevention perspective, it’s important for the government to engage with communities so that people understand the outbreak and how quickly the virus is able to spread.
From a treatment perspective, health authorities need to set up treatment centers and access to laboratory diagnosis. Given the death rate, epidemiologists will have to be on hand to carry out detailed investigations on the origins of the outbreak. This is the only way the chain of transmission can be broken.
The DRC has had numerous outbreaks of Ebola. What challenges does the country face handling a virus like this?
The DRC has had more Ebola virus outbreaks than any other country in the world. Over the past 10 years there have been five: 2007, from 2008 to 2009, 2012, 2014 and 2017.
As a result the country has gained a lot of experience in how to control the disease. But there are still many unknowns. One of the most critical gaps is understanding the transmission dynamics of the virus from its animal reservoir to humans.
The country has good systems for diagnosing the disease – its reference laboratory was able to test and confirm cases within 24 hours. But when it comes to surveillance and monitoring its systems are weak. Stronger surveillance systems would ensure that cases were reported early, and a country-led response mounted.
Nigeria is on high alert following the outbreak in the DRC. What are the concerns?
Nigeria, as well as other countries in Africa are at medium risk, according to a classification by the World Health Organization.
Nigeria has learnt that it is better to be prepared than to be caught unaware. To mitigate the risk, the country’s Center for Disease Control has taken extra precautionary measures. This has included placing its emergency operations centre on alert and issuing a public health advisory. In addition, the national port health services have heightened screening at points of entry.
There are also protocols in place to ensure that if a case is suspected, it’s detected early and response activities are initiated immediately.
It’s important for countries to ensure that their citizens are well aware of the risk the disease poses. Nigerian health authorities are working hard to ensure that this happens.
What steps will Nigeria take to help the DRC?
During the 2014 Ebola outbreak, the African Union arranged for health workers from Nigeria to go to Liberia and Sierra Leone. As a result of this initiative, Nigerian health authorities have a large cohort of well-trained resources that can be deployed to support the country if that’s needed.
How Nigeria beat the Ebola virus in three months
The diagnosis of the first case of Ebola in Lagos, Nigeria in July last year set off alarm bells around the world. The fear was that it would trigger an apocalyptic epidemic that would make the outbreaks in Liberia, Sierra-Leone and Guinea, where 1322 cases were reported and 728 people had died within five months, pale in comparison.
This fear was very justifiable. Lagos has a population of over 21 million with a population density in built up areas of about 20 000 people per square kilometer. In some areas it is as high as 50 000 people per sq km.
But within three months, the most densely populated country on the continent had managed to contain the deadly virus with only eight deaths. By October 20 the World Health Organization declared Nigeria Ebola free. In stark contrast, fourteen months after the first case of Ebola was declared in Liberia, the country is celebrating the announcement that it is Ebola free.
A combination of factors enabled Nigeria to contain the virus in such a short space of time. These included fast thinking on the part of government, a tried and tested tracking system, pooled expertise and assistance from national and international agencies.
The killer game plan
The disease was brought into the country on July 20 by Patrick Sawyer, a Liberian-American financial consultant. Sawyer initially denied exposure to Ebola. He was treated for presumed malaria after suffering from a fever, vomiting and diarrhea.
Sawyer died five days after his arrival. By then he had triggered a line of exposure. By September, 20 people had been infected. Twelve of whom were in Lagos state and eight in Rivers state. Seven more subsequently died.
In the week that Sawyer was diagnosed, an emergency operation center was set up. At its core was the system Nigeria had developed for its war against polio and lead poisoning. The deputy manager of the polio campaign was brought in to head the Ebola response team and operations were rapidly scaled up.
The success of the system lies in a strong coordinating team that supervises house-to-house surveillance. A team of 40 trained epidemiologists and 150 contact tracers was mobilized. They drew up a list of all Sawyer’s contacts and those of the subsequent Ebola cases. Locations were mapped and hot spots identified. Fifty teams of contact tracers did house-to-house, in-person visits within a radius of each Ebola contact. In total, they visited 26 000 households in Lagos and Rivers States.
Aside from an initial case assessment, the team also managed the data, infection alerts and rumors, and implemented community-based surveillance.
Five other units backed up their work. These included strategy and coordination, case management and infection control, social mobilization, laboratory services and points of entry.
The strategy team coordinated the activities of the ministries of health and the international partners, dealt with the media and ensured funding, administrative and logistic support. The social mobilization team worked on advocacy, dealing with issues of stigma, the psychological and social well-being of contacts and the reintegration of discharged patients into their communities.
All ports of entry were monitored. The temperature of everyone passing through airports, seaports and land borders were checked for potential exposure.
The case management and infection control team treated and managed every laboratory-confirmed or suspected case. Their job was also to prevent the infection being transmitted. This involved training health care workers at treatment centers and health care facilities on how to take precautions and set up screening centers. They also focused on ensuring safe burials.
Good fortune played a part
Good fortune also played a part in limiting the impact of the Sawyer case. Although he had contact with 72 people in the two days before the virus was suspected, only 20 became infected.
It was also fortunate that Sawyer arrived by plane rather than on congested public transport. If he had traveled by land he would have been in close proximity to a great many more people. Passengers would have got on and off at stops along the way, increasing the risk of exposure significantly.
His diplomatic status was also a major bonus. It meant that he was taken straight to a private hospital by diplomatic staff where he was nursed in a private room and diagnosed by an astute clinician.
It was also good fortune that Sawyer landed in Lagos state which has a disease surveillance system in place and facilities at the federal teaching hospital to make the laboratory diagnosis.
Managing the message to kill the panic
In the hours and days following news of Sawyer’s diagnosis, fear, myths and rumors spread like wild fire. Much of this was fanned by the press. This led to health care workers refusing to treat any bleeding or feverish patients.
The strategy team brought things under control by engaging the media, communities and key opinion leaders. A multi-pronged plan was put in place. Health care workers in communities were given hands on training about standard precautions and infection prevention. Protective equipment was also made available to health care centers in the communities.
Simple messages were developed that considered the available resources at health care facilities. In some instances, it was as basic as placing a chair at the end of a hospital corridor and cordoning off an area so that suspected cases could be isolated from other patients.
There was also a concerted effort to educate the media and to keep people informed. Daily briefings on patient recovery helped reduce fear.
Despite the tragedy, the Ebola outbreak proved how important it is to rapidly respond to an outbreak with a unified plan, backed up with expertise, manpower and a health system with effective infection controls.
But equally important was the lesson in national unity evident in the unprecedented co-operation between the Nigerian public and private sectors, teaching hospitals, universities and volunteers. It was a massive team effort led by Nigerians assisted by the international agencies. Nigeria proved the pundits wrong.