Nigeria’s Ebola Outbreak Response: Lessons for Future Epidemic Preparedness

Abstract

Introduction: An extra-ordinary outbreak of Ebola which started in Guinea in December 2013 rapidly spread to Liberia and Sierra Leone in 2014 affecting at least eight countries, and culminated in the introduction of Ebola into Nigeria in July 2014 by an ill Liberian traveler to Lagos. The outbreak spread in two large densely populated cities of Lagos and Port Harcourt with a combined population of 25 million. This paper describes the key activities of the response, highlights the key achievements and presents the major lessons learned including the implications for future epidemic preparedness.
Methods: An Ebola Emergency Operations Centre (EEOC) and incident management system was activated to effectively coordinate the response. Resources were rapidly mobilized. The approach used was a coordinated, and integrated rapid implementation of EVD control measures using multidisciplinary teams. Five response teams were set up to mount an effective and high quality response. Data was collected, analyzed and daily situation reports of the response activities were disseminated to all stakeholders.
Results: Overall, a total of 20 cases and 8 deaths were recorded. A total of 892 contacts were listed and completed the daily follow-up for 21 days. A total of 117 alerts and rumors were reported and investigated between August and September, 2014. All alerts and rumors were investigated within 24 hours. 13 confirmed cases were isolated in the Ebola Treatment Center (ETC). 9 were discharged and 5 died. Our response was effective and successful in rapidly controlling the outbreak because of available laboratory capacity and local human resources and infrastructure that were rapidly mobilized with effective results. Strong government leadership and commitment, country ownership of response activities, effective community awareness and engagement, strong coordination of partners and harmonization of resources and the unprecedented support from the private sector, media organizations and professional bodies contributed to the success.
Conclusions: The key lessons learned reinforce the importance of country ownership of epidemic preparedness and response activities and building local capacity for the critical improvements that are still needed to strengthen early warning systems and improve rapid response capabilities in preparation for any future outbreaks.

Full text

Nigeria’s Ebola Outbreak Response: Lessons for Future Epidemic Preparedness
Emmanuel Musa1*, Abdulsalam Nasidi2, Faisal Shuaib3, Patrick M Nguku4 and Rui Gama Vaz1
1World Health Organizaon, Nigeria Country Oce, Nigeria
2Nigeria Centre for Disease Control, Abuja, Nigeria
3Federal Ministry of Health, Abuja Nigeria
4Nigeria Field Epidemiology and Laboratory Training Program
*Corresponding author: Emmanuel Musa, World Health Organizaon, Nigeria Country Oce, Nigeria, Tel: +2348033067959; E-mail:
musazie@yahoo.co.uk
Received date: October 25, 2016; Accepted date: November 03, 2016; Published date: November 10, 2016
Citaon: Musa E, Nasidi A, Shuaib F, Nguku PM, Vaz RG. Nigeria’s Ebola Outbreak Response: Lessons for Future Epidemic Preparedness. Arch Med.
2016, 8:6
Copyright: © 2016 Musa E, et al. This is an open-access arcle distributed under the terms of the Creave Commons Aribuon License, which
permits unrestricted use, distribuon, and reproducon in any medium, provided the original author and source are credited.
Abstract
Introducon: An extra-ordinary outbreak of Ebola which
started in Guinea in December 2013 rapidly spread to
Liberia and Sierra Leone in 2014 aecng at least eight
countries, and culminated in the introducon of Ebola into
Nigeria in July 2014 by an ill Liberian traveler to Lagos. The
outbreak spread in two large densely populated cies of
Lagos and Port Harcourt with a combined populaon of 25
million. This paper describes the key acvies of the
response, highlights the key achievements and presents the
major lessons learned including the implicaons for future
epidemic preparedness.
Methods: An Ebola Emergency Operaons Centre (EEOC)
and incident management system was acvated to
eecvely coordinate the response. Resources were rapidly
mobilized. The approach used was a coordinated, and
integrated rapid implementaon of EVD control measures
using muldisciplinary teams. Five response teams were set
up to mount an eecve and high quality response. Data
was collected, analyzed and daily situaon reports of the
response acvies were disseminated to all stakeholders.
Results: Overall, a total of 20 cases and 8 deaths were
recorded. A total of 892 contacts were listed and completed
the daily follow-up for 21 days. A total of 117 alerts and
rumors were reported and invesgated between August
and September, 2014. All alerts and rumors were
invesgated within 24 hours. 13 conrmed cases were
isolated in the Ebola Treatment Center (ETC). 9 were
discharged and 5 died. Our response was eecve and
successful in rapidly controlling the outbreak because of
available laboratory capacity and local human resources and
infrastructure that were rapidly mobilized with eecve
results. Strong government leadership and commitment,
country ownership of response acvies, eecve
community awareness and engagement, strong
coordinaon of partners and harmonizaon of resources
and the unprecedented support from the private sector,
media organizaons and professional bodies contributed to
the success.
Conclusions: The key lessons learned reinforce the
importance of country ownership of epidemic preparedness
and response acvies and building local capacity for the
crical improvements that are sll needed to strengthen
early warning systems and improve rapid response
capabilies in preparaon for any future outbreaks.
Keywords: Ebola outbreak; Nigeria; Lessons learned;
Outbreak response; Epidemic preparedness
List of Abbreviaons
BSL: Biosafety Level; CDC: Centers for Disease Control and
Prevenon; EVD: Ebola Virus Disease; DNA: Deoxyribonucleic
Acid; ETC: Ebola Treatment Center; EEOC: Ebola Emergency
Operaons Center; FMOH: Federal Ministry of Health, HR:
Human Resources, IDSR: Integrated Disease Surveillance and
Response; IHR: Internaonal Health Regulaons; IPC: Infecon
Prevenon and Control; MOH: Ministry of Health; MSF:
Médecins Sans Froneres; NFELTP: Nigeria Field Epidemiology
and Laboratory Program; NGO: Non-governmental Organizaon;
RT-PCR: Reverse Transcriptase-Polymerase Chain Reacon; VHF:
Viral Hemorrhagic Fever; WHO: World Health Organizaon
Introducon
An extra-ordinary outbreak of Ebola which started in Guinea
in December 2013 rapidly spread to Liberia and Sierra Leone in
2014 aecng at least eight countries with 28,646 cases and
over 11,323 deaths [1]. The disease was introduced into Nigeria
on the 20th July 2014 by a 40 year old man who arrived Lagos by
air from Liberia. It was the rst me EVD was spread to any
country by air travel [2]. The introducon also marked the onset
of Nigeria’s rst outbreak of Ebola virus disease (EVD) which
lasted between July and September 2014, aected two complex
mega cies, Lagos and Portharcourt with a combined populaon
Perspective
iMedPub Journals
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DOI: 10.21767/1989-5216.1000171
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of 25 million and a high inux of people from neighboring
countries with limited supporve infrastructure. Many crowded
slums and squaer selements exist in both cies providing a
good seng for the rapid spread of EVD and making control
dicult. The spread of EVD to Lagos caused great concern in the
internaonal community and triggered the declaraon of a
Public Health Emergency of Internaonal Concern (PHEIC) by the
Director General of the World Health Organizaon (WHO).
Overall, the outbreak recorded 20 cases were with 8 deaths, and
was declared over by the WHO on October 20, 2014 [3].
The Nigerian Centre for Disease Control (NCDC) of the Federal
Ministry of Health (FMOH) in collaboraon with the State
Ministries of Health in Lagos and Rivers States ulized exisng
local capacies and the Integrated Disease Surveillance and
Response (IDSR) system to rapidly diagnose and control the EVD,
while also repurposing exisng public health resources to
address the new challenges posed.
This paper describes the key acvies of the response,
highlights key achievements and presents major lessons learned
and implicaons for future epidemic preparedness. These could
provide valuable informaon for developing countries that are
reinforcing their epidemic preparedness and response capacies
for future outbreaks of EVD and other epidemic-prone diseases.
Methods
The EVD response in Nigeria was led by the NCDC of the
federal ministry of health in collaboraon with the Lagos and
Rivers States Ministry of Health, research and academic
instuons, private sector organizaons and internaonal
technical partners. The approach used was a coordinated and
integrated rapid implementaon of EVD control measures using
muldisciplinary teams [4].
Standard case denion
The WHO standard case denion for EVD was adapted and
used:
Suspected case denion: A suspected EVD case under
invesgaon is dened as any person with or without known
history of travel or stay in a country that has reported contact
with at least one conrmed case of EVD, within a period of 21
days before the onset of symptoms [5], and who presents with:
Sudden onset of high fever (>38.0°C) and at least three of the
following symptoms:
• Headache, voming, diarrhea, anorexia/loss of appete,
lethargy, stomach pain, aching muscles or joints, sore throat,
and dicult breathing (or)
• Inexplicable bleeding/hemorrhaging (or)
• Inexplicable sudden death
A probable case: A suspected case evaluated by a clinician
(or)
Any deceased suspected case (where it has not been possible
to collect specimens for laboratory conrmaon) having an
epidemiological link with a conrmed case.
A conrmed case: A suspected case with laboratory
conrmaon (posive IgM anbody, posive RT-PCR or viral
isolaon).
Rapid case invesgaon and laboratory diagnosis
Laboratory analysis of blood samples from suspected EVD
cases were carried out at the virology laboratory of the Lagos
University Teaching Hospital (LUTH)-a BSL II laboratory with
known RT-PCR capacity for diagnosing viral hemorrhagic fevers
(e.g. Lassa fever) in the country. Laboratory invesgaon using
Pan Filo wobble primers for blood samples were undertaken.
Dengue and Lassa viruses were analyzed in samples negave for
EVD. In addion, Pan Filo virus and Ebola Zaire MGB virus strain
specic genomic analysis were conducted at the World Bank-
funded African Centre of Excellence for Genomics of Infecous
Diseases (ACEGID), Redeemers’ University in Ogun State to
detect the Ebola Zaire viral DNA in blood samples. Samples were
shipped for further conrmatory analysis and quality assurance
to the WHO Collaborang laboratory for VHF-the Bernhard
Notch Instute Hamburg.
In Port Harcourt, a mobile laboratory was established at the
University of Port Harcourt Teaching Hospital (UPTH) by the
laboratory sta from the Lassa Fever Research and Training
Instute, Irrua with the support of WHO.
Contact tracing, acve case search and rapid control
eorts
Contact tracing and follow-up was conducted according to a
naonal standard operang procedure (SOP) adapted from
WHO [6]. Trained contact tracers comprised Residents of the
Nigeria Field Epidemiology and Laboratory Training Program
(NFELTP), Epidemiologists from the NCDC and Lagos and Rivers
States Ministry of Health and WHO surveillance ocers.
A contact was dened as any person without any disease
signs and symptoms but had physical contact with a case (alive
or dead) or the body uids of a case within the last three weeks.
Physical contact includes sharing the same room/bed, caring for
a paent, touching body uids, or closely parcipang in a
burial.
All contacts to a conrmed case were idened, listed and
classied into the four following categories to reect the level of
risk associated with the exposure
• Touched body uids of the case (blood, vomit, saliva, urine,
feces)
• Had direct physical contact with the body of the case (alive
or dead)
• Touched or cleaned the linens, clothes, or dishes of the case
• Slept or ate in the same household as the case
Daily temperature measurements were recorded by the
contact tracers on an android mobile phone applicaon with GIS
features, which also recorded the locaon of the assessment
against the registered residenal address of the contacts.
Contacts were reclassied as suspected cases if they were
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observed to have temperature ≥ 37.5°C axillary or ≥ 38.0°C core
and met one of the following criteria:
• Had voming, diarrhea, or bleeding from stool or mucous
membranes; or
• Had two addional symptoms including headache, myalgia,
arthralgia, or weakness.
The contacts were counseled, advised on social distancing
during the period of 21 days of monitoring. The mobile phone
applicaon was centrally monitored real-me at the Ebola
Emergency Operaons Centre. This was used as an innovaon in
the response for data collecon by contact tracers. It also
ensured that all contacts were eecvely tracked and eliminated
provision of cous informaon by some contact tracers
without physically vising a contact [7]. A few contacts proved
very dicult to follow-up or escaped follow-up. Special teams
were set up to track such non-compliant contacts.
Alert and rumor management
An alert and rumor management system was established and
alert teams were sensized in all other states in the country to
invesgate and respond to any alert, rumor of a suspect case or
escape contact, and conduct acve case search. Toll-free
telephone lines were opened to the public to report suspicious
cases using community case denions, and improve early case
detecon. The toll-free lines, manned by trained health workers
were widely disseminated alongside prevenve measures
through awareness campaigns in the electronic and social
media. Members of the public were encouraged to call in when
they have alert cases or when they have any query. All incoming
alert calls were registered using alert forms and the informaon
conveyed to the relevant team or alert team for vericaon/
invesgaon.
Managing the cases
Ebola Treatment Centres (ETC) were established in Lagos and
Port Harcourt to manage suspected and conrmed cases of EVD
using a clinical management protocol. In Lagos, a 40-bed ETC
was established by the Lagos State MOH with the support of the
NCDC at the Mainland hospital, Yaba with another surge facility
with a capacity of 10 beds. The ETC was managed by WHO, MSF,
and Nigerian health workers. A team of Nigerian health workers
including 15 doctors, 28 nurses and 16 ancillary sta were
idened and trained on Ebola case management and infecon
prevenon and control (IPC) by WHO. These personnel provided
24 hours care alongside the WHO and MSF sta.
In Port Harcourt, a 26 bed ETC was established by the Rivers
state MOH supported by Partners, with a surge capacity of 8
beds. A team of 12 doctors, 24 nurses and 24 environmental
health ocers drawn from Rivers State MOH, WHO and MSF
were trained and worked at the ETC. All ETCs were fully
equipped with medicines and consumables, personal protecve
equipment (PPEs), body bags, communicaon facilies and
ambulances.
Decontaminaon and burial teams disinfected the homes of
all cases, and vehicles including ambulances, and conducted safe
burials of the deceased respecvely.
Safeguarding the points of entry (PoE)
The point of entry team carried out entry and exit screening
under the leadership of the Port Health Service and supported
by airport, seaport and land border authories [8]. They also
worked with airline operators, naonal aviaon authories,
immigraon, marime, custom and security ocials to establish
screening facilies and protocols for checking temperatures and
screening of incoming and exing passengers in Lagos and
Portharcourt airports, sea ports and ground crossings. 500
Volunteers were engaged and supplied with 1247 thermo-scans
for temperature screening. Holding facilies were also set up at
the PoE to temporarily keep any detected suspected case before
transfer to the ETC in an ambulance for further evaluaon.
Personal Protecve Equipment (PPE) was supplied to the PoE
team for use when handling suspected cases.
Involving the community and creang public
awareness
Ebola key messages on prevenve measures were distributed
from house to house by trained community mobilizers.
Community sensizaon meengs were held with tradional
and religious leaders, school teachers, market women
associaons, youth organizaons and the Associaon of General
and Private Medical Praconers of Nigeria (AGPMPN).
Electronic, print and social media plaorms were also used to
disseminate informaon to members of the public to increase
their awareness of EVD.
Ensuring eecve coordinaon of the response
Ebola Emergency Operaons centers were established in
Lagos and Port Harcourt by the NCDC in collaboraon with the
State Ministries of Health in Lagos and Port Harcourt and
internaonal Partners to ensure an eecve and ecient
coordinaon of the response. An Incident Management System
(IMS) was introduced by the FMOH under the oversight of the
NCDC, and response teams and operaons were streamlined for
a more ecient and rapid response (Figure 1).
The response teams were organized into (i) Epi-surveillance
comprising alert/rumor management, contact tracing, data
management and operaons research, (ii) Case management
comprising clinical management, Rapid response, infecon
prevenon and control, psychosocial support, decontaminaon,
burial sub teams; (iii) social mobilizaon, (iv) Points of entry and
(v) Management and coordinaon comprising HR,
administraon/nance, and logiscs/procurement. Each
response team had a Leader working with the sub-team heads,
under the overall leadership of an Incident Manager. A technical
strategy group chaired by the Incident Manager provided the
day-to-day strategic direcon on the management of the
response and had representaves of the NCDC, State MOH, the
Team Leads of WHO, UNICEF, MSF and CDC as members. A daily
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situaon report of the response acvies was disseminated to
all stakeholders.
Figure 1 The organogram of the Ebola Emergency Operaons Centre (EEOC).
Providing strong polical leadership
The President of Nigeria declared the EVD outbreak as an
emergency within 24 hours of its diagnosis. All Commissioners of
health and state Governors were directed to take all necessary
measures to prevent the spread of the disease in the country.
The Governors also transmied the same message to the local
government Chairmen in their respecve States. The Minister of
health as the Chief public health ocer of the country assumed
the day-to-day overall coordinaon of the response and
reported progress regularly to the president and the execuve
council.
Results
The EVD outbreak in Nigeria occurred from July to September
2014 in the two large cies of Lagos and Portharcourt.
Transmission paern
In Lagos, a total 16 cases were recorded (15 conrmed, 1
probable) and 6 deaths, while in Port Harcourt, 4 conrmed
cases with 2 deaths were recorded giving a total of 20 cases and
8 deaths (CFR 40%) (Table 1). The epi-curve displaying the onset
of illness of all conrmed cases (conrmed and probable)
associated with the outbreak is showed in Figure 2; the
transmission chain is shown in Figure 3.
Table 1 Summary of EVD cases, deaths and ETC discharges in
Nigeria, July-September 2014.
Description Lagos
N (%)
Portharcourt
N (%)
Total
N (%)
Cases: 16 (80.0) 4 (20.0) 20 (100.0)
Confirmed 15 (75.0) 4 (20.1) 19 (95.0)
Probable 1 (5.0) 0 (0.0) 1 (5.0)
Deaths 6 (75.0) 2 (25.0) 8 (100.0)
Confirmed 5 (62.5) 2(25.0) 7 (87.5)
Probable 1 (12.5) 0 (0.0) 1 (12.5)
Case Fatality
Rate: Confirmed
and probable
(%)
-40 -50 -40
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Cases among
healthcare
workers
9 (81.8) 2 (18.2) 11 (100.0)
Deaths among
healthcare
workers
4 (80.0) 1 (20.0) 5 (100.0)
Confirmed cases
admitted into
ETC*
11 (84.6) 2 (15.4) 13 (100.0)
Discharged 7 (53.8) 1 (7.7) 8 (61.5)
Died 4 (30.8) 1 (7.7) 5 (38.5)
*ETC: Ebola Treatment Center
Figure 2 Epi-curve of EVD outbreak in Nigeria, July-
September 2014.
Figure 3 Chain of EVD transmission in Nigeria, July-
September 2014.
Contact tracing
A total of 892 contacts were listed for daily follow-up. In
Lagos, 362 (40.6%) contacts were registered comprising 70
primary contacts of the index case and 292 secondary contacts
located in 17 local government areas of Lagos State. They were
all followed-up for 21 days by 15 contact tracing teams. In Port
Harcourt, a total of 530 (59.4%) primary contacts were listed
from 7 local government areas of Rivers State and were followed
up by 30 teams of contact tracers for 21 days (Table 2).
Table 2 Contact tracing during the EVD outbreak response in
Nigeria, July-Sept 2014.
Description Lagos
N (%)
Portharcourt
N (%)
Total
N (%)
Number of contacts listed 362
(40.6)
530 (59.4) 892
(100.0)
Contacts monitored for 21 days 362
(40.6)
530 (59.4) 892
(100.0)
Contacts lost to follow-up 0 0 0
Number of LGAs covered*17
(70.8)
7 (29.2) 24
(100.0)
Number of contact tracing teams 18
(37.5)
30 (62.5) 48
(100.0)
*LGA: Local Government Area (of contact’s residence)
Alert and rumor management
A total of 117 alerts and rumors were reported and
invesgated between August and September, 2014. All alerts
and rumors were invesgated within 24 hours (Figure 4).
Figure 4 Trend in alert and rumor reporng, Nigeria EVD
response, August-September 2014.
Case Isolaon and management
Thirteen conrmed cases were isolated in the ETC; 11 (84.6%)
in Lagos and 2 (15.4%) in Port Harcourt, River state. Of these 7
died in the ETC, one died at home and the other one is the index
case that died at the adming health facility. One conrmed
case in Port Harcourt was transferred to Lagos ETC (Table 1).
Discussion
Lessons learned and implicaons for future
epidemic preparedness
The response to the EVD outbreak in Nigeria provided
important insights into the elements in epidemic preparedness
and response that countries need to take into consideraon in
leveraging health system changes aimed at bolstering populaon
health security.
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The rst lesson learned is that building a crical pool of in-
country technical experse in eld epidemiology, laboratory,
clinical care, anthropology and psychosocial support for
immediate deployment as rapid response teams in outbreak
sengs can help to truncate infecous disease transmission.
This capacity should be established in all the dierent regions of
the country and equipped with rapid deployment capabilies.
Nigeria deployed a rapid response team comprising NFELTP
residents, clinicians, MOH and in-country partners including
from the private sector with sucient capacies, hence the
response was eecve. Contact tracing was done by eld
epidemiologists from the NFELTP and WHO surveillance ocers
from the Polio program. This improved the quality of contact
tracing, a feat that was aptly described by WHO as “a piece of
world class epidemiological detecve work” [3]. Addionally,
the provision of hazard incenves and life insurance was helpful
in dousing the inial fear among healthcare workers and
movated them to come forward and provide service.
The second lesson learned is that adequate and quality
laboratory capacity is crical in mounng a quick and eecve
response to any outbreak. The establishment of laboratory
capacity for detecon of viral hemorrhagic fevers in the country
due to previous experiences of Lassa fever outbreaks came very
handy for the diagnosis of the rst EVD case. Delays in diagnosis
could lead to delay in isolaon of EVD cases and exacerbate the
spread of the disease. Also noteworthy is the fact that the
diagnosc primers and reagents for EVD diagnosis were
available in the laboratory at the me and there were trained
laboratory sciensts to undertake the assays. This underscores
the need for countries to establish capacies for adequate and
qualitave diagnoses of pathogens of epidemic potenal.
The third lesson learned is that the weak infecon prevenon
and control (IPC) pracces including the absence of triage in the
health facilies predisposed many health workers (and some
paents) to the risk of EVD infecon, thus some of them were
needlessly lost. Health care workers infecon accounted for
majority of the cases and deaths recorded in the Nigeria EVD
outbreak [9]. Currently, majority of public and private health
facilies do not place appropriate value on basic IPC pracces
such hand hygiene or triage of paents. Thus, nosocomial
spread of infecons is common. Basic IPC pracces (standard
precauons) need to be fully instuonalized, closely monitored
and rewarded in all health facilies to ensure safety of health
workers, paents and their families. Availability of basic hygienic
supplies and personal protecve equipment (PPE) in health
facilies must also be ensured [10].
Adherence to minimum safety standard of care in private
health facilies as well as public health facilies should be
monitored regularly. Private health facilies oen complement
public health facilies and connue to provide services to the
public during periods of frequent health workers’ strikes when
public health facilies are closed. All private health facilies
including for-prot ones should be empowered to meet
recommended minimum IPC standards, and compliance
rewarded. Equal aenon should be paid to building IPC
capacies for both private and public health workforce.
Regulatory authories in the ministry of health should be
empowered to monitor compliance and implement sancons on
persistently non-compliant health facilies or workers.
We also learned that early community engagement is vital for
eecve response. The community must be seen by health
workers as an interested ally and not just as a beneciary, and
must take ownership of its health including responding to
epidemics [11]. Communies are beer poised to mobilize
themselves and idenfy resources that could be rapidly
deployed at the onset of an outbreak to stop further
propagaon. For instance, working with the community, the
health workers were able to overcome and resistance to
establishment of ETCs in some communies due to the fear and
anxiety of the spread of Ebola [12]. With lile incenves,
communies were also helpful in tracking down escapee
contacts, nofying suspect cases, promong hand-washing,
social distancing and increasing populaon awareness of EVD
prevenve measures such as unsafe burial pracces, and in
many instances prevailed on community members to co-operate
with healthcare workers in tracing and following up contacts of
Ebola cases. Tradional and religious leaders, as community
gatekeepers, played very important roles in this respect. Youth
leaders, women leaders, local NGOs, community-based
organizaons (CBOs) and faith-based organizaons (FBOs) were
all engaged. In our experience, we found that the management
of EVD outbreak and the care of aected people go beyond
addressing their medical needs. Anthropological and
psychosocial services were crical and benecial in providing
care to the aected individuals, communies and contacts
[13-15].
Community engagement is therefore vital in every epidemic
preparedness endeavor and community capacies should be
reinforced to support prevenon, early detecon and response
to disease outbreaks and other health emergencies.
Furthermore, collaborang with the organized private sector
has the capacity to leverage enormous resources and support
for emergency response. Nigeria is the fastest growing economy
in Africa and has a robust private sector [16]. At the beginning of
the outbreak when government bureaucrac processes delayed
the release of funds, the organized private sector such as oil
companies, telecommunicaon and some pharmaceucal
companies supported the EEOC with mobile phones, airme,
vehicles, ambulances, infrared thermometers, and medicines.
These were very helpful in keeping the operaons on track
before the availability of public funds.
The EVD outbreak revealed that epidemics could have major
social and economic impacts, and therefore is a social problem
[2]. Response eorts could somemes require enormous
resources which may not be swily provided by the public sector
alone. Consequently, in limited resource sengs, establishing
collaborave mechanisms for co-funding and undertaking
outbreak preparedness and response between government, the
private sector and internaonal Partners should be explored.
Besides the role of the community in idenfying, tracking and
following up contacts of Ebola cases, security operaves and
telecommunicaon companies played a major role in providing
valuable informaon that led to the nding of escapee and
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dicult contacts for follow-up. Security warrants were obtained
and mobile telephone records of escape contacts were tracked
and they were idened and followed up.
Addionally, the media played a crucial role also in stemming
the Nigeria EVD outbreak. People desperately needed
informaon on how to prevent and treat Ebola. However, at the
onset of the outbreak, the reportage in electronic and print
media fueled a lot of fear (as contracng EVD was considered a
death sentence), sgmazaon and misinformaon among
members of the public. In one instance of such misinformaon
that drinking of salt water prevents Ebola allegedly resulted in
the death of at least two persons. Early and intensive
disseminaon of key messages to the public on Ebola
immediately the outbreak was declared, using a wide range of
media would have prevented such a situaon. However, the
EEOC immediately moved to engage and conduct orientaon
meengs with key media organizaons in the country, and this
posively reversed the situaon. Subsequently, publicity was
intensied through the media, providing connuous access to
informaon about the disease, including its mode of spread,
prevenve measures and acons being undertaken to stop the
disease. For instance, the Minister of Health’s press conferences
on the progress was widely disseminated through the media.
This helped to allay further fear and sgmazaon. Addionally,
the social media proved to be a veritable tool for informaon
disseminaon to the public on the disease e.g. through face-
book and tweeter, and provided a plaorm for providing
feedback on quesons and comments from the public,
addressing misinformaon and monitoring community alerts
[17]. This approach needs to be further developed and
promoted as part of future epidemic preparedness and response
eorts.
We learned that strong polical will and leadership at the
highest level promotes eecve coordinaon of outbreak
response and mobilizaon of adequate resources. The President
and the Governors wield enormous power and inuence in the
country and they put their authority rmly behind the response.
The Governors of Lagos and Rivers States parcularly provided
exemplary leadership, nancial resources and personally
monitored the response eorts closely. This movated the
healthcare workers in the frontline to make a dierence
recognizing that they had the support of the leadership at the
highest level.
Finally, we learned that that public health response capacity
at the points of entry must be fully developed as a maer of
priority to prevent the internaonal spread of diseases in this
age of globalizaon. As disease knows no boundary, the need to
strengthen public health measures at the points of entry
(ground crossings, seaports and airports) as required by the
Internaonal Health Regulaons (2005) becomes imperave.
Cross-border surveillance acvies including community
awareness and engagement, and improved referral system and
capacies would reinforce early detecon and rapid control of
EVD. This approach has been shown to be crical to building and
sustaining eecve public health response capacies at local,
naonal and global levels [8,18-20].
Limitaons and constraints
The Ebola outbreak in Nigeria was rather short-lived, lasng
only three months; while this may be aributed to the eecve
response and rapid containment, it provided a limited
opportunity to consider a large number of cases and contacts
and the associated features. Secondly, the idencaon of
contacts was dependent on the informaon on exposure that
was provided by individuals and health workers who came in
contact with an Ebola case, but somemes the informaon
provided may not be accurate. However, the use of experienced
Field Epidemiologists who were also trained on interviewing
techniques minimized this occurrence.
Conclusion
The EVD outbreak in Nigeria was rapidly contained with major
lessons learned that could be leveraged to improve epidemic
preparedness and future response eorts. While Nigeria was
able to successfully stop the outbreak by leveraging exisng
local capacity, crical improvements are sll needed to
strengthen early warning systems and rapid response
capabilies in preparaon for any future re-introducon of EVD
to the country. Although no new Ebola cases have been e
reported in Nigeria since October 2014, community- based and
health facility surveillance, public health measures at Points of
Entry have been strengthened and a Naonal EOC set up at the
NCDC. Rapid response teams have been inaugurated at the sub-
naonal levels (States). Post Ebola containment plan has been
developed and the experience acquired from the EVD control
acvies has been used to ght other new outbreaks such as
Lassa fever. Nigeria now needs to focus on rapid implementaon
of the IHR (2005) core capacies requirement [21,22], which are
crical to improving future epidemic preparedness, migang
potenal re-introducon of EVD and assurance of populaon
health security.
Authors' contribuons
AN, EM contributed to the concepon, design and
preparaon of the rst dra. AN, EM, FS, PN, RGV parcipated
in data collecon, analysis and interpretaon and preparaon of
the manuscript. All authors read and approved the nal
manuscript.
Acknowledgments
We acknowledge the former Honorable Minister of Health,
Prof. CO Onyebuchi Chukwu and the Lagos State Commissioner
for Health, Dr. Jide Idris, The River State Commissioner of Health,
Dr. Sampson Parker, Dr. Olukayode Ogunmehin, Dr. Ismail A
Abdus-salam, Dr. Nnanna Onyekwere, Dr. Oni Idigbe, Prof.
Sunday Omilabu, Mrs. Sara Nyan, Mr. Charles Nzuki, all EEOC
strategic group members, all the responsible team leads and
members at the Lagos and Portharcourt EEOCs.
References
1. WHO (2016) Ebola situaon report.
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2016
© Under License of Creave Commons Aribuon 3.0 License 7

2. Chan M (2014) Ebola virus disease in West Africa-no early end to
the outbreak. N Engl J Med 371: 1183-1185.
3. WHO (2015) WHO declares end of Ebola outbreak in Nigeria.
4. Shuaib F, Gunnala R, Musa EO, Mahoney FJ, Ogunmehin O, et al.
(2014) Ebola virus disease outbreak-Nigeria, July-September 2014.
MMWR Morb Mortal Wkly Rep 63: 867-872.
5. WHO (2014) Case denion recommendaons for Ebola or
marburg virus diseases.
6. WHO (2014) Contact tracing during an outbreak of Ebola virus
disease.
7. Tom-Aba D, Olaleye A, Olayinka AT, Nguku P, Waziri N, et al (2015)
Innovave technological approach to Ebola virus disease outbreak
response in Nigeria using the open data kit and form hub
technology. PloS one 26: e0131000.
8. Moore M, Dausey DJ (2015) Local cross-border disease
surveillance and control: experiences from the mekong basin.
BMC 8: 90.
9. WHO (2014) Ebola response roadmap situaon report.
10. Okwor TJ, Tobin-West C, Oduyebo O, Anayochukwu-Ugwu N,
Adebola O, et al (2015) Idenfying infecon prevenon and
control gaps in healthcare facilies operang in Rivers state during
the EVD outbreak in Nigeria 2014. Anmicrob Resis Infec Cont 4:
11.
11. Marais F, Minkler M, Gibson N, Mwau B, Mehtar S, et al (2015) A
community-engaged infecon prevenon and control approach to
Ebola. Health promot int 12: dav003.
12. Maduka O, Maleghemi S, Komakech W, Nwaduito I, Green P, et al.
(2016) Eecve risk communicaon and contact tracing for Ebola
virus disease prevenon and control-Experiences from Port
Harcourt, Nigeria. Public Health 135: 140-143.
13. Ogoina D (2016) Behavioural and emoonal responses to the 2014
Ebola outbreak in Nigeria: a narrave review. Int Health 8: 5-12.
14. Abramowitz SA, Bardosh KL, Leach M, Hewle B, Nichter M, et al.
(2015) Social science intelligence in the global Ebola response.
Lancet 385: 330.
15. Umeora OU, Emma-Echiegu NB, Umeora MC, Ajayi N (2014) Ebola
viral disease in Nigeria: The panic and cultural threat. Afr J Med
Heal Sci 13: 1.
16. Oshikoya TW (2008) Nigeria in the global economy. Business
Economics 43: 31-43.
17. Adebimpe WO, Adeyemi DH, Faremi A, Ojo JO (2015) The
relevance of the social networking media in Ebola virus disease
prevenon and control in Southwestern Nigeria. Pan Afr Med J 22:
7.
18. Briand S, Bertherat E, Cox P, Formenty P, Kieny MP, et al. (2014)
The internaonal Ebola emergency. N Engl J Med 371: 1180-1183.
19. WHO (2014) Ebola virus disease in west africa-the rst 9 months
of the epidemic and forward projecons. N Engl J Med 371:
1481-1495.
20. Green A (2014) Ebola emergency meeng establishes new control
centre. Lancet 384: 118.
21. Gosn LO (2014) Ebola: towards an Internaonal Health Systems
Fund. Lancet 384: e49-51.
22. WHO (2012) Summary of 201 states pares report on IHR core
capacity implementaon.
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ISSN 1989-5216 Vol.8 No.6:2
2016
8This article is available from: http://www.archivesofmedicine.com/