How Nigeria fought Ebola

A feverish patient suspected to have Ebola left a hospital in Liberia on July 17, disregarding the advice of doctors there. Three days later, he took a commercial flight to Lagos, Nigeria, the most populous city in Africa, where he was hospitalized with fever, diarrhea, and vomiting. He told doctors in Lagos he had no exposure to Ebola.

It was a nightmare in the making. The exposure risked spreading an uncontrolled epidemic to an urban hub of trade and travel that’s home to 21 million people—about as many as Guinea, Sierra Leone, and Liberia combined. “The dense population and overburdened infrastructure create an environment where diseases can be easily transmitted and transmission sustained,” researchers wrote of Lagos in an Oct. 3 report published by the U.S. Centers for Disease Control.

Yet Nigeria’s response limited the toll to 20 Ebola infections, including eight patients who died. Disease detectives traced 891 contacts with possible exposure, and no new cases have been reported since the end of August. It’s been twice the maximum 21-day incubation period since the last patient tested negative. If no new cases arise, expect the World Health Organization to declare Nigeria’s outbreak over, as the group did in Senegal last week.

The risk of travelers bringing the Ebola virus into new countries will remain as long as the epidemic continues to ravage Guinea, Liberia, and Sierra Leone. But how Nigeria averted disaster holds lessons for the rest of the world, including the U.S. and Spain, the two other countries where imported cases have infected others. Here’s how Nigeria appears to have beaten Ebola:

1. Swift quarantine and diagnosis. The initial patient in Nigeria, Patrick Sawyer, was isolated immediately. Unlike Thomas Eric Duncan, the Liberian man who traveled to Dallas and eventually developed Ebola symptoms and died, Sawyer was seriously ill at the airport. Even when Duncan first showed up sick at the emergency room in Dallas, he was misdiagnosed and sent home for reasons that remain unclear.

Two labs in Lagos had the capability to test for Ebola, a capacity that not every city will be able to match. But confirming diagnoses quickly remains extremely important wherever new suspected cases are spotted. The more time that elapses between when a patient presents with symptoms and when a diagnosis is confirmed, the longer it takes to find and isolate those who’ve been in contact with the patient. Likewise, quickly ruling out false alarms—such as the Ebola-like symptoms of a graduate student admitted to Yale-New Haven Hospital on Oct. 16—is important to keep people calm.

2. Clear management structure. Three days after Sawyer landed in Lagos, the Nigerian government had established an incident-management system that included state and national officials and international partners such as the CDC and WHO. That’s how crisis managers in the U.S. coordinate agencies, and Nigeria had used a similar structure to respond to past polio outbreaks. Early coordination was critical, says John Vertefeuille, an epidemiologist at the CDC who worked in Nigeria. “You had a central point of response leadership,” he says. Such a system wasn’t in place in Liberia until months into the outbreak there.

Four weeks into the response in Nigeria, more than 1,000 people were involved in patient care, decontamination, communications, tracing contacts, and other related activities. “What you don’t want is a thousand people coming, sitting in a meeting for three or four hours each day,” Vertefeuille says. Instead, each morning field teams got to work immediately while leaders checked in for a limited time and left knowing what they needed to do. They reviewed action items in the evening. The structure assures that time isn’t wasted and that the people in charge are accountable for results.

That may sound like basic management, but anyone who’s been in pointless office meetings understands how important it is. Getting it right during a chaotic and fast-moving crisis isn’t something to take for granted.

3. Effective public communication. Even though Nigerians saw the news about Ebola in other West African countries, Vertefeuille says that “early in the response there was a lack of broad information about Ebola” in the population at large and among health-care workers. That left gaps that rumors and fear could fill. Some people drank “large quantities of salt water, even in places distant from the outbreak” under the mistaken belief that it would help, according to the CDC report.

Press briefings and online outreach—Lagos is a wired city, Vertefeuille notes—helped point people to reliable information. Educating Lagos’s medical community early on was important, too. “We really had to do a lot of work early in the outbreak,” he says, to recruit and train health-care workers.

Reassuring the public helped make sure people who might be infected came forward so they could be treated and their contacts monitored. “They needed to be brought in within hours, not days,” says Vertefeuille. Public perception improved as some patients admitted for Ebola were treated and recovered. “You had put in place a clinic that could provide care, and all of a sudden people started coming out alive,” he says.


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