How Nigeria tackled the much dreaded Ebola.

Authors of a paper published October 9 in Eurosurveillance attribute Nigeria's success in "avoiding a far worse scenario" to its "quick and forceful" response. The authors point to three key elements in the country's attack:

1. Fast and thorough tracing of all potential contacts
2. Ongoing monitoring of all of these contacts
3. Rapid isolation of potentially infectious contacts.

Race to prevent spread
Nigeria's index patient had been caring for a family member in Liberia who died from Ebola on July 8. Despite having been hospitalized in the Liberian capital Monrovia with fever and Ebola symptoms on July 17, he left medical care (against advice) and three days later took a commercial flight to Nigeria via Togo. After landing he collapsed at the Lagos airport and was taken to the hospital.
There it took three days before an Ebola diagnosis was made. The patient said he had no known exposure to Ebola, so he was first thought to have malaria, which is common and can have similar symptoms including fever, vomiting and headache. After malaria treatment failed to improve the patient's symptoms, however, medical staff began to consider Ebola, especially given his recent travel history. He was moved to isolation while test results confirmed the virus.
From this single individual, who died from the disease July 25, infectious disease experts generated a list of 898 contacts. Why so many? In addition to having become ill in a public place, the patient also infected an individual who then flew to and back from another Nigerian city, Port Harcourt, in late July while sick. That individual passed the infection to three other people, including a health care worker who died on August 22—but not before generating 526 more contacts. The index patient's primary and secondary contacts had only added up to 351.

The fact that two individuals were able to generate so many contacts shows just how vigilant authorities must be in tracking every last potential exposure. But the vigilance paid off. No new cases have been diagnosed in more than a month, and October 1 marked the date at which all of Nigeria’s 898 contacts passed the 21-day incubation period during which Ebola symptoms can present themselves.

The arrival location of the index patient was a prime place to cause a widespread outbreak. Lagos is Africa's largest city, with a population of 21 million. It is a major hub for travel and business. "A dense population and overburdened infrastructure create an environment where diseases can be easily transmitted and transmission sustained," wrote the authors of a paper for the U.S. Centers for Disease Control and Prevention's (CDC) Morbidity and Mortality Weekly Report (MMWR). As such, "A rapid response using all available public health assets was the highest priority."
But, says Folorunso Oludayo Fasina, a senior lecturer at the University of Pretoria in South Africa, co-author of the Eurosurveillance paper and a native Nigerian, it was actually lucky that the index patient in Nigeria fell ill at the airport. "Had the index case gotten the opportunity to contact persons in Lagos or Calabar—[another Nigerian city] where he was to deliver a lecture—it may have been a complete disaster."
Although it took three days to diagnose Ebola (a period during which nine health care workers were infected with the disease), once the diagnosis was confirmed health authorities swung into action. The Federal Ministry of Health worked with the CDC’s Nigerian office to declare an Ebola emergency. On July 23—the very same day the patient was diagnosed—they created an Incident Management Center (which morphed into the Emergency Operations Center) and kicked into action an Incident Management System to coordinate responses. Such a centralized and coordinated system "is largely credited with helping contain the Nigerian outbreak early," the MMWR authors wrote.
It wasn't the Emergency Operations Center's first time tackling a highly infectious disease. Two years ago, after a global call from WHO, Nigeria redoubled its efforts to eradicate polio, another infectious virus, within its borders. The center has played a large role in working toward that goal, improving response times and preparedness along the way, the authors of the MMWR paper wrote.
The key takeaways are: coordinate, track and monitor. "The Nigerian experience offers a critically important lesson to countries in the region not yet affected by the [Ebola] epidemic as well as to countries in other regions of the world," the Eurosurveillance authors noted. "No country is immune to the risk…[but] rapid case identification and forceful interventions can stop transmission."