Stopping Ebola

A YSPH alumnus and top health official in Nigeria discusses how Africa’s most populous country became “Ebola free.”

Dr. Olajide “Jide” Idris is the Commissioner for Health for Lagos State, Nigeria’s most populous state with some 22 million residents. When the first cases of Ebola were reported there this summer, it had catastrophic potential. Dr. Idris and others responded rapidly, overcoming numerous challenges, and managed to contain and then eliminate the virus before it spread widely. Recently, Nigeria to declared to be free of the virus.

Dr. Idris earned an M.P.H. degree from the Yale School of Public Health in the early 1990s and credits Yale with giving him a global perspective on health, something that was vital in Nigeria’s response and success against Ebola. 

In late October it was declared that Nigeria was free of Ebola. How did the country do this?

Yes, Nigeria was declared “Ebola free” by the World Health Organization. Firstly, we had the good fortune that the index case was managed at a medical institution where astute clinical judgment led to the suspicion that the case was Ebola. Then the fortuitous circumstance that Lagos State had a disease surveillance system in place. Finally, with sheer determination, we established strategic partnerships between the Lagos State Government, the federal government of Nigeria, and international organizations (like the World Health Organization, the U.S. Centers for Disease Control and Prevention, UNICEF, Medicins Sans Frontiers, local governments and other faith/community-based organizations.

Every member of the team brought in specific expertise and resources under a well coordinated and integrated structure and response plan, which included:

  • Active surveillance through aggressive contact tracing
  • Rapid investigation of suspected cases or deaths including rumors
  • Active case management
  • Preventive action
  • Massive community / public enlightenment
  • Continuous capacity building

However, it is pertinent to bring certain things into perspective. Nigeria is a huge country with a population of about 170 million people. Nigeria recorded a total of 20 cases and eight deaths from Ebola, all of which occurred in only two states out of a total of 36 in the country. Lagos State, which is the smallest but most populated with a population of 22 million, recorded 16 of the total cases and six of the deaths. Therefore, a huge proportion of the containment activities occurred in Lagos State. A major factor responsible for the successful containment effort of Ebola is the infrastructure established by the government of Lagos State, in anticipation of the health requirements of a megacity, a status already achieved by Lagos.

What kinds of challenges were overcome to make this happen?

There were many challenges. They include:

1) Population.

The government has the colossal task of catering to its large population (22 million people) with significant resource constraints. As such, the infrastructure, human resources, finances and other logistics required to contain this disease had to be innovatively deployed to contain its spread.

2) Human Resources.

There was an ongoing nationwide strike by medical doctors at the inception of the outbreak. This was compounded by the nationwide fear evoked by Ebola, resulting in a delay in securing the adequate number and mix of health care workers needed (especially doctors, nurses, infection prevention and control experts) at the initial stages.

We created an incentive program comprising life insurance, monetary compensation and encouragement for volunteers who participated in case management, contact tracing and surveillance activities at the ports of entry.

3) Public Awareness Campaigns.

There was panic shortly after the announcement of the index case of Ebola. Our team had to counter misinformation about the presentation, transmission and control by partnering with media organizations, radio and television stations in disseminating relevant information, fact sheets and authentic updates. An important aspect of this enlightenment campaign had to do with community engagement and grassroots mobilization (house-to-house mobilization, motorized campaigns, i.e. road shows and engagement of town announcers, collaboration with the Nollywood (Nigerian cinema) stars and community dialoguing with high risk communities). The aim of these campaigns was to proactively prepare communities for the potential of a widespread outbreak. 

4) Stigmatization, Rumors, Cultural Practices and Religious Beliefs.

We also had to deal with the stigmatization of volunteers, their contacts and confirmed cases that eventually recovered. Additionally, there were rumors about deaths, new infections and superstitious ways to prevent the disease circulating and burial practices. All these were dealt with through aggressive public enlightenment using different methods which include advocacy and sensitization of different segments of the community, development of messages in different formats and local languages, development and dissemination of information, education and communication materials, engagement of the print and electronic media, including the social media platforms, and regular press briefings and updates.

5) Knowledge base about Ebola

Regular training and retraining of the different categories of workers and community members on the different aspects of the containment program (infection prevention and control, case management including handling of the personal protective equipment, social mobilization and communication, preventive measures in schools, evacuation and decontamination).

Are Nigeria’s successful strategies being replicated elsewhere?

The Lagos State Government is planning to send volunteers to Sierra Leone to help contain the epidemic that is ravaging the country. This is being coordinated at the federal level.

What might be happening now in Nigeria without the government’s strong response?

Nigeria is the most populous black nation in the world, and Lagos the largest megacity in Africa with connections to the rest of the world by finance, commerce and human infrastructure. Lagos is a major international hub between the West-African sub-region and the rest of the world. The population of Lagos State in 2014 has been estimated to be 22.58 million. With a landmass of 3,577 square kilometers, the population density translates to about 6,300 people per square kilometer.  Because the state is mainly urban with six out of the 20 local government areas having a population density greater than 50,000 per square kilometer, the emergence of an epidemic in such a setting has potentially great health care, social and economic ramifications not only for our country, but also the rest of the world.

What has been Nigeria’s experience with Ebola historically?

Ebola was never recorded in Nigeria prior to July 20th. However, there have been periodic outbreaks of Lassa fever and Dengue fever, both of which are hemorrhagic fevers.

What was your role in fighting this outbreak?

As the Commissioner for Health for Lagos State, Nigeria, the tasks of mobilizing the resources available and coordinating the collaboration with the federal Ministry of Health and international agencies was mine.  Having been at the helm of the Ministry of Health for the past 16 years, first as permanent secretary and subsequently as commissioner, I have been involved with the upgrade of the Lagos State health system through a comprehensive health sector reform agenda covering infrastructural upgrades at all tiers, the revitalization of the primary care system, health care financing, health promotion and disease prevention. Specifically on this Ebola outbreak, the responsibility of ensuring that all necessary steps are taken to contain the outbreak within the state came from my office. I led the Lagos Stare response team and was a leading member of the incident management structure under the federal government. 

How is this outbreak different from previous outbreaks?

Whilst there has never been a previous outbreak of Ebola, there have been outbreaks of cholera, measles, SARS and bird flu. The sensitization to these outbreaks contributed to the creation of the infrastructure that proved helpful in containing Ebola.

What did you study at the Yale School of Public Health?

I studied health services administration.

How did this prepare you for your current work?

My M.P.H. degree and the research experience at Columbia University gave me a global perspective of health systems, which I have strived to replicate in Lagos State for the past 15 years. 

It sounds as if the Nigerian government had a very organized action plan in place when this latest epidemic hit.

Lagos State was at the epicenter of the initial contact with Ebola and the immediately available infrastructure were mobilized and deployed by the State. These include the following: The Infectious Disease Hospital which housed the isolation and treatment center used for the outbreak, The Lagos State Emergency Management Agency, The Lagos State Ambulance Service, The Integrated Disease Surveillance and Response System at both the state and local government levels, the enactment of the Public Health Law, the Coroner’s Law and the crematorium, the enactment of the Sanitation Law, the State Environmental Health Monitoring Unit and the Lagos State Waste Management Authority. The experience garnered in tackling previous emergencies and epidemics such as cholera, SARS, pipeline explosions, collapses buildings and air crashes served as the templates and mechanisms for the interstate, intergovernmental and international collaboration.

Given the most recent experience with the disease, will Nigeria do anything differently in the future if there is another outbreak?

We have learned how to become more effective in the things we do. We have also made more resources, including financial and manpower, available for future outbreaks. 

What are some of the other health issues that you work on in addition to Ebola?

I work on health care planning, health care financing, communicable and non-communicable disease prevention, human resources for health, service delivery at all tiers and community mobilization and building partnerships for health.

What is your favorite memory of your time at Yale?

The initial shock of the biostatistics class.

Do you have any plans to visit the university in the foreseeable future?

Yes, I do, though I have not been back there in a long time.

 

 

This article was submitted by Denise L Meyer on November 11, 2014.