Ebola: What Texas can learn from Nigeria

By Washington Post

While devastating reports continue to stream out of West Africa, where the deadly virus has overwhelmed already weak public health systems and left thousands of people dead, and anxiety grips the United States over the first case of Ebola diagnosed in the country, one nation serves as an example of hope: Nigeria, which appears to have successfully contained Ebola.

As concerns spread over U.S. hospital readiness, there are some lessons to be learned from Nigeria, where officials managed to get ahead of the fast-moving virus after it was brought into Africa’s most populous country by an Ebola-infected man who’d flown into Lagos. This week, the U.S. Centers for Disease Control and Prevention reported that the outbreak could be coming to an end in Nigeria, with no new Ebola cases since Aug. 31.

As in the U.S. case, Ebola arrived in Nigeria by passenger plane. But unlike Thomas Eric Duncan — who arrived in Dallas before he became symptomatic and was therefore not contagious during his flights from Liberia to Texas through Brussels and Dulles International Airport — Patrick Sawyer was already symptomatic when he landed in Lagos on July 20. At that point, Sawyer, Nigeria’s Patient Zero, was contagious and dying.

It was a nightmare scenario with the potential to spiral out of control, given the bustling city of Lagos, Africa’s largest, is a major transportation hub. As Sawyer was placed in isolation, public health officials had to track down every single person who’d come into contact with him, from the flights he’d boarded to the Lagos airport and the private hospital where he went after landing. And they had to do so quickly, making the process known as contact tracing a priority.

“In the whole system approach in beating the war on Ebola, contact tracing is the key public health activity that needs to be done,” said Gavin MacGregor-Skinner, who helped with the Ebola response in Nigeria with the Elizabeth R. Griffin Research Foundation. “The key is to find all the people that patient had direct close contact with.”

From that single patient came a list of 281 people, MacGregor-Skinner said. Every one of those individuals had to provide health authorities twice-a-day updates about their well-being, often through methods like text-messaging. Anyone who didn’t feel well or failed to respond was checked on, either through a neighborhood network or health workers.

Nigeria took a “whole community approach,” with everyone from military officials to church elders in the same room, discussing how to handle the response to the virus, MacGregor-Skinner said.

Such an approach, and contact tracing in general, requires people be open and forthright about their movements and their health, he said. Stigmatization of patients, their families and contacts could only discourage that, so Nigerian officials sent a message to “really make them look like heroes,” MacGregor-Skinner said.

“This is the best thing people can do for Nigeria: They are going to protect and save Nigeria by being honest, by doing what they need to do, by reporting to the health commission,” he said. This made people feel like they were a part of something extremely important, he said, and also took into account real community needs. “You got real engagement and compliance from the contacts. They’re not running and hiding.”

Sawyer had come into contact with someone who ended up in Port Harcourt. That person, a regional official, went to a doctor who ended up dying from Ebola in August. Within a week, 70 people were being monitored. It ballooned to an additional 400 people in that one city.

Success stories of people coming through strict Ebola surveillance alive and healthy helped encourage more people to come forward, as they recognized that ending up in a contact tracer’s sights didn’t mean a death sentence.

In the end, contact tracers — trained professionals and volunteers — conducted 18,500 face-to-face visits to assess potential symptoms, according to the CDC, and the list of contacts throughout the country grew to 894. Two months later, Nigeria ended up with a total of 20 confirmed or probable cases and eight deaths.

The CDC also pointed to the robust public health response by Nigerian officials, who have had experience with massive public health crises in the past — namely polio in 2012 and large-scale lead poisoning in 2010.

When someone is on a contact list, that doesn’t mean that person has to stay at home for the entire incubation period of 21 days from the last contact with someone who had Ebola. People on contact lists are not under quarantine or in isolation. They can still go to work and go on with their their lives. But they should take their temperature twice a day for 21 days and check in with health workers.

Officials in Texas began with a list of about 100 names; they have whittled the list down to 50 people who had some contact with Duncan. Of those, 10 are considered high-risk.

The CDC recommends that people without symptoms but who have had direct contact with the bodily fluids of a person sick with Ebola be put under either conditional release, meaning that they self-monitor their health and temperature and check in daily, or controlled movement. People under controlled movement have to notify officials about any intended travel and shouldn’t use commercial planes or trains. Local public transportation use is approved on a case-by-case basis.

When symptoms do develop, that’s when the response kicks into high gear. People with Ebola are contagious only once they begin exhibiting symptoms, which include fever, severe headaches and vomiting.

While four people in Dallas are under government-ordered quarantine, that is not the norm. Those individuals “were non-compliant with the request to stay home. I don’t want to go too far beyond that,” Dallas County Judge Clay Lewis Jenkins said Thursday.

On Friday, the four people were moved to a private residence from the apartment where Duncan had been staying when he became symptomatic.

A law enforcement officer will remain with them to enforce the order, and none of the people are allowed to leave until Oct. 19.

Duncan is the only person with an Ebola diagnosis in Dallas, and no one else is showing symptoms at the moment. But, as Nigeria knows, the work in Dallas has just begun.