On July 20, 2014, an acutely ill traveler from Liberia arrived at the international
airport in Lagos, Nigeria, and was confirmed to have Ebola virus disease (Ebola) after
being admitted to a private hospital. This index patient potentially exposed 72 persons
at the airport and the hospital. The Federal Ministry of Health, with guidance from
the Nigeria Centre for Disease Control (NCDC), declared an Ebola emergency. Lagos,
(pop. 21 million) is a regional hub for economic, industrial, and travel activities
(1) and a setting where communicable diseases can be easily spread and transmission
sustained. Therefore, implementing a rapid response using all available public health
assets was the highest priority. On July 23, the Federal Ministry of Health, with
the Lagos State government and international partners, activated an Ebola Incident
Management Center as a precursor to the current Emergency Operations Center (EOC)
to rapidly respond to this outbreak. The index patient died on July 25; as of September
24, there were 19 laboratory-confirmed Ebola cases and one probable case in two states,
with 894 contacts identified and followed during the response. Eleven patients with
laboratory-confirmed Ebola had been discharged, an additional patient was diagnosed
at convalescent stage, and eight patients had died (seven with confirmed Ebola; one
probable). The isolation wards were empty, and 891 (all but three) contacts had exited
follow-up, with the remainder due to exit on October 2. No new cases had occurred
since August 31, suggesting that the Ebola outbreak in Nigeria might be contained.
The EOC, established quickly and using an Incident Management System (IMS) to coordinate
the response and consolidate decision making, is largely credited with helping contain
the Nigeria outbreak early. National public health emergency preparedness agencies
in the region, including those involved in Ebola responses, should consider including
the development of an EOC to improve the ability to rapidly respond to urgent public
health threats.
The Ebola Outbreak
The first known case of Ebola in Nigeria was in a traveler exposed in Liberia. On
July 17, 2014, while under observation in a Monrovia, Liberia, hospital for possible
Ebola, the patient developed a fever and, while symptomatic, left the hospital against
medical advice. Despite advice against travel, on July 20 he flew by commercial airline
from Monrovia via Accra, Ghana, to Lomé, Togo, then changed aircraft, and flew to
Lagos. On arrival the afternoon of July 20, he was acutely ill and immediately transported
to a private hospital where he was noted to have fever, vomiting, and diarrhea. During
hospital admission, the patient was queried about Ebola and said he had no known exposure;
he was initially treated for presumed malaria. Based on the patient’s failure to respond
to malaria treatment and his travel from an Ebola-affected country in the region (2),
treating physicians suspected Ebola. The patient was isolated and tested for Ebola
virus infection while local public health authorities were alerted about a suspected
case of Ebola. A blood specimen sent to Lagos University Teaching Hospital was confirmed
positive for acute Ebola virus infection. The patient died on July 25.
Port Health Services conducted early contact tracing at the airport and worked with
airlines and partners to ensure notification of the outbreak through International
Health Regulations (IHR 2005) mechanisms (3). The EOC case-management team took over
management of each laboratory-confirmed or suspected case, triaged potential patients,
and decontaminated areas inhabited by them. Patients with suspected infection were
isolated in the suspected case ward at the Ebola treatment facilities, initially in
Lagos and subsequently in Port Harcourt. A contact tracing team staffed and supervised
by skilled, dedicated epidemiologists was established to investigate all primary contacts
and alert the case management team of symptomatic contacts for assessment and possible
reclassification.* A suspected case† was reclassified as a confirmed case if reverse
transcription–polymerase chain reaction (RT-PCR) detected Ebola virus in a blood specimen,
and was ruled out if RT-PCR testing of two blood specimens collected at least 48 hours
apart was negative. Additionally, testing for anti-Ebola virus immunoglobulin G, indicating
an immune response to Ebola virus, was added to the testing protocol for PCR-negative
suspected cases in persons with some symptoms who were epidemiologically linked to
subsequent confirmed cases. When a contact became ill with a suspected case, the contact
tracing team gathered data on persons exposed to that contact from the date of symptom
onset in the event the suspected case should become laboratory confirmed. Having the
capacity to conduct Ebola laboratory diagnosis in-country at the Lagos University
Teaching Hospital facilitated rapid identification of confirmed cases and quick discharge
of persons with suspected Ebola who tested Ebola negative.
As of September 24, 19 laboratory-confirmed Ebola cases and one probable case had
been identified (Figure 1). A total of 894 contacts were identified, and approximately
18,500 face-to-face visits were conducted by contact tracers to assess Ebola symptom
development. Persons with suspected Ebola were transported to a suspected case isolation
ward by the case management team, and persons who subsequently tested Ebola positive
were moved to the confirmed case ward at the same facility in either Lagos or Port
Harcourt. Eleven patients had been discharged, one additional patient had a confirmed
diagnosis in the convalescent stage, and eight had died (seven confirmed; one probable)
for an overall case fatality ratio of 40%. The isolation and treatment wards were
empty, and 891 (all but three) contacts had successfully exited follow up. The remaining
three contacts became ill but tested Ebola negative and were released from the isolation
ward in Lagos. As is standard practice, upon release, the patients who had been suspected
cases started a new 21-day follow-up as contacts because of the possibility that they
were exposed in the ward. In this instance, no one was diagnosed with Ebola while
these three contacts were in the ward, thus the likelihood of Ebola exposure was very
low, and all three are due to exit follow-up on October 2.
Investigation of the index patient and all exposed contacts required coordination
between multiple IMS response teams and across several cities in the course of the
response. The three-generation spread of Ebola (all 19 confirmed and probable cases)
to date can be traced to the index case through contact networks (Figure 1). Twelve
of the 20 patients were exposed in two health facilities in Lagos. Four of the cases
have been associated with a suspected case in a patient who traveled while ill via
commercial aircraft from Lagos to Port Harcourt, Rivers State, and back (Figure 1).
After the patient who traveled was discovered, manifests were collected from both
flights, and attempts were made to contact passengers to ensure they had not become
ill because >21 days had passed since the travel occurred. No ill or deceased passengers
were identified. Overall, no new cases have occurred since August 18 in Lagos and
August 31 in Port Harcourt, suggesting that the Ebola outbreak in Nigeria might have
been contained (Figure 1).
Public Health Response
The threat to Nigeria posed by the arrival in Lagos of a patient acutely ill with
Ebola was potentially enormous. Lagos is Africa’s largest city and is also a transit
hub for the region with air, land, and sea ports of entry (1). The dense population
and overburdened infrastructure create an environment where diseases can be easily
transmitted and transmission sustained. Suboptimal infection control practices in
health centers lacking necessary equipment and supplies increase the risk for Ebola
transmission to health care workers. Contact tracing efforts are burdened by the complex
nature of transit, commercial, and public health notification and reporting mechanisms.
The implementation of a rapid response that made use of the available public health
assets was the highest priority at the onset of the outbreak, as was organizing the
response using proven structures for the delivery of public health in Nigeria. To
effectively address Ebola in this complex environment, the response was mounted quickly
and used an IMS; both actions are largely credited with helping contain the outbreak
early.
Initially, NCDC and the Lagos State Ministry of Health established an Incident Management
Center, which served as the overall implementing arm of the national response. The
initial Incident Management Center was subsequently recast as the national EOC, in
line with IMS nomenclature and national structures aimed at emergency response. The
EOC expanded its operations to Rivers State when cases emerged there, and oversaw
the monitoring of contacts in Enugu State with state health officials as part of the
early outbreak response. There was a stated expectation that all partner organizations,
donors, and response teams would work through the EOC structure, reporting to an Incident
Manager (IM). In turn, the IM would be responsible to deliver accountable and transparent
results to the NCDC and the federal Ministry of Health (Figure 2). The IM, responsible
for oversight of the response, was selected based on IMS experience and competency
rather than rank in government or public service.
Nigeria’s response benefited from the rapid use of its national public institution
(i.e., NCDC), previous outbreak responses such as a major lead poisoning response
in 2010, and its recent experience with polio eradication. In October 2012, responding
to the declaration by the World Health Organization of polio eradication as a global
public health emergency, and to improve its national response, the Government of Nigeria
used the IMS to establish a national EOC as part of a new national emergency plan
for the global polio eradication initiative (3). The use of IMS through the EOC changed
the operational tempo, accountability measures, and programmatic success of the polio
program. Indicators and dashboards (electronic displays of high level indicators for
each response team monitored at the EOC) were developed to increase accountability
of the program staff and spending. Through the EOC and the Nigeria Field Epidemiology
and Laboratory Training Program (NFELTP) polio activities, state health system strengthening
and preparedness was prioritized (4–6).
With the emerging Ebola outbreak, the Nigerian government moved quickly to enforce
coordination of the national and state Ebola response efforts using the IMS/EOC structures
and drew from its successful experiences. Specifically, the Ebola EOC IM was the polio
EOC Deputy IM, and seeded the Ebola EOC with several secretariat and technical staff
members from the National Polio EOC. Critical to demonstrating both national and state
commitment, the Deputy IM was a senior member of the Lagos State Ministry of Health
(Ebola was imported to Lagos State), with access to human and financial resources
within the state health system. Immediately, the EOC developed a functional staff
rhythm that facilitated information sharing, team accountability, and resource mobilization
while attempting to minimize the distraction of teams from their highest priorities.
An “Action Tracker” was developed that included specific tasks arising from each meeting,
the person responsible, and the due date.
The overall design of the response rested within a senior strategy team made up of
the IM, Deputy IM, and primary partner agencies (Doctors Without Borders, the United
Nations Children’s Fund, the World Health Organization, and CDC). Six response teams
were developed within the EOC specific to an Ebola response, including: 1) Epidemiology/Surveillance,
2) Case Management/Infection Control, 3) Social Mobilization, 4) Laboratory Services,
5) Point of Entry, and 6) Management/Coordination (Figure 2). Terms of reference and
priority activities were developed by the strategy team to guide each operational
team’s work; operational teams developed their own staffing, lists of material and
financial needs, and a goal-oriented operational plan. The strategy group reviewed
and approved all of the teams’ work and needed resources. Technical partners assigned
staff throughout the operational teams in technical advisory roles aimed at building
the capacity of the local teams and ensuring quality work.
What is already known on this topic?
The ongoing Ebola virus disease (Ebola) outbreak in West Africa has had an enormous
negative impact on civil and public health systems in Liberia, Sierra Leone, and Guinea.
Nigeria’s public health system includes a national public health institute (NCDC)
and an Emergency Operations Center (EOC) and Incident Management System (IMS), created
in 2012 when Nigeria declared polio a public health emergency and restructured its
national polio program.
What is added by this report?
Applying lessons from its NCDC and successful polio EOC, Nigeria quickly established
a National Ebola EOC after importation of the disease on July 20, 2014. The early
use of the EOC/IMS system enabled the country to streamline a coordinated and effective
response in Lagos, (pop. 21 million) and to expand that response to Port Harcourt,
another large city. As of September 24, a total of 894 contacts in three states had
been monitored, and 20 confirmed or probable Ebola cases identified, of whom eight
died. No new cases had occurred since August 31, suggesting that the Ebola outbreak
in Nigeria might have been contained.
What are the implications for public health practice?
African nations need to rapidly assess their readiness to manage the importation of
Ebola. Preparedness activities could include planning EOC/IMS structures that can
guide a coordinated and effective response to Ebola or any other public health threat.
Where EOC already exists for other diseases like polio, such structures should be
strengthened and used to mount effective responses to new threats like Ebola.
As an example of work planning efforts, the EOC Point of Entry team, led and staffed
heavily from the Port Health Service, was responsible for identifying, listing, documenting,
and risk-ranking of all the contacts of the index patient at the airport, including
those on aircraft and those exposed during airport transit/handling of the index patient.
Early in the response, this team mobilized to identify and track the index patient’s
contacts in the airport and outside Nigeria. Port Health Service worked with airline
and airport authorities and other stakeholders to gather information about contact
passengers, decontaminate affected areas of the airport, and send a notice through
the World Health Organization-International Health Regulations system to avoid possible
spread of the disease. The Point of Entry team also established entry and exit screening
at ports, which is being rolled out at additional ports and will continue for the
duration of the regional outbreak to minimize the likelihood of either further importation
or exportation of Ebola.
The Epidemiology/Surveillance team was responsible for contact tracing, operational
research, management of alerts and rumors, and implementing community-based surveillance.
For successful contact tracing, the Epidemiology/Surveillance management team included
over a dozen trained, dedicated NFELTP, WHO, and CDC epidemiologists and was provided
the target of listing all contacts of the index and subsequent Ebola cases in the
response, and monitoring them in person daily to measure body temperature and check
for the presence of other Ebola signs and symptoms (e.g., vomiting, diarrhea, and
hemorrhage). In response, the team developed a staffing plan for Lagos that included
over 150 contact tracers, vehicles, telephones, and mobile data platforms that the
contact tracers could use to administer their questionnaires and report contact responses.
In addition, the operational research arm of the Epidemiology/Surveillance team conducted
a community Ebola assessment that informed training and communication efforts.
Directly linked to the contact tracing was the Social Mobilization strategy. This
included teams of three social mobilizers who were trained and deployed to conduct
house-to-house, in-person visits within specific radii of the homes of the Ebola contacts.
For high-density areas, house-to-house teams covered a 500m radius, 1km in medium
density areas and 2km for low density (7). As of September 24, approximately 26,000
households of persons living around Ebola contacts had been reached with house-to-house
visits in Lagos and Rivers states.
Several issues were observed by the response team during Nigeria’s Ebola outbreak
that could, in retrospect, have been mitigated through additional preparedness planning
for public health emergencies. First, financial resources were slow to arrive at the
EOC, a delay that threatened to impede the rapid expansion of containment activities
across the response. Early activities were funded by the Lagos State government, international
partners, and nongovernmental organizations. National preparedness efforts should
consider how resources can be quickly accessible to fund the early stage of the response.
Second, there were discrepancies among the levels of political leadership in fully
appreciating the enormous consequences that even a small Ebola outbreak could have
on civil institutions such as hospitals, airports, and public gatherings. Targeted
education about the urgent need to fund, staff, and supply a response effort was provided
to political leadership and should be considered for preparedness efforts elsewhere.
Similarly, the Nigerian public did not have specific information about Ebola, and
early information provided by the press, in advance of official information from the
health authorities, was sometimes inaccurate and created a nationwide scare. This
scare resulted in some persons resorting to extreme and sometimes harmful and ineffective
measures to avoid infection such as consuming large quantities of salt water, even
in places distant from the outbreak. Both issues could have been addressed through
preparedness activities that focused on education and planning, as well as explaining
Ebola to the public and describing how to respond should Ebola arrive in Nigeria.
The Case Management team indicated that early efforts to establish an isolation ward
were delayed due to a lack of Nigerian health care workers willing to care for patients
with Ebola because of a lack of information and training about how to care for Ebola
patients, and because care providers had been disproportionately impacted by Ebola
in other affected countries. Preparedness activities should include orientation and
training of physicians, nurses, and attendants to safely provide services with attention
to infection control procedures and quality Ebola treatment at an appropriately designed
facility. Another challenge was ensuring appropriate coordination of private sector
engagement. The EOC system facilitated improved coordination through the designation
of the Management and Coordination Team Lead as the private sector point of contact.
Finally, some partners and parts of government were unfamiliar with the EOC/IMS system
and its use as a means of streamlining coordination and response elements into one
unified approach. The government-led EOC process could define opportunities for partners
to place staff strategically in the national and local response efforts and could
encourage this through the EOC response teams and management system. Further, EOC
mechanisms should be tested through strategic exercises and use in non-Ebola responses.
Even with these identified challenges, Nigeria’s decision to use EOC/IMS to respond
to Ebola resulted in a rapid, effective, and coordinated outbreak response. As of
September 24, the Nigeria response had successfully limited the outbreak to 20 laboratory
confirmed and probable cases (in two states) with the last cases occurring on August
18 and August 31 in Lagos and Port Harcourt, respectively. This limited spread and
the rapid scale-up against the backdrop of the large, dense, urban environments of
Lagos and Port Harcourt suggest early response efforts were successful; this is likely
directly attributable to the Nigerian government’s strategic use of its public health
institutions and the EOC/IMS structure to manage the response. The EOC/IMS approach
should be a central part of national and subnational preparedness efforts for public
health threats. EOC/IMS is a key component of the global health security agenda, along
with Integrated Disease Surveillance and Response/International Health Regulations
(IHR 2005).