Prologue: We are putting up this post as a result of increasing demand for information on this disease. As of today, the 7th of August 2014 there have been 9 cases (2 probable, 7 suspect) on Ebola Virus Disease in Nigeria and 2 deaths. All nine cases have been known primary contacts of the index case in Nigeria; Mr Sawyer. At this point therefore, as far as we know, while there has been transmission in Nigeria, it is limited to contacts of the primary case. There is no confirmed community transmission i.e. further transmission from any of the currently infected cases.
This is significant because the rest of this post has to be interpreted in this context. If community transmission occurs –it changes the scenario significantly. However, given that the contacts of each case will need to be under close observation, and using a conservative estimate of 3 contacts for each case, there will be over 100 people under close observation at the moment. If any of them develops symptoms, this will change the picture dramatically.
My name is Chikwe Ihekweazu – I am an infectious disease epidemiologist and have worked on several WHO outbreak responses across the continent including an Ebola outbreak in South Sudan in 2004. I have included this information in order to contextualize the information below.
Having said this, we are in the middle of the largest Ebola outbreak ever; showing that the virus is adapting fast to the environment and causing more harm. At the same time medical science is making rapid advances so, as much as I may have some understanding of the issues at hand, knowledge is expanding rapidly and this post may rapidly become out of date.
We will frame the post in line with the questions we have been asked recently.
1. Should we be worried?
We should be worried enough to inform ourselves appropriately but we must not panic. The people most at risk at the moment are healthcare workers and family members caring for ill patients that may have been exposed to the index case, or caring for other returned patients from Sierra Leone, Liberia or Guinea. Specific efforts are going at the moment targeting these two groups. They must follow the infection control guidelines that I presume have been issued to them “religiously”. If you do not fall into any of these categories, please keep yourself informed of the general picture, take normal precautions and go about daily life. If you are caring for anyone with fever, body aches etc, please continue to care for the patient with compassion. The most important question to ask is if there has been contact with any of the nine known cases or a recent travel history to the 3 most affected countries; Guinea, Liberia or Sierra Leone. If this is the case, please call the helpline 0800ebolahelp. Remember to continue taking precautions against other communicable diseases; use a bed net against malaria, condoms to prevent STIs and HIV, boil your water – a cholera outbreak is going on in Plateau State, and if you are coughing for more than 2 weeks, see your doctor; TB killed approximately 27,000 people in Nigeria last year.
2. Where can you get information on the disease?
An excellent website has been put up – http://www.ebolaalert.org/. This was initiated by the Lagos state government with its partners. The information contained there is accurate and informative. The website could have benefitted with some audiovisuals – find here and here links to two good podcasts in pidgin English by Ruona Meyer. Another aspect missing on the website is information for health care workers, here the CDC manual will be useful to some extent.
3. How is the virus spread?
The virus is spread by contact with body fluids (blood, sweat, semen, saliva) of an infected and sick person. There is no evidence that it can be spread by air, water, or vectors such as mosquitoes or flies. People who are well cannot transmit Ebola. So, it is actually not an easily transmissible virus and proper adherence to infection control principles will protect most people from getting the virus. Next time you visit your doctor or nurse and he/she tries to give you an injection without gloves on – insist on their wearing gloves and report him/her to the appropriate medical/nursing council, and change your care provider. No ifs, no buts. The most important thing now is to break the chain of transmission – the first patient in Nigeria infected 8 others, if we continue at that rate of transmission – we are in big trouble. We must ensure that these nine do not infect any more, and the main way to do this is through effective and consistent implementation of infection control measures.
4. Should we stop eating meat?
The “jump” of the virus from an animal host (we still do not know the host animal(s) for sure) to humans is an extremely rare event. Once this happens, the most likely subsequent source of infection is human-to-human transmission. Heating kills the virus so all cooked meat is safe; yes, including suya. The most important risk at the moment is from humans infected with the virus and not animals!
5. Can prayer cure the virus?
No – God has given us brains – He expects us to use them.
6. Is Government doing enough to contain the disease?
They are doing the best they can, given the circumstances. A lot of support is now being received from the World Health Organisation, the US Centres for Disease Control and other partners. There are many Nigerians and International colleagues working for these organisations that are rapidly scaling up the response. Could we have been better prepared? Maybe – but this is not the appropriate time to discuss this. We must all rally around the incredibly brave colleagues that are on the frontline of the response now.
7. Is the strike by doctors having an impact on the level preparedness of the clinical response?
Yes – obviously. It is a tragedy for the country that doctors and the government have not found a resolution to their differences during this trying period for the county. Our patients need us the most now. Whatever the issues are, I appeal to my colleagues to suspend the strike and rise to the challenge of today. Our patients need us not only to provide clinical care but to restore confidence in the ethos of our profession. In no other country would the index patient have been taken to a private hospital for care as was the case in Nigeria with Mr. Sawyer. Nigerians need us, now more than ever.
8. Who is actually leading the Nigerian response?
The response is being led by the Nigerian Centre for Disease Control, a directorate under the Department of Public Health of the Federal Ministry of Health. As Nigeria is a Federal Republic, the states also have a leading role to play. The responsibilities for the provision of care are poorly delineated by the Nigerian constitution. A National Health Bill that will solve this has been pending between the National Assembly and the president for over eight years.
9. Why are African patients not being given the experimental medicines being used on the two American survivors?
First, every country has the option of developing its own scientific capacity in drug development, therefore they can use these drugs as they deem fit. We could ask what new compounds have been developed by the Nigerian Institute for Medical Research (NIMR) and the Nigerian Institute for Pharmaceutical Research (NIPRD) since their inception, but again, that is a question for another day.
Secondly there are very difficult ethical issues around using experimental treatments. Many Nigerians will remember the consequences of the use of an unlicensed medicine during a meningitis outbreak in Kano by Pfizer in 1996. Discussions are going on at the moment, led by WHO on how access to these experimental medicines can be scaled up, but it will not happen overnight as we still do not know for sure that they made a difference for the two Americans. Remember 10 – 40% of all those infected will survive.
10. What is your most important advice?
Do not panic. Dealing with the outbreak itself is hard enough; dealing with panicking public will be disastrous. The outbreak can be contained by doing “simple” things diligently and consequently.
If you think that someone you know may be infected call 0800Ebolahelp.
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