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Soon to be Ebola-free, Nigeria and Senegal show merits of early response

Both countries credited with aggressive investigation and vigilant surveillance, as virus spreads elsewhere

Patrick Sawyer’s collapse at the arrivals hall of Lagos airport on July 20, could have led to a devastating chain of events in Nigeria. Suffering from Ebola, the Liberian-American’s presence in the country sparked fears that Africa’s most populous nation could become the vector for the virus to spread not just across the continent but around the world.

But Nigeria, a country with vast but unequal oil wealth and sectarian rifts that have been widened by the Boko Haram insurgency, has surprised many with how deftly it mobilized its health care personnel working on other disease outbreaks like polio to stem Ebola in the country after just seven fatalities — a tiny fraction of the 4,447 confirmed victims so far, the vast majority of whom were from the three worst-hit nations of Liberia, Sierra Leone and Guinea.

As of next week, Nigeria will have been without a new case for 42 days — two incubation cycles of the virus — and therefore officially considered Ebola-free by the World Health Organization (WHO).

On Tuesday, the same day it announced there will likely be up to 10,000 new cases of Ebola a week in the three worst-hit countries, WHO said it expected to soon declare the Ebola outbreaks in Nigeria and Senegal over — a testament to both “world-class epidemiological detective work” and the early preparedness of those countries’ relatively well-funded health care infrastructure, the U.N. health agency said in a statement.

Nigeria and Senegal — which curbed the virus at just one death — “will give the world some welcome news in an epidemic that elsewhere remains out of control,” the WHO added.

The responses in both countries cannot easily be compared with those of Liberia, Sierra Leone and Guinea — all smaller nations with poor health care infrastructure before Ebola broke out. Senegal and Nigeria had months of warning and faced outbreaks that began with a single case whose contacts could be rapidly investigated and isolated in order to prevent further infection.

But their ability to do so can be credited at least in part to early preparations adopted as the virus began to spread across West Africa in the spring.

“Even back in April, Senegal started to think about what would happen if it came here,” said Meredith Stakem, a regional health adviser for Catholic Relief Services in the Senegalese capital, Dakar. She said the group began working on community awareness along Senegal’s southern border with Guinea, where the outbreak was already raging, several months before Senegal’s first and only case arrived in July.

“It also helped that only one person came in,” she said. “If you think about how many people have had contact once there are 15 to 20 cases, the number you need to track down and isolate is huge." The dozens of contacts in Senegal’s case were relatively manageable, she said.

Nigeria’s success was more remarkable. After Sawyer was confirmed to have Ebola and not malaria, as doctors initially suspected, the Nigerian government established an outbreak operations center with the help of the WHO, Doctors Without Borders, UNICEF and the U.S. Centers for Disease Control. From there it launched an aggressive investigation to find anyone who came into contact with Sawyer — an effort that deployed nearly 200 epidemiologists and other health workers to conduct 18,500 face-to-face interviews and 26,000 household visits, all in only about one month.

Nigeria also disseminated information over mass media, including setting up a dedicated website, on how people could avoid the virus, without stirring hysteria in the world’s eighth-most-populous nation.

“You need to rapidly counterattack misinformation, because panic and fear tends to decrease the chances of people reporting to the health facilities,” said Faisal Shuaib, the deputy incident manager of Nigeria’s polo eradication program, who helped manage the country’s Ebola response, in an interview with Quartz.

In Liberia, Sierra Leone and Guinea, three countries with anemic health care systems and startlingly low numbers of medical professionals — Liberia had just 50 doctors when Ebola broke out — people have been reluctant to even enter hospitals for fear of contracting the deadly virus. Medical facilities are severely lacking in prophylactic supplies, including masks and gloves, which puts health care workers at risk. Scores of hospital workers have died in three countries since the outbreak began.

That has not been the case in Nigeria, which has repurposed the country’s extensive polio surveillance infrastructure to monitor and identify potential new cases of Ebola. The Gates Foundation, which works on a number of public health initiatives around the globe, transferred $50 million that had been earmarked for the country’s polio eradication program toward its Ebola response.

Though health experts were quick to credit the Nigerian government, they also noted that Nigeria and Senegal have received more international aid per case than the worst-hit countries. That falls in line with the WHO road map for defeating the Ebola outbreak that places greater emphasis on stopping the spread of the virus in new countries, which is thought to be a more efficient use of limited resources.

“WHO recognized that there is a very limited window of opportunity to stop the outbreak from taking off once there is an initial case,” said Catholic Relief Services’ Stakem.

Neither country can rest easy. Nigeria’s airports are major regional hubs, and Senegal’s land border with Guinea is similarly vulnerable.

But their success is already being studied by public health experts as examples of how countries with resources — Nigeria has the world’s 23rd-largest GDP, according to the U.N., and Senegal is slightly better off than its Ebola-ridden neighbors — can execute WHO guidelines to nip an infectious disease outbreak in the bud.

"If Nigeria can control an outbreak caused by such a deadly and highly contagious virus, right from the start, any country in the world can do the same," the WHO concluded in a recent report.

"These responses can be replicated," said Olimpia de la Rosa, medical coordinator of the Doctors Without Borders emergency unit, who has worked on the Ebola outbreak from Liberia. "Not everywhere — Liberia, for instance, doesn’t have the resources — but there are certainly lessons on early detection to be exported to other countries.”

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