can’t Ebola virus infect all corrupt government officials during
air travel to free the country from corruption?"
"Does Nigeria have the capacity to handle Ebola outbreak?"
"If I happen to travel along with an infected person on the
same car, would I contract the disease?"
"Could hot salt
and water bath prevent the transmission of Ebola virus"?
"Is it true that bitter Kola nut could treat EVD?"
In Nigeria, whenever a situation arises, people always look
to a simplistic or near impossible fantasy for solution. The
funniest of all the questions was the one I heard coming from
Boko Haram enclave, Borno State, that;
"Is it not
possible to have Ebola Virus Disease Outbreak in Sambisa Forest
which will ultimately free us from the scourge of Boko Haram?"
To buttress his point, the inquirer cited the recent chasing
away of Boko Haram members from the Sambisa Forest by
"supernatural" means including attack of members by snakes,
scorpions and bees which he believes were due to prayers! These
have been reported by a large cross-section of newspapers in the
country at the onset of the rainy season.
similar attack by Ebola virus at Sambisa Forest will not be out
of place", he said.
I am not an expert in EVD, however, with my background in
International Health, I believe I can attempt to answer some of
the questions raised. Although the social media has been
saturated with messages and articles about EVD, notwithstanding,
there is a need to further refresh our memories on EVD i.e. its
characteristics, dynamics, treatment, epidemiology and control
in order to address the questions raised in a proper context.
According to the World Health Organisation (WHO) website and
other sources, Ebola
Virus Disease (EVD)
or Ebola Hemorrhagic
is a severe often fatal illness in humans caused by Ebola
viruses with Case Fatality Rate (CFR) as high as 90%. This means
up to 9 in 10 of people infected with the disease would die
(depending on the epidemics). The current outbreak is the worst
ever with over 961 deaths spanning across Liberia, Sierra Leone,
Guinea and Nigeria. With reference to history, Ebola first
appeared in 1976 in two simultaneous outbreaks, in Nzara,
southern Sudan, and Yambuku in northern Democratic Republic of
Congo. The latter was in a village situated near the Ebola
River, from which the disease takes its name. The disease is
first acquired by the human population when a person comes in
contact with the blood or bodily fluids of an infected wild
animal. Handling of several wild animals has been documented
including infected chimpanzees, gorillas, fruit bats, monkeys,
forest antelope and porcupines found ill or dead.
However, fruit bats are believed to carry and spread the
disease without being affected themselves; this has raised
speculation that these mammals may play a role in maintaining
the virus in the tropical forest. Once infection occurs in human
beings, Ebola then spreads in the community through
human-to-human transmission, with infection resulting from direct contact through broken skin
or mucous membranes (inner skin of the eyes, nose, mouth,
genital and anal tract) with the blood, secretions, organs,
vomitus, faeces or other bodily fluids of infected people.
Transmission through Indirect contact with environments
contaminated with such fluids may also happen.
Other means of transmission include during burial ceremonies
in which mourners have direct contact with the body of an
infected person. Men who were lucky to recover from the disease
can still transmit the virus through their seminal fluid up to
61 days following recovery from the illness. Health-care workers
are commonly infected while treating suspected or confirmed EVD
patients through close contact without correct infection control
precautions and adequate barrier nursing procedures.
The usual Incubation Period is 8-10 days (rarely from 2 to 21
days). This is the period between contact with the virus and
manifestation of sign and symptoms. Some infections could be
transmitted from one person to another during the incubation
period before the onset of symptoms; fortunately, Ebola patients
are not contagious until they are acutely ill (we will later see
the role of this in EVD control). Symptoms are characterised by
sudden onset of fever, intense weakness, muscle pain, headache
and sore throat. This is followed by vomiting, diarrhoea, rash,
impaired kidney and liver function, and in some cases, both
internal and external bleeding. Diagnosis requires high index of
suspicion because the disease mimics the symptoms of malaria,
hepatitis, typhoid fever, shigellosis, cholera, leptospirosis,
plague, rickettsiosis, relapsing fever, meningitis, and other
viral haemorrhagic fevers.
Definitive diagnosis is made in the laboratory through
several types of tests: Antibody-capture Enzyme-linked
immunosorbent Assay (ELISA), Antigen Detection Tests, Serum
Neutralization Test, Reverse Transcriptase Polymerase Chain
Reaction (RT-PCR) Assay, Electron Microscopy and Virus isolation
by cell culture. New developments in diagnostic techniques
include non-invasive methods of diagnosis (testing saliva and
urine samples) and testing inactivated samples to provide rapid
laboratory diagnosis to support case management during outbreak
Like many other viral diseases, EVD has no treatment nor
vaccine for prevention. Supportive treatment include giving the
person either Oral Rehydration Therapy (ORT) or intravenous
fluids. Treatment is primarily supportive in nature and includes 4
minimizing invasive procedures, balancing fluids and
electrolyte to counter dehydration, administration of
anticoagulants early in infection to prevent or control
Disseminated Intravascular Coagulation (DIC) which is fatal,
administration of pro-coagulants late in infection to control
external and internal bleeding, maintaining oxygen levels, and
administration of analgesics for pain, antibiotics or
anti-mycotics to treat secondary infections. As outlined
earlier, the disease has a high death rate: often between 50%
and 90%. The current CFR is estimated at 60%.
Primary prevention i.e. prevention from the animal source to
humans include reducing the risk of wildlife-to-human
transmission from contact with infected fruit bats or
monkeys/apes and the consumption of their raw meat. Gloves and
other appropriate protective clothing should be used in handling
wild animals. Animal products (blood and meat) should be
thoroughly cooked before consumption.
Pig farms in Africa can play a role in the amplification of
infection because of the presence of fruit bats on these farms.
Routine cleaning and disinfection of pig or monkey farms with
sodium hypochlorite (bleach) is effective in inactivating the
virus. If an outbreak is suspected in a farmland, the premises
should be quarantined immediately. Other measures to reduce
further transmission include culling of infected animals, burial
or incineration of carcasses, restricting or banning the
movement of animals from infected farms and so on.
To reduce the spread of Ebola infection among people, raising
awareness of the risk factors for Ebola infection and other
individual protective measures should be instituted. Reducing
the risk of human-to-human transmission in the community arising
from direct or close contact with infected patients or their
bodily fluids should also be instituted. Close physical contact
with Ebola patients should be avoided. Regular hand washing with
soap and other disinfectants where available is required after
visiting patients in hospital, and also after taking care of
patients at home.
Attending burial ceremonies is a major traditional rite in
Africa, affected communities should be informed about the nature
of the disease and its containment measures, including burial of
the dead. People who have died from Ebola should be buried
immediately and safely using recommended guidelines.
WHO has created a guide on standard precautions in health
care practice. Standard precautions are recommended in the care
and treatment of all patients regardless of their perceived or
confirmed infectious status. These include the basic level of
infection control—hand hygiene, use of personal protective
equipment to avoid direct contact with blood and body fluids,
prevention of needle stick and injuries from other sharp
instruments, and a set of environmental controls. Tracing and
following up people who may have been exposed to Ebola through
close contact with patients are essential.
Before answering the questions raised, we need to be
conversant with some epidemiological concepts with regards to
disease transmission. Some factors influencing the transmission
of disease in general include; the infectiousness of the
causative organism, duration of infectivity of affected patients
and the number of people at risk in contact with the affected
patient and the Basic Reproduction Number (Ro). Ro of a disease
is the number of cases one case generates on average over the
course of its infection period, in an otherwise uninfected
If the Ro is less than 1, epidemics will not be maintained
(i.e. the disease will die out), and if Ro is greater than 1,
the infection will spread in the population. It is difficult to
calculate the exact value of Ro for different diseases; using
data from several epidemics and mathematical models, the value
of Ro is determined. For Ebola virus, Ro= 2.7 (1-4). This means
on an average, Ebola is transmitted to about 3 people from an
infected patient during its period of infectivity (i.e. before a
patient dies or recovers). When compared to other viral diseases
like measles, Ro ranges from 12-18! EVD creates more fear than
any other disease because of the high case fatality rate.
Now back to our questions. Most of them were addressed during
the course of our discussion, but I will dwell on Nigeria’s
capacity to handle EVD and the possibility of an outbreak in
Does Nigeria have the capacity to handle Ebola outbreak?
President, Academy of Science, Prof
Oyewale Tomori while responding to the announcement of the
outbreak as reported on the Nations Newspaper of 29th July, 2014
"Nigeria does not have a laboratory that can diagnose Ebola,
describing it as the greatest shame of all. Besides, if we have
any case in Nigeria now, the samples will have to be taken to
the Centre for Disease Control (CDC), in the United States or
other advanced countries; that is why a lot of health workers
are getting infected."
At the onset of the outbreak, all precautionary measures to
mitigate against the spread of the infection were instituted; 70
contacts (39 hospital, 22 airport and 9 laboratory) were
identified and traced. The Minister for Health while having a
meeting with the House of Representative Committee on Health
said; "Mr Sawyer
left Liberia for an ECOWAS meeting to be held in Nigeria. But
before he left Liberia, he knew he was sick, and the government
told him not to travel, but he ignored the directive and
travelled for the meeting." Similarly,
video recording showed Tom sawyer to be terribly sick but he
decided to travel against advice. Therefore, it is not
surprising that he was able to infect 8 Nigerians with one death
recorded; also being very sick, raised the chances of
responding on the identified contacts and Nigeria’s capacity to
handle the outbreak, Derek Gatherer, a virologist at Britain’s
University of Lancaster said anyone on the plane near Sawyer
could be in "pretty
serious danger," but relatively wealthy Nigeria, Africa’s most
populous country, was better placed to tackle the outbreak than
poorer neighbours. Nigeria have deep pockets and they can do as
much as any western country could do if they have the motivation
and organisation to get it done", he
Similarly, Peter Piot,
the Director of London School of Hygiene and Tropical Medicine
and the discoverer of Ebola Virus said he wouldn’t be worried to
sit next to someone with Ebola virus on the tube as long as they
don’t vomit on you or something; it is an infection that
requires very close contact. "He went further to
say that a "really bad" sense of panic and lack of trust in the
authorities in West Africa had contributed to the world’s
largest ever outbreak. Recent history in Liberia and Sierra
Leone was complicating efforts to tackle the deadly virus which
kills as many as nine-tenths of people infected. Let’s not
forget that these countries are coming out of decades of war."
Going by these discussions, it is obvious that Nigeria has
the capacity to overcome the outbreak especially with the
international support from WHO and other allied organisation and
of course the political will from the Federal Government
(evidenced by the recent declaration of Ebola as a National
Emergency by the president). However, earlier statement by some
government officials during an Ebola briefing few days after the
outbreak that no Nigerian was infected with the virus was too
pre-mature and uncalled for. Unfortunately, despite all the
assurances (which is the normal thing to do during outbreaks), eight of
the primary contacts were infected.
Can Ebola outbreak occur in Sambisa Forest?
This is even more difficult to answer. Let’s
assume an inhabitant of Sambisa Forest happened to travel on
board the Monrovia-Lome and Lome-Lagos flight and the purported
passenger was seated next to the infected Liberian. Travelling
together to such a distance without contact with the bodily
fluid of the infected Liberian means a minimal risk of
transmission (the discoverer of the virus can happily sit next
to an infected person on a train). Therefore, chances of
transporting EVD to Sambisa Forest is really remote. But if such
a person was vomited or bled upon, defies security odds and
reached Sambisa Forest without being grounded by the disease
(considering the closure of Maiduguri airport, very long road
distance travel from Lagos to Maiduguri occasioned by multiple
road blocks), then that could be considered as a possibility.
Using the above analogy, EVD reaching Sambisa Forest through
human-to-human transmission is near impossible. An easier way to
achieve an outbreak is to consider a different route of
transmission. Since Sambisa is a forest with rich wildlife;
let’s assume that the specie of fruit bats are abundant and such
bats are infected with Ebola virus (don’t know how that
happens). An inhabitant of Sambisa Forest may decide to go out
to hunt for "bush meat" (which is unlikely because it may not be
considered Halal, but could not be ruled-out in a war situation)
and could accidentally get infected. Going by the second
analogy, the chances of transmission and outbreak (though very
rare) through the latter seems more feasible.
Assuming such an outbreak occurred, Will that be the solution
to the existing insurgency? Will the infection be contained at
the forest? How about its potential spread to other neighbouring
states surrounding Sambisa? The person praying for the outbreak
to occur in Sambisa Forest will definitely not be spared too! I
don’t want to think about the possibility of an outbreak in the
North-East on top of the current insecurity, hunger, political
instability, non-functioning health system, NMA strike,
psychological trauma, and so on.
No matter the level of distrust of current leadership that
exists, people shouldn’t go to the extent of inviting Ebola
virus to Sambisa Forest on top of our current situation.
Although Boko Haram is deadly, EVD outbreak is never a
solution to even the deadly Boko Haram.
"Could hot salt and water bath prevent the transmission of
EVD?", "Is it true that bitter kola nut could treat EVD?"
I think these are the greatest jokes I
have heard in years. To answer this, I will borrow a leaf from
the response given by a senior colleague, that eating the right
adrenal gland of a right handed pure bred chicken followed by
warm saline bath at midnight and 3 pieces of bitter kola nut is
a cure for EVD!
In another development, rumours had it that some health
workers tendered their resignations following the designation of
their hospitals as Ebola Reference Centres. Going by our
discussion, it was very unfortunate that those 8 contacts were
infected by the index patient. Being the first case, strict
precautionary measures were not followed and the index patient
was terribly sick (which resulted in higher transmission). I am
not immune to EVD, but I will gladly accept the responsibility
of heading an Ebola Response Team anywhere in the country!
To address the current challenges, the government should
intensify on raising awareness about EVD through radio jingles,
at motor parks and other public places. All 36 States and the
FCT should each form an Ebola Response Team. The NMA has already
set-up a committee to combat the spread of EVD in the country.
NMA should also liaise with the State Ministry of Health (SMOH),
WHO and Centre for Disease Control (CDC) at the State level. The
SMOH should also establish a Viral Haemorrhagic Fever
surveillance system. This system should not be just limited to
case identification, but also appropriate reporting to the SMOH
and the established Committee via the Monitoring and Evaluation
unit. Sick passengers should be screened and isolated at the
airports and other boarders.
A community based rapid awareness campaign through community
and religious leaders will be invaluable. Messages on
transmission and prevention should be delivered during Friday
sermons in mosque and Sunday church services.
At the hospitals, the SMOH should provide guidelines on EVD
prevention and strict adherence to such protocols should be
emphasized. The history of travel to Lagos State should also be
included in such protocols.
At individual level, people should wash their hands regularly
with soap and water, minimize or avoid handshakes, or use hand
sanitizers with at least 60% of alcohol.
Long term control measures include the
establishment/modifying existing law with regards to the
restriction of movement of patient identified/suspected as case.
I pray and hope the current effort at containing the outbreak
limits the existing infection to the confirmed cases, while the
sufferers defy all odds to survive the deadly disease.
Dr Bukar Abba Zarami.