Ebola: West Africa and the medical game plan

When a disease outbreak occurs, doctors, nurses, aid workers and epidemiologists from international organisations fly in to help. The outbreak of Ebola Virus Disease (EVD) in West Africa has elicited global concern, including Nigeria as it has continued to evolve with many barriers standing in the way of rapid containment.

With no immediate end in sight, the sub-region, with a population of over 350 million people, is witnessing the most challenging outbreak since the disease first appeared in 1976 in two simultaneous outbreaks in Nzara, Sudan and Yambuku in Democratic Republic of Congo (DRC).

The most severely affected countries- Guinea, Liberia, and Sierra Leone- have only recently returned to political stability following years of conflict, which left health systems largely destroyed or severely disabled.

More worrisome is the fact that Ebola hemorrhagic fever is one of the deadliest viruses known to mankind, killing around two-thirds of those who contract the disease. While the most severe cases of the illness have a 90-percent fatality rate, there is no cure or specific treatment, although there are experimental vaccines such as ZMapp, VSV-EBOV, Nanosilver provided by a Nigerian in the Diaspora, among others.

Between August 10 and 11, 2014, a total of 128 new cases of EEVD (laboratory-confirmed, probable, and suspect cases) as well as 56 deaths were reported from Guinea, Liberia, Nigeria, and Sierra Leone, according to the World Health Organisation (WHO).

Contact tracing in Guinea, Nigeria, and Sierra Leone has resulted in a range between 94 percent and 98 percent of contacts of EVD cases being identified and followed-up. This comes as 1975 cases and 1069 deaths have been recorded in the four affected countries since the outbreak began December 2013, WHO Ebola update as at August 11, 2014 showed.

Fear has led to a very high level of vigilance and clinical suspicion worldwide, as seen in the number of false alarms everywhere. Such a high level of alert, experts believe, increases the likelihood that any imported case will be quickly detected and properly managed, limiting onward transmission.

This pattern was clearly seen during the 2003 SARS outbreak. Of the total number of cases during that outbreak, 98 percent occurred in the four countries affected prior to the WHO global alert issued on March 15. The high level of vigilance and preparedness that followed that alert helped additional 26 outbreak sites with imported cases to prevent onward transmission or hold it to just a handful of cases.

Presidents of hardest-hit countries have made outbreak containment a top national priority. While several extraordinary measures have been introduced within last week, it is too early to assess its impact, the WHO stated.

The Nigerian situation

As at the time this report was being filed in, Nigeria recorded 10 confirmed cases of EVD since the disease came into the country through the late Patrick Sawyer, a Liberian-American on July 20, 2014. Out of these, four have died while eight are currently under treatment, BD SUNDAY findings gathered. The fourth death recorded was a Nigerian nurse, Justina Egelonu, who participated in initial management of the index case at First Consultants Hospital in Lagos.

The total number of persons under surveillance in Lagos is 169 with those under surveillance for all secondary contacts. Also, all primary contacts have completed the 21-day incubation period and have been delisted to resume their normal lives.

Onyebuchi Chukwu, minister of Health, said that Enugu State now had six persons under surveillance as 15 after complete evaluation were found not to have had contact with the nurse, a primary contact of the index case who became symptomatic and tested positive.

The minister noted that the nurse who had been placed under surveillance in Lagos disobeyed the Incidence Management Committee and travelled to Enugu.

“At the time she made the trip, she was yet to show any symptom and did not infect anyone on her way as transmission of the disease is only possible when a carrier of the virus becomes ill. However, she has since been brought back to Lagos. Before the return journey, she had become symptomatic and had to be conveyed to Lagos with her spouse in special ambulances.

“The husband is not symptomatic neither is he positive for Ebola Virus Disease but has been quarantined given the intimate contact with her while in Enugu. It is therefore important to emphasise that there is no Ebola Virus Disease in Enugu. All cases are still confined to Lagos State. Reports of EVD in Abia, Imo, Akwa Ibom and Anambra States as well as the Federal Capital Territory, Abuja have all been investigated and none of them was found to be Ebola Virus positive,” the minister explained.

An emergency National Council on Health (NCH) meeting, the highest meeting comprising ministers of health, 36 state commissioners and other stakeholders in the sector was convened in Abuja last week to review the state of preparedness to contain the outbreak of EVD and actions to be taken in the country. President Goodluck Jonathan also convened a meeting of 36 state governors and minister of the FCTA, commissioners for health and secretary of health, FCTA as measures to contain the virus nationally.

Laboratories where specimen could be taken for laboratory analysis include NCDC Laboratory at LUTH, Idi-Araba Lagos, NCDC Laboratory, Abuja, Redeemer’s University Laboratory, Lagos-Shagamu Expressway and UCH Laboratory, Ibadan.

In-country Ebola response

Besides Federal Government’s N1.9 billion Ebola intervention plan announced by President Goodluck Jonathan, the country’s effort to halt the spread of the deadly contagious received the support of businessman philanthropist, Aliko Dangote, with the announcement of N152, 956, 250.00 from Dangote Foundation for the establishment of a National Ebola Emergency Operations Centre (EOC) at Yaba, Lagos.

The EOC is a key part of Nigeria’s response to the outbreak of Ebola on its shores. Headed by Faisal Shuaib, a US-trained public health expert with extensive international experience, the centre serves as the engine room of national response, providing coordinating mechanism for prevention, surveillance, patient care, tracking, data analysis and containment of the spread of the virus. 

It also facilitates coordination of partners, serves as a platform to link to the medical community across the country and also internationally, especially with countries also battling the virus in West Africa.

Aliko Dangote said that this is a period of national health emergency and government’s comprehensive containment strategy requires the support of all Nigerians to succeed.

“We have therefore decided to lend our support to the effort. The Ebola EOC is an important innovation that will strengthen our health system, even long after this particular health crisis has abated. We encourage all well-meaning Nigerians to support government as the country rallies to combat the Ebola virus. Our support is in line with our Foundation’s goal to improve the wellbeing of all Nigerians,” Dangote stated.

Medical game plan

Over the past decades, research efforts have been invested into developing drugs and vaccines for Ebola virus disease. Some of these have shown promising results in the laboratory, but they have not yet been evaluated for safety and efficacy in human beings. The large number of people affected by the 2014 West Africa outbreak, and high case-fatality rate, prompted calls to use investigational medical interventions to try to save the lives of patients and to curb the epidemic.

On Monday last week (August 11, 2014), WHO convened a consultation to consider and assess ethical implications for clinical decision-making of potential use of unregistered interventions. Provided certain conditions are met, the panel reached consensus that it is ethical to offer unproven interventions with as yet unknown efficacy and adverse effects, as potential treatment or prevention.

There was unanimous agreement that there is a moral duty to also evaluate these interventions (for treatment or prevention) in the best possible clinical trials under the circumstances in order to definitively prove their safety and efficacy or provide evidence to stop their utilization.

Research and development (R&D) on viruses like Ebola usually comes from sources interested in bio-terrorism. While investment funds for R & D focused on drugs to be used in treating such diseases as malaria, sickle cell, and Ebola are not as financially rewarding to a profit-driven pharmaceutical industry.

Ben Okelana, a US-based Nigerian physician, said that there is a possibility that bringing this caveat to the attention of pharmaceutical industry would spur increased private funding. While a vaccine against Respiratory Syncytial Virus (RSV), a very common cause of morbidity and mortality in children five years and younger, would be worth hundreds of millions of dollars and could confer immunity against Ebola as an alternate benefit.

According to Okelana “There is a critical role for African countries in the fight against Ebola. First, they must push the point that African lives are worth saving. Information about the use of survivor plasma, and active collection and stocking by primarily African governments, will save many African lives. With foreign help, expertise, and global compassion, the process would be cheaper, but not as lucrative as tax-exempt synthetic drug donations.

“Rather than clamour and beg the US to release the drug on orphan drug status, a method that bypasses full phase and human Federal Drug Administration (FDA) testing protocols in pivotal drugs, a country like Nigeria should champion the more rudimentary but equally efficacious use of survivor antisera. For cultural and other reasons, including issues of security, the use of African survivor plasma in the West is impractical and subconsciously anathema compared to a synthetic product derived from tobacco plants, as is ZMapp. Beyond investing in readily available human antisera, West African countries should immediately adopt protocols for epidemiological control and containment.”

Alexander Chiejina