The grave shortcomings of Nigeria’s Ebola prevention strategy

In their BMJ editorial on airport screening for Ebola, Profs David Mabey and Stefan Flasche, said the adoption of the policy of “enhanced screening” gives a false sense of reassurance. This is an approach that the Nigerian government has embraced in allaying the concerns of citizens regarding the potential spread of the Ebola outbreak in DR Congo to Nigeria.

Early May, the World Health Organization (WHO) officially announced the reemergence of Ebola virus disease in DR Congo. Even though the organization and its partners sprung into immediate action and quickly deployed the Ebola vaccine, the disease was able to spread to more densely populated regions and alert was raised across Africa.

Nigeria’s Federal Executive Council sprung into action and gave a matching order to the federal ministry of health to beef up surveillance activities at all lands and airports borders to keep Nigerians safe from Ebola epidemic.

Describing the country’s Ebola response strategy, health minister, Prof Isaac Adewole, said Nigeria would be screening all travelers entering Nigeria, particularly passengers from DR Congo and neighboring countries.

“The Port Health services unit has been placed on red-alert and will heighten screening measures at ports of entry,” Adewole said.

Even though the specific details of the screening measures were not made public, Nigerians trusted the ministry was doing all it could to secure Nigeria’s legal and illegal borders against the entry of individuals infected with Ebola.

But on social media platforms, Nigerians expressed shock at the decision of the country’s sports ministry to host the national team and crew members from DR Congo that played a friendly football match with Nigeria’s Super Eagles particularly at a time when the country’s health workers were on strike.

Several Nigerians slammed the government’s decision to allow the match to hold, describing it as a depiction of the government’s incompetence.

A presidential aspirant on the platform of the All Progressives Grand Alliance (APGA), Yul Edochie, and a former media assistant to former President Goodluck Jonathan, Reno Omokri, were among those that called out the Nigerian government. In his statement, Omokri compared the current administration’s Ebola response to that of the former president’s.

These pressures compelled the health minister to reveal what the health ministry has done to prevent the spread of Ebola to Nigeria. According to a statement issued by the health ministry, Nigeria has responded to the Ebola outbreak by installing “monitoring/screening gadgets” at airports across the country.

Speaking on the Ebola screening exercise at the Abuja airport, Airport Manager, Sanni Mahmud, said that screening of passengers had not stopped at any time as it is an essential element of security checks put in place to safe-guard the country from diseases afflicting other countries.

According to the News Agency of Nigeria (NAN), inbound and outbound passengers at the Murtala Muhammed International Airport (MMIA) Lagos are being screened for Ebola with a similar device, a thermal and infrared scanning equipment.

At the airport, Port Health officials use camcorder-like scanners to ascertain the body temperature of travellers. In the toilets, the airport said it is also providing sanitisers and soaps to ensure passengers maintain a high level of hygiene.

“All the equipment put in place when Ebola was brought into Nigeria in 2014 by an American-Liberian, Patrick Sawyer, had been re-activated,” said regional manager, MMIA, Victoria Shinaba. She added that any passenger with traces of any communicable disease will be isolated and attended to.

Are scanners reliable?

Nigeria’s decision to rely on the scanners is a far-cry from practices across the world. The British Medical Journal in 2014 published a report on airport screening for Ebola which concluded that the policy of “enhanced screening” gives a false sense of reassurance.

“Our simple calculations show that an entrance screening policy will have no meaningful effect on the risk of importing Ebola,” the report stated.

During the SARS (severe acute respiratory syndrome) epidemic, Canada, introduced airport screening and the results are not encouraging. Thermal scanners were installed at six major airports. Of the 467 870 people screened, 95 were referred to a nurse for further assessment. None of them was confirmed to have a raised temperature. The cost of this unsuccessful programme was CA$ 17 million (£9 million; €12 million; $15 million).

The US experience

In the United States, Time also queried the effectiveness of airport screening for Ebola by citing a report published in the MMWR by officials at the U.S. Centers for Disease Control (CDC).

CDC’s policy during the 2014 outbreak was that anyone with a fever or other symptoms—or who reported having a high risk of being exposed to Ebola, such as having contact with Ebola patients—was not allowed to fly. According to the CDC report, none of those who were denied boarding were diagnosed with Ebola.

The interesting part was that two patients without symptoms when they left West Africa, Thomas Eric Duncan and Dr. Craig Spencer, eventually developed Ebola after arriving in the U.S.

According to the report, U.S.’s more stringent airport entry screening for all passengers arriving from the three affected countries did not prove successful either.

Passengers from the affected West African countries that visited US were required to fly into one of five airports: John F. Kennedy International Airport in New York, Newark Liberty International Airport in New Jersey, Washington-Dulles International Airport, Chicago O’Hare International Airport or Hartsfield-Jackson Atlanta International Airport.

They were also required to take their temperatures for 21 days, the incubation period for the Ebola virus, and report them to local health officials.

From Oct. 11 to Nov. 10, 1, 993 passengers were screened this way, and 4.3% were referred to the CDC for additional evaluation. Seven people had symptoms and were referred to proper medical personnel, but none developed Ebola.

“Using these processes to educate each traveler and then link the traveler to public health authorities for the duration of the incubation period is of critical importance to facilitate rapid detection of illness and implementation of appropriate public health control measures,” the authors of the report wrote.

The shortcomings of Nigeria’s strategy

What Nigeria currently has in place is a far-cry from what failed in USA since travelers entering Nigeria are only made to face scanners and only those with suspicious thermal scans are set aside for further screening.

The strategy does not have a way of knowing which traveler has come in contact with some infected with Ebola.

According to a CDC guideline on how to screening passengers at airports for Ebola, fever greater than 38.0 degrees Celsius or 100.4 degrees Fahrenheit, is just one of the symptoms that should be suspected. In addition, the guideline pointed out that passengers that are feeling feverish, experiencing severe headache, muscle pain, vomiting, diarrhea, stomach or abdominal pain, unexplained bleeding or bruising, should also be taken aside.

In other words, Nigeria is only targeting one out of ten categories of travelers. It could capture others by administering questionnaires as recommended by the CDC.

“Risk of Ebola exposures should be assessed by using a public health questionnaire during the primary screening process,” CDC urged.

It added that the following persons are posing the greatest risks:

• Caring for confirmed Ebola patients either at home or in a healthcare setting without the appropriate use of personal protective equipment (PPE)
• Engaging in the preparation of bodies or burial rites for those who have died from Ebola
• Working in a laboratory where Ebola samples are processed without using appropriate PPE or
  following biosafety precautions

In addition to not finding out all it can about travelers entering Nigeria, current strategy also fails to take care of the incubation period for the disease.

According to WHO, the time interval from infection with the virus to onset of symptoms is 2 to 21 days. This suggests that several individuals with the virus that have not started to present with symptoms can easily be missed by Nigeria’s Ebola control plan.

What the NCDC is doing

Bothered by Nigeria’s Ebola preparedness, the U.S. Department of State Bureau of Consular Affairs on May 31 revealed it has alerted the Nigeria Center for Disease Control (NCDC) Port Health Services to heighten measures at the country’s ports.

But the NCDC has only issued one official statement on Ebola disease since May.

On his Medium page however, the Director General of NCDC, Chikwe Ihekweazu, described the country’s preparedness for Ebola.

In the 1129 word-long piece on “How prepared is Nigeria for another Ebola outbreak?“, he only mentioned ‘port’ once and it was a reecho of the health minister’s assurance that “the national port health services have been put on high alert and screenings heightened at all points of entry”.

According to him, the NCDC is focusing more on preparedness which he said was the biggest lesson learnt from the 2014 outbreak that claimed 8 lives in Nigeria including that of Dr. Ameyo Stella Shade Adadevoh.

“Four years after, we have learnt that indeed national public health institutes have to be the focus of disease preparedness and response activities. They can and should provide leadership in disease surveillance and outbreak investigations, reference laboratory services, including specialist diagnostic services for rare organisms, and advise their governments on development and evaluation of public health interventions.

“This is the role NCDC now plays, creating a better health security infrastructure for Nigeria than what we had in 2014. With this, Nigeria is much safer and prepared than it has ever been,” Ikwehazu said.

Way forward

The BMJ editorial concluded that the best way to prevent Ebola from spreading is to stop it at the source and encouraged developed countries to help West African countries struggling to control the disease. But in Nigeria’s case, in addition to supporting DR Congo, it cannot afford to have porous borders.

Previous experiences in Nigeria and elsewhere affirmed that thermal screening is of limited use in preventing the spread Ebola at borders.

In addition to installing thermal screening machines, experts believe Nigeria also needs to introduce questionnaires to be filled by all travelers entering and leaving the country.

Since the fever symptom can be obscured by taking anti-fever drugs, Nigeria’s Port Health authorities also need introduce modalities to quickly screen for the remaining 9 symptoms mentioned by the CDC.

While the NCDC’s interest in ensuring better preparedness is commendable, the center also needs to play more proactive roles and assist port health authorities in detecting asymptomatic patients and in monitoring travelers from DR Congo and other suspicious regions for at least 21 days.

If airport screening has previously failed in Canada, Nigeria, and USA, experts believe Nigeria needs more than assurance and scanners to protect its citizens against a reemergence of Ebola.