Emerging and re-emerging diseases: Stopping the spread (2)

Lecture Delivered at the 2014 Health Week ceremony of the University of Lagos by Prof. Akin Osibogun, MBBS (Lagos); MPH(Columbia); FMCPH; FWACP; FRSPH(UK), Professor of Community Health, University of Lagos, & Consultant Public Health Physician/Epidemiologist, Lagos University Teaching Hospital (LUTH).

By July 23 2014, the physicians at First Consultant became suspicious that they might have a case of Ebola Virus Disease on their hands and immediately informed the Lagos State and Federal Health Authorities. A blood sample was sent to the Lagos University Teaching Hospital for testing and the result came back positive for Ebola Virus Disease. While all these were unfolding, officials of the ECOWAS and the Liberian Embassy were piling pressure on the management of First Consultant Hospital to release Mr Sawyer to go and present a paper at the meeting in Calabar. These officials chose to ignore the potential public health risk of a possible Ebola patient in a public gathering. It was in the middle of these unhealthy “diplomatic” pressures that Dr Ameyo Adadevoh who was the Senior Physician at First Consultant possibly got infected in trying to enforce the non-release of Mr Sawyer until State and Federal health officials arrived.

The singular action of refusing to release Mr Sawyer was largely contributory to our being able to immediately identify the source of the importation of the Ebola Virus Disease into Nigeria. For Dr Ameyo Adadevoh, the cost was ultimate as she eventually came down with the disease and lost her life in an attempt to ensure that the disease is not spread into the Nigerian population. Some other health workers from the First Consultant Hospital also lost their lives to this exposure. I should mention that Dr Adadevoh got her medical degree from the University of Lagos and we remain proud of her professional performance.

I think it was between 23rd and 24th July 2014 when I got a call from Dr Abdulsalam Nasidi, the National Director of the nascent Nigerian Centre for Disease Control, Abuja. He had previously retired as a Director and Epidemiologist at the Federal Ministry of Health and we had known each other for nearly twenty years.

I also got a call from the Lagos State Commissioner for Health, Dr Jide Idris whom I had known for some 40 years, since we both attended and finished at the same time from the College of Medicine, University of Lagos. The phones began ringing in all directions and I am not sure I can recollect clearly from whom I got the first call. All of us were stricken by both fear and a sense of urgency and we scheduled our brainstorming meetings at the Central Public Health Laboratory in Yaba. It was here we decided on the centre to be used as the Isolation Centre in Lagos instead of having diffused centres all over the place. The Infectious Diseases Hospital in Yaba is one of the Lagos State Government facilities and hitherto had been used essentially in the management of Tuberculosis and HIV patients. In view of this national emergency, the TB patients would have to be dislodged and the centre immediately established.

Dr Yewande Jinadu, the Medical Director of the Federal Medical Centre Ebute Metta, who herself is a Public Health Physician was unequivocal on the need to immediately convert the Infectious Diseases Hospital for the new purpose. The Honourable Commissioner accepted this responsibility and began to mobilise resources to achieve the objective. Although the facility was not initially in the best of shapes, with the backing of the State Governor, Mr Babatunde Fashola, the Commissioner for Health was able to get rapid improvements in the facility. The State Government later received financial support from the Federal Government.

It is important to note the collaboration between Federal and State agencies that in fact defined our ability to contain the Ebola Virus Disease. The Lagos University Teaching Hospital and the Federal Medical Centre are Federal Institutions acting under the Honourable Minister of Health. Federal Field Epidemiologists were deployed to Lagos to enhance the capabilities of the Emergency Operations Centre. An Incident Manager in the person of Dr Faisal Shuaib was deployed to Lagos from the National Centre for Disease Control in Abuja. The Lagos State Government was able to deploy ambulances for Contact tracing and also mobilise all Disease Notification Officers located in its Local Government Areas to participate in contact tracing and follow up.

Dr David, as he was fondly called, arrived from WHO to assist us in Case Management based on his previous experience in the management of cases in other countries. For the next ten days, it was difficult to find volunteers to participate in Case Management. On one occasion we gathered some twenty doctors and other health workers at LUTH and after a lengthy meeting encouraged them to volunteer for service in the control of this epidemic. We then agreed to go to the evolving Emergency Operations Centre as the Public Health Laboratory at Yaba would turn out to become. A bus was provided and by the time we got to Yaba, we could see only 8 people! Seven of the eight people were from the Department of Community Health while a Consultant Physician, Dr Amadi was also present. Dr Chima Ohuabunwa who had also arrived from the Centres for Disease Control Atlanta, was now invited to address the volunteer staff to see where we would be deploying them.

At this initial stage, I must confess there was a lot of fear and panic and most of the people present gave cogent reasons as to why they would be best suited in Contact Tracing rather than in Case Management. It became clear that getting Case Managers was work in progress. Here was a classical example of a conflict between the “duty to care” and the “right to life” of medical personnel. While medical personnel have a duty to care for patients, they also have a right to live and not being members of any armed force, I doubt if there is any law to compel them to see a patient that on contact may transmit a deadly disease to them.

Ebola claimed the lives of several health workers in Liberia and Sierra Leone and some health workers from the First Consultant Hospital where Mr Sawyer was treated were already infected with grim prospects.

Eventually we were able to get some doctors and nurses from LUTH including Dr Kunle Badmus, a full time Orthopaedic Surgeon who until recently headed the Accident & Emergency Department of LUTH to volunteer and receive appropriate training to participate in Case Management. Several of the Resident Doctors from Community Health Department participated actively in Contact Tracing with the Head of Department, Prof Bayo Onajole being appointed by the Honourable Minister of Health to Head the Communication and Mass Mobilisation Committee of the Emergency Operations Centre. Dr Oyin Oduyebo, Head of LUTH’s Department of Medical Microbiology headed the Infection Prevention and Control Committee while Prof J.D. Adeyemi of our Department of Psychiatry headed the Psychosocial Committee. The head of our Medical Social Services Department, Mrs Doherty was also in the Psychosocial committee together with Dr Umeh our Clinical Psychologist.

Prof Sunday Omilabu, the Hospital Virologist at LUTH provided leadership for the team responsible for testing and Ebola Disease confirmation. The Laboratory received samples from as far as Sokoto, Enugu and Port Harcourt and was the laboratory for the control of the Ebola outbreak. Cross-validation of laboratory result was on a few occasions done in collaboration with the Redeemer’s University Laboratory. This laboratory was the Reference Laboratory for our control of this particular outbreak. The staff were very professional in the handling of sample and wastes such that there was no viral escape. In fact, the hospital had to do an emergency procurement of a giant autoclave to be used in the laboratory to first treat all waste items before bringing them out carefully for incineration.

I have not mentioned the names of the young Resident Doctors who volunteered for Case Management in view of some unnecessary stigmatization that has been observed in relation to Ebola Virus Disease and its management. I hope that at some point in future, we as a people will recognize the heroism of all the fighters who worked silently to help us contain Ebola in Nigeria.

For the sake of posterity, let me mention that some of the staff who participated in the control effort never went home to their families for up to 4-6 weeks. They had to be quartered somewhere within the Lagos University Teaching Hospital. For some of them, that was the agreement they had with their spouses – to be sure that they never came back home with the virus. For another, it was a question of security granted that meetings at the Emergency Operations Centre at times finished late into the night and it would be safer to sleep within LUTH than to attempt to be going back home in some other parts of Lagos. It is on record that no single member of the Emergency Operations Centre Team contracted the Ebola Virus throughout our containment efforts.

With over 93% successful contact tracing and follow up, Ebola was contained in Lagos only for us to discover that there were Nigerian versions of Mr sawyer. One of the nurses at First Consultant Hospital who had been a primary contact of Mr Sawyer went off to Enugu and a special team had to be deployed to evacuate her back to Lagos. Fortunately after follow up, none of her contacts in Enugu came down with the disease. Another primary contact of Mr Sawyer who is a staff of the ECOWAS also went off to Port Harcourt and at one point switched off his phone to evade tracing. He resurfaced three days later in Lagos without symptoms and everybody thought there was no problem until a doctor died in Port Harcourt and the ECOWAS staff now came to confess that he had been to Port Harcourt to receive treatment from the dead doctor.

Obviously, he had infected the doctor with the virus and while he survived, the doctor not only died, but also infected his wife before dying. The doctor’s wife who herself is also a doctor was evacuated to Lagos for management and she survived and was discharged. Information that emerged later showed that the doctor who died in Port Harcourt probably knew he was treating the ECOWAS official for Ebola Virus Disease since it was claimed he made attempts to disinfect the Hotel room in which he treated the patient. Only God knows what could have motivated him to have done what he did.

Based on the experience gathered in Lagos, an Emergency Operation Centre was also quickly established in Port Harcourt and some of the experienced personnel deployed to go and strengthen the Port Harcourt team for maximum effectiveness. A total of some 220 were followed up in Port Harcourt and again the Ebola Virus disease was brought under control but not until a woman who was treated in the same hospital where the adventurous Port Harcourt doctor had rushed himself had died from the Ebola Disease. Overall, a total of 19 cases of Ebola Virus Disease were recorded in Nigeria – 5 died in Lagos including the Index Case (Mr Sawyer) while two died in Port Harcourt. Seven patients were successfully treated and discharged in Lagos. The Case Fatality Rate recorded for Nigeria was 36.8% compared to the 60-80% recorded elsewhere.

The above summary of our Ebola Control effort has been provided as a problem-based learning methodology which we can use in our preparedness and control of future epidemics. Before stopping on this particular topic, let me reiterate that we have won the battle for now but we must maintain surveillance so that we can finally win the war because the Ebola virus is a formidable foe.

Some Challenges faced from Emerging and Re-Emerging Infectious Diseases:
The agent in an emerging infectious disease is new and there may be no known specific treatment or cure
The disease might not have been characterized previously or the symptoms may be similar to those of some other diseases and the medical community may lack experience in identifying and treating
Because of the lack of experience in identifying and managing, health workers may be inadvertently exposed to infective agent
There may be paucity of resources for diagnosis, treatment and isolation.
Psychosocial fears and social stigmatization of patients, contacts, health workers and paranoia among members of the general public.
Pressure on health workers and conflict between “duty of care” and likely exposure to infectious agents.

Prevention and Control of Emerging and Re-Emerging Infectious Diseases
If we go back to what Girolamo Frascatoro said some 450 years ago and what we know about factors fuelling the emergence and re-emergence of diseases, we must accept that based on what we know today and the technology at our disposal, we can not say that there will be an end to the emergence and re-emergence of diseases. What we need to do is to take steps that will help us minimise and contain these diseases so that our civilisation and race is not destroyed.

Two major interrelated approaches will help us in the prevention and control of emerging and re-emerging diseases:

Reduction of the likely of occurrence of these diseases

A quick look at the factors fuelling the emergence of diseases will tell us what we need to do to reduce the emergence and re-emergence of diseases.

FACTOR EXAMPLES OF REQUIRED/SUGGESTED ACTIONS
1 Microbial Adaptation More appropriate use of anti-microbial agents to prevent the emergence of resistant strains
2 Human Susceptibility Promotion of healthy lifestyles and where available the use of vaccines to boost herd immunity
3 Climate and Weather Global cooperation to reduce global warming and adopt eco-friendly strategies
4 Changing Ecosystem Man’s activities at destroying some predators give room for population explosions among their preys and where these preys harbor microbes that are transmissible to man, there then occurs disease outbreaks in human population
5 Human Demographics and Behaviour Promotion of healthy lifestyles including healthy sexual and other practices
6 Economic Development and Land Use Conducting detailed analysis of the possible health impacts of massive deforestation programmes and implementing measures to mitigate those likely impacts.
7 Technology and Industry Conducting detailed analysis of the possible health impacts of newly deployed technology and implementing measures to mitigate those likely impacts.
8 International Travel and Commerce International collaboration to maintain surveillance and necessary containment strategies to limit importation of disease from affected to unaffected territories.
9 Breakdown of Public Health Infrastructure Strengthening Public Health Infrastructure to be better able to promote health and monitor for likely disease outbreaks as well as respond appropriately in a timely manner to perceived and real threats.
10 Poverty and Social Inequality Encourage governments to adopt more socially equitable measures to generally improve the living conditions of citizens e.g reducing the proportion of citizens living in slums where contact with vectors of disease is imminent.
11 War and Famine Reducing wars through credible alternative dispute resolution mechanisms and promoting inclusive and transparent governance
12 Political Will Encouraging governments to recognize and accept critical role in promoting public good by appropriate budgetary allocations to measures required
13 Intent to Harm Enhanced surveillance by both the health and other appropriate sectors to identify potential sources of threat

In the particular instance of the Ebola Virus Disease, it would appear that the major factors that fuelled its emergence and spread were changing ecosystems, economic development and land use and other activities that brought man into close contact with the natural reservoir of the virus which has been reported as Fruit Bats and some other animals. Once the disease broke out in Zaire and Sudan in 1976, the factor of international travel and commerce was set to get it to other parts of the world. Of course, weak health systems, poverty and social inequity combined with lack of political will would have ensured late recognition of the outbreak and poor containment. Just to mention that the outbreak in West Africa is from the Zaire strain of the virus and that strain is more virulent than the Sudan strain.

Stopping the spread of the diseases
To be able to stop the spread of any emerging or re-emerging disease, the following key tasks must be performed:
Surveillance
A virile disease reporting system is important in helping us maintain meaningful surveillance. Although we have been more fortunate than some of our African brothers inn that we have some disease reporting system in place we need to digitalise and update that system so that reporting can be real time. If Dr Adadevoh had merely completed a Disease Reporting Form and sent to the Local Government Health Department, it might have taken us up to a month for us to discover that we had an importation of EVD. But a few phone calls were able to ring an alarm in several quarters.

Now in these age of the internet, we can take our surveillance system to the next level and it should be possible for every health facility, public or private to report cases on a daily basis to a designated site. Appropriately trained personnel will man and monitor trends at these sites. Keeping and monitoring numbers will help us to know that a disease is emerging

Even in resource poor settings where sophisticated laboratories such as the one at Idi-Araba is not available, carefully designed syndromic reporting can be put in place. Strange or excess syndromes will then attract appropriate further action from a zonal or state centre. A review of the signs and symptoms presented by patient Sawyer made the First Consultant Hospital team to become suspicious that they could be having an EVD case on their hands and hence called for help.

Well-equipped functional laboratories with well trained staff are critical to quick confirmation of the diagnosis or at least of a classification of the diagnosis. The Laboratory at Idi-Araba was able to identify the virus in Mr Sawyer’s blood sample as belonging to the filovirus group and marrying that information to the patient’s signs and symptoms, a quick working diagnosis of EVD was made. This was good enough but we can upgrade to gene sequencing capabilities in which case we will be in a position to also say where the virus was coming from!

Our epidemiological investigation must also enable us establish various community and individual practices and behavior that may be facilitating the rapid spread of the disease e.g washing of dead bodies in an ebola outbreak . We must also look out for other ecological factors such as human habitation and overcrowding that may be facilitating spread.

Investigation and Early Control
Having confirmed the diagnosis in a disease outbreak, we must quickly establish who is affected, where and when. And in the case of an infectious disease such as Ebola, we also need to quickly establish those who have been in contact with cases. Early control requires that all contacts have to be placed under varying restrictions to stop further spread. Asymptomatic contacts can be restricted in their own homes since in the case of Ebola, infectivity is high only when the patient is symptomatic. Such contacts are requested to self-monitor and followed up periodically by designated health worker or community member. Once symptoms exists, the contact will then have to be taken to a designated facility for supportive treatment and isolation to minimize the risk of further spread. It is very important to put in place appropriate treatment and caring centres for patients affected by an outbreak. The absence of humane care will only result in cases going underground and the outbreak becoming uncontrollable

Implementation of Prevention Measures
Prevention measures will vary depending on the reservoir of infection, the route of transmission and host characteristics fuelling the outbreak.In the Nipah Virus Encephalitis outbreak in Malaysia in 1998 which caused 109 deaths, more than a million pigs were culled to bring the outbreak under control as pig was the amplifying host.

Whenever it is possible, the reservoir of infection has to be eliminated or brought to a level at which transmission is no longer a threat to man. Where microbicides are available to clear the pathogen in human population, this is also used and in some other cases prophylactic use of some microbicides can support a break in the chain in transmission. For diseases transmitted by rodents, deratisation and keeping rats away from human population has been adopted.

For the Ebola Virus Diseases transmitted from man to man through contact with body fluids, the strategy would be to eliminate contact with infected body fluids through the use of Personal Protective Equipment (PPE) particularly by health workers who have to manage such patients.

Prevention measures can only be effective when there is appropriate and adequate communication with members of the public, health workers themselves and the political leadership. Sustained and reinforced communication on prevention steps will help members of the community to protect themselves as well as break the chain of transmission. Where other rights have to be abridged, such as the right to free movement, members of the community have to be educated that this in the overall public interest. Political leadership must also be educated on the necessary steps to control the outbreak and prevent further spread and the resources required to achieve results.

Monitoring and Evaluation
Following the successful containment of an infectious disease outbreak, there is a need for continuos monitoring and checking data from all segments of the community to ensure that the disease is truly contained or detect any sign of resurgence. It is also important to review all activities carried out during the disease outbreak control efforts with a view to learning lessons for improved performance in any future outbreak.

CONCLUSION
The words of Girolamo Frascatoro still ring true today. Our best bet is to strengthen our public health systems, address the factors fuelling the emergence and re-emergence of disease and be in a state of perpetual preparedness because there will always emerge a new infectious agent either through genetic reassortment, or genetic recombination etc or simply through a more conducive climatic and environmental change.

Thank you.
• Osibogun is also the immediate past Chief Medical Director of LUTH.
Email: akinosibogun@yahoo.co.uk