Nigeria has not recorded a case, but the country is being urged to prepare laboratories, isolation facilities and border systems as the outbreak in the Democratic Republic of the Congo grows.
The most important time to prepare for Ebola is before the first patient arrives.
That warning has taken on renewed urgency for Nigeria after the World Health Organization issued updated recommendations to countries as the Bundibugyo Ebola outbreak in the Democratic Republic of the Congo entered its fourth month.
More than 5,200 cases have now been recorded in the DRC, making the outbreak the country’s fastest-growing. About 90 confirmed cases were reported each day during its first three months, while the virus has spread across six provinces.
Nigeria has not recorded a case linked to the outbreak. However, the country’s busy international airports, seaports, regional travel connections and porous land borders mean preparedness cannot wait for the detection of an infected traveller.
Following the second meeting of its International Health Regulations Emergency Committee, WHO issued new temporary recommendations on August 24.
The agency assessed the public health risk in the DRC as “very high” and the risk in nine neighbouring countries as “high”. Other countries, including Nigeria, fall within WHO’s low-risk category.
But low risk does not mean no risk.
For countries outside the immediate outbreak zone, WHO wants authorities to be able to detect, assess and manage travellers arriving with unexplained fever. Countries should identify laboratories capable of testing for Bundibugyo virus and isolation facilities where suspected patients can be assessed and treated safely.
Health authorities should also provide travellers arriving from affected areas with information about what to do if they develop symptoms within 21 days, the maximum incubation period for Ebola.
WHO also wants countries to prepare for the evacuation or repatriation of nationals, including health workers, who may be exposed while supporting the response in the DRC.
Nigeria has already assessed its risk as high
WHO’s international classification differs from a national assessment conducted by the Nigeria Centre for Disease Control and Prevention.
In May, the NCDC assessed the risk of the disease being imported into Nigeria as high. It cited international travel, regional population movements, major airports and seaports, informal border crossings and trade routes.
The two assessments measure the risk from different perspectives. WHO’s classification compares countries according to their proximity and epidemiological links to active transmission, while NCDC’s assessment considers Nigeria’s own vulnerabilities and possible routes of importation.
NCDC subsequently activated its national Emergency Operations Centre in alert mode and asked all 36 states and the Federal Capital Territory to strengthen their preparedness.
It placed Lagos, the FCT, Rivers, Kano, Enugu, Borno, Akwa Ibom, Cross River, Taraba and Adamawa in its highest preparedness tier because of their airports, seaports, borders or major travel and trade routes.
Ogun, Nasarawa, Kaduna, Plateau, Kogi, Niger, Jigawa, Katsina, Bauchi, Ebonyi, Abia and Bayelsa were classified as moderate-risk states, while the remaining states were asked to maintain baseline preparedness.
Among the actions requested from states were the identification of at least one functional isolation facility, preparation of safe referral pathways and ambulances, training of frontline workers, availability of personal protective equipment and stronger surveillance at transport hubs and points of entry.
The NCDC also asked public and private health facilities to ensure that suspected patients can be separated safely and reported immediately.
A difficult virus to detect early
One of Nigeria’s biggest challenges is that the early symptoms of Bundibugyo Ebola can resemble illnesses commonly treated in the country.
Initial symptoms may include fever, fatigue, headache, muscle pain, vomiting, diarrhoea, abdominal pain and sore throat. These can be mistaken for malaria, typhoid fever, Lassa fever or other infections.
Bleeding does not occur in every patient and may appear only after the disease has progressed. NCDC has therefore warned health workers not to wait for unexplained bleeding before considering Ebola in someone with compatible symptoms and a relevant travel or exposure history.
The virus is not airborne. It spreads through direct contact with the blood or other body fluids of an infected person, the body of someone who has died from the disease, contaminated materials or infected animals.
The Bundibugyo virus also presents a different medical challenge from the Zaire Ebola virus that caused the 2014 West African epidemic. There is currently no approved vaccine or targeted treatment specifically shown to work against Bundibugyo virus.
The international vaccine stockpile has allocated 70,000 doses of the Ervebo vaccine to the DRC. The vaccine is licensed against Zaire Ebola, and it is not yet known whether it can protect humans against Bundibugyo virus.
Of the allocated doses, 20,000 will be used in a Phase 3 clinical trial, while 50,000 are intended for frontline and health workers. Laboratory and animal studies suggest the vaccine could offer some protection, but WHO says the outbreak cannot be controlled by medical products alone.
Early detection, rapid isolation, contact tracing, infection prevention, supportive treatment and safe burials remain central to the response.
WHO rejects blanket travel bans
Despite the continuing spread, WHO is not recommending the suspension of flights or the denial of entry to travellers coming from the DRC.
Instead, the agency is asking countries to use targeted health measures, including traveller information, prompt assessment of unexplained fever and international contact tracing when a suspected case is detected during a journey.
The approach is intended to reduce the risk of unnecessary disruption to travel and trade while ensuring that countries can respond quickly to an imported case.
In the DRC, the situation remains severe. WHO said deaths occurring outside Ebola treatment centres accounted for around 60 per cent of the 260 weekly fatalities recorded over the previous six weeks. This suggests that many patients are still being detected late or are unable or unwilling to reach treatment facilities.
Conflict, population displacement, attacks on health facilities and community distrust have further complicated the response.
“The choices we make now will determine how quickly we can bring this outbreak under control, protect and save lives,” said Dr Mohamed Janabi, WHO Regional Director for Africa.
For Nigeria, the immediate task is not to close borders or create panic. It is to ensure that the first possible case is recognised early, health workers are protected and the systems required to prevent further transmission are already functioning.
As NCDC Director-General Dr Jide Idris warned when the agency issued its preparedness advisory: “The window for preparedness is before the first suspected case is reported.”