Ebola diaries: Rapid response contains Nigeria's outbreak

Erika Garcia, epidemiologist

For the past 15 years, Erika Garcia has worked for WHO as an infectious disease control specialist. Erika has been deployed for a variety of disease outbreaks, including Middle East Respiratory Syndrome Coronavirus in Qatar and an unknown cause of illnesses and deaths in Panama that was later characterized as renal failure syndrome due to consumption of contaminated medications, among others.

Ebola awareness campaign, Nigeria
Ebola awareness campaign, Nigeria
WHO/A. Esiebo

"I arrived in Lagos, Nigeria, on 12 August 2014, 2 weeks after the first Ebola cases were reported in the country. I joined 3 other WHO colleagues who were already on the ground: a field coordinator, a clinician and a logistician. The first thing they told me was: 'We got a great set of people here. You really will be able to fit in, it is a big team but everybody’s spirit is that we are willing to work with each other.'

On my first day, I met a man and I wanted to shake his hands as a greeting. But he said, 'I am sorry, we cannot shake hands.' I felt a bit awkward we couldn’t do so, but they had a nice jovial way of getting around that through the Ebola elbow shake. And everybody was shaking my hand that way.

Data analysis, numbers and databases

The next morning, I headed to the office. We were about 15 WHO colleagues, 4 internationals and 11 national staff. The first thing they asked me was, 'Erika, what are you good at and what can you contribute?' I know that Nigeria has a lot of epidemiologists, because during previous outbreaks, I knew how capable they are. So I told them that I would be able to do analysis, working with numbers, projections, databases, etc. I am a mathematician, so I am good at that type of work, rather than being in the frontline and actively looking for Ebola cases.

I am glad I made that choice, because it made me really understand what was happening with the outbreak. It must have been my second week in Nigeria when I realized the weaknesses in the response operations. There were weak linkages between data and the people who were doing the contact tracing. There wasn’t anybody coordinating work between the 2 teams, to make sure that we were having the right information.

Dr Faisal, the national coordinator for the Ebola response, realized the same issues. Few days later, he really used the information that the data management team was generating to tell him where we were with the outbreak. Every evening we would have a one-hour meeting with him to discuss and see where we were. Dr Faisal really made it a point that epidemiology and data management have to be really well synchronized. He saw that I was bridging both and I ended up becoming that liaison between the two.

Ebola in Port Harcourt, the country's oil hub

I’d been about 2 weeks in Nigeria when we suddenly found out about a confirmed Ebola case in Port Harcourt. This was concerning, because Port Harcourt is West Africa's largest oil-producing hub. I was told to go there. When I reached Port Harcourt, we left immediately for the office. On my way, we suddenly saw 2 dead bodies on the side of the road. I was with a Nigerian infection control person and we both told the driver, 'Wait, stop, what’s going on?' The driver said, 'Nobody wants to touch dead bodies anymore because of Ebola.'

Erika Garcia, epidemiologist, WHO
Erika Garcia, epidemiologist, WHO

We reached the city centre and all I remember seeing were newspapers being sold with headlines: 'Ebola Ebola Ebola'. Everything was about Ebola. You turned on the radio – 'Ebola Ebola'. I felt like this was the beginning of a city that could be paralyzed.

In Port Harcourt, I was a lot more involved in contact tracing. One of the cases ended up generating about 350 contacts. One lady became sick after she shared a hospital room with an Ebola case. She thankfully didn’t infect any of her children, even though they had cleaned up her vomit.

But she had so many high-risk contacts. She had attended a church because she was sick. So they did a prayer session for her and she did a night vigil. She was even in a car when she vomited. She died 2 days later, after she was admitted to the Ebola treatment centre. So we had 350 people to follow and all these contact tracers from Port Harcourt were completely new to the job. But none of the contacts became positive. We can’t explain why.

Communities need to be on board

One morning, I saw the footage of a patient that fled an Ebola treatment centre in Kenema, Sierra Leone. He just walked out of the treatment centre. He didn’t want to be there and left, walking through the market. Some MSF colleagues were behind him and you can see that the community were really upset with this individual. I grabbed this footage and showed it to Dr Musa, the lead epidemiologist in Port Harcourt. I told him, this is what we don’t want to happen. We cannot have this outbreak get out of control like this. I think it was very clear in Faisal’s and Musa’s minds that the most important thing was for the Port Harcourt treatment centre to be viewed by the community as good. As soon as the communities feel like oh we don’t want to go there, we have lost the game.

One of the cases in Port Harcourt was treated at the MSF treatment centre. She survived, got discharged but was really upset. One of the contact tracers had come to visit her, to see how she was doing after being discharged and she started yelling and screaming at her neighbourhood. 'I am going to tell this whole neighbourhood not to come to the treatment centre, look at what they did to me, my whole house is ruined', she said. They had to burn her mattress and disinfect her house with chlorine, her TV got spoiled, her mobile phone was no longer with her, etc.

"I think no single person was the hero of this response, I think it was a team effort. The key to containing the outbreak in Nigeria was just really strong leadership, good coordination and having resources."

Erika Garcia, WHO epidemiologist, in Nigeria

So when Dr Faisal got to learn about this, he immediately went to her house and spoke with her. He said what do you need? So she explained her discontentment. You need a bed? We will give you a bed. Dr Faisal immediately realized that it is not only about curing the patient. There is a whole thing around the individual that needs to be reconstructed again. It is not just a mattress.

When he explained this to the whole operations team, many colleagues said 'Yes, but you can't do this for every individual.' But Faisal said 'Look, this is what we need to do. If the community is not going to be happy with the way we are managing this, they are not going to collaborate with us.'

Strong leadership, coordination and resources is the key to success

When I left Nigeria towards the last week of September, the outbreak wasn’t over yet, but under control and very well managed. In the end, we had 4 confirmed cases in Port Harcourt, the physician, his wife and sister, and the elder lady, who generated a lot of contacts. I think no single person was the hero of this response, I think it was a team effort. The key to containing the outbreak in Nigeria was just really strong leadership, good coordination and having resources.

Dr Faisal made everybody feel so important and that everything you did was the right thing. Because no matter what idea you had, you were encouraged to speak up.'‘We want to hear. No matter what your nationality is, what organization you come from, which agency, we are here to stop Ebola, and all those hidden agendas are out the door.' It was a combination of attitude and an incredible energy. People were tired, yes, but the energy was incredible. Everybody was very scared.

But it is not only leadership, it is also resources and good coordination. Put these 3 things together and you will get a good response."