An unprecedented outbreak of a deadly viral disease in Nigeria is showcasing the newfound might of the country’s public-health agency. Reforms put in place since a devastating Ebola epidemic struck West Africa in 2014 have transformed how Nigeria responds to infectious disease — including the current Lassa-virus outbreak.
Since 1 January, Lassa fever has sickened 365 people and killed 81, making it the country's largest recorded outbreak of the virus. But public-health experts say that the toll would be much worse had Nigeria not strengthened its Centre for Disease Control (NCDC) over the past few years. The agency, Nigeria’s first line of defence against disease outbreaks, has grown from roughly 30 physicians in 2011 to more than 130 epidemiologists, microbiologists and other specialists today. And it is deploying sophisticated data-management tools and building diagnostic labs to monitor the current outbreak and prepare for the future.
Later this year, the Nigerian government is expected to approve legislation that would make the NCDC an independent agency with its own budget and decision-making power.
“The Nigeria CDC has become stronger and faster,” says Kingsley Ukwaja, a physician at the Federal Teaching Hospital, Abakaliki in Ebonyi state — a hotspot for the current Lassa outbreak. “They came quickly with protective gear, and have sent epidemiologists to detect the source of the outbreak, and to locate the contacts of patients who may have the disease.”
Outbreaks of Lassa fever occur regularly in West Africa, where the virus is carried by rats. An infected person can spread Lassa to others via their blood, urine and other bodily fluids. Symptoms of the disease include fever — and in some cases, internal bleeding that can lead to death.
The 2014-2016 epidemic of Ebola, a virus that can cause similar deadly symptoms, accelerated the transformation of the Nigeria CDC. The agency launched in 2011 with medical staff that lacked epidemiological training and the authority to act fast to curb outbreaks, says NCDC chief executive Chikwe Ihekweazu, who works in Abuja.
Nigeria became part of the Ebola epidemic in July 2014, when a man infected with the virus entered the country in Lagos, Nigeria's largest city. Although only 19 people in the country ultimately became infected, many Nigerians felt their country had narrowly skirted disaster. The man in Lagos visited a renowned private clinic where he was diagnosed immediately. That might not have happened had he entered one of the general hospitals that serve much of Nigeria's population, and often lack equipment, doctors and nurses.
In addition, international health organizations were poised to assist Nigerian authorities because they had already been alerted to the escalating Ebola crisis in Liberia, Sierra Leone and Guinea.
“We were very lucky,” says Ihekweazu, who took the NCDC’s helm in 2016 and has changed how it operates. He convinced politicians to grant the agency more autonomy to provide top government officials with information on outbreaks, without concern about political ramifications. Ihekweazu also has improved how the NCDC interacts with the public. The agency uses television, radio and social media to educate people about public health; that includes combatting false information about how diseases such as Lassa spread.
“We are not where we want to be, but we are miles ahead of where we were,” Ihekweazu says.
Now, the agency’s public-health researchers are trying to understand why the current Lassa outbreak is so bad. The scientists are collecting samples of the virus to see whether it has become easier to transmit; they are also exploring other hypotheses, such as whether people are living in closer contact to the common African rats (Mastomys natalensis) that can carry the virus.
NCDC workers are also building long-term infrastructure and systems to battle this outbreak and those to come. The agency is coordinating its response at an emergency-operations centre that is modelled on “war rooms” deployed during polio outbreaks and the Ebola epidemic. Staff members are monitoring suspected and potential cases using software called SORMAS, which runs on tablet computers and smartphones. It was developed in response to the plodding pen-and-paper method used to track Ebola.
Yet the NCDC still faces some significant challenges. Many Nigerian states lack facilities to quickly diagnose diseases such as Lassa and Ebola, Ukwaja says, making it harder for the public-health agency to fight outbreaks from the start. In January, three of his colleagues at the hospital in Abakaliki died of Lassa fever. They were exposed to the virus during a four-day wait for test results from samples that had to be shipped out of the state for processing.
Now that wait has been cut to 24 hours, because the NCDC has built a laboratory in Ebonyi state that has the equipment needed to identify Lassa fever. The facility, which began operating last week, is the fourth such lab in Nigeria.
“Sometimes things need to get worse before they get better,” says Richard Garfield, an epidemiologist who advises the US Centers for Disease Control and Prevention. “Pretty much everything big we have done in epidemiology was in response to a problem we didn’t know how to handle.”
Nature 555, 421-422 (2018)