Boston Pathologist Hears From Colleagues: How Nigeria Prepares For Ebola

The Ebola outbreak in Western Africa has now claimed more than 1,000 lives. Here, Dr. Michael Misialek, associate chair of pathology at Newton-Wellesley Hospital and assistant clinical professor of anatomic and clinical pathology at Tufts University School of Medicine, shares what he's hearing from his Nigerian pathology colleagues.

By Dr. Michael Misialek
Guest contributor

As I sat in the meeting on Monday, helping plan our hospital's response to a hypothetical suspected Ebola case, it seemed surreal.

Just a few days previously, I bet most Americans would have had trouble finding Liberia, Sierra Leone or Guinea on a map, and Ebola was most certainly not a household name. What a difference a few days can make.

Could Ebola come to Boston? It  could, theoretically. Many other local hospitals are having similar meetings to plan for that contingency. The World Health Organization recently stated that the Ebola outbreak is moving faster than it can control, and thus labeled it an international health emergency. The countries of Liberia, Sierra Leone and Guinea have been hardest hit. Nigeria recently reported two deaths with 10 confirmed cases.

When asked if they are ready, Dr. Ogunbiyi says, 'No, there is work to be done.'

Nigeria, the most populous country in Africa, is understandably worried. To find out how it is preparing itself and use some of that knowledge for our own preparations, I recently spoke with two colleagues there: Dr. Yawale Iliyasu, an attending pathologist at Ahmadu Bello University in Zaria, Nigeria, and president of the West African Division of the International Academy of Pathologists; and Dr. J.O. Ogunbiyi, a pathologist at the University College Hospital in Ibadan, Nigeria, and former president of the same division.

As pathologists trained in the study of disease, we may often be the first to recognize and report on new and emerging illnesses.

Laboratory testing is crucial in identifying and tracking disease among individuals and the community. The specimens may also be used in research to help develop therapies and cures — exactly what we are seeing unfold with Ebola.

And though Nigeria has had relatively few cases, the prospect of Ebola's spread to Nigeria, with its densely populated cities, is especially concerning. Zaria is a city of about a half million people, home to the largest university in sub-Saharan Africa. Ibadan is the third largest city in Nigeria, with a population of almost 3 million. It is just 75 miles north of Lagos, the site of Nigeria’s Ebola cases.

Two cities, thousands of miles from Boston, yet closer than one might think. In today’s world, globalization has brought everyone closer. We are all neighbors. What I learned from my colleagues:

The first Ebola-related death was Patrick Sawyer, a Liberian-American diplomat, who collapsed at the airport in Lagos, Nigeria, after traveling from Liberia. He later died of the virus, as did a nurse taking care of him. The hospital that treated him has been shut down and is undergoing decontamination. All hospital staff who were in contact with him have been placed on a mandatory 21-day quarantine. The government has tracked down 177 known contacts and placed them under quarantine. Recently, the president of Nigeria declared a national state of emergency and approved $11.7 million to battle the disease.

Nigerian hospitals have been mobilizing, with extensive contingency plans in place. The Nigerian Federal Ministry of Health is coordinating efforts to inform and protect the public. Both Dr. Iliyasu and Dr. Ogunbiyi report undergoing planning and preparation of what to do if a suspect case arrives. Interestingly, the preparations are very similar to what we are doing here in the Boston area. They confront the same questions we do: How might a patient present to the hospital? Do they fit the definition for a close contact? Where should they be isolated? For how long? What lab testing should be done, and how?

When asked if they are ready, Dr. Ogunbiyi says, “No, there is work to be done.” For instance, there needs to be better and more widespread distribution of basic equipment: personal protective equipment, suits, masks and more.

Both Drs. Iliyasu and Ogunbiyi tell me that there are isolation centers set up in areas throughout the country but these need to be expanded. A current strike in the health-care sector is complicating plans somewhat. Fortunately, there have been no Ebola cases reported beyond Lagos.

When I ask him about the atmosphere in the country, Dr. Iliyasu says there is no panic or fear currently. He tells me that having endured years of war and terror by Boko Haram, Nigerians are by nature a resilient people.

West Africa's lack of pathologists, who oversee lab testing, is definitely impacting the outbreak across the region. According to Dr. Iliyasu, there are only 200 pathologists in the entire country. “Funding and training programs are grossly inadequate," he says.

Dr. Iliyasu adds: “There are no active pathologists in Liberia, it is being covered by our members from Ghana. There is only one active pathologist in Sierra Leone."

To put things in perspective, there are 300-plus pathologists in Massachusetts.

According to Dr. Ogunbiyi, "There has been no coordinated effort to engage pathologists properly. In one or two hospitals the directors have talked about cremation, but without facilities to carry these out, they're hoping to rely on private Asian communities with setups to do these. What we are doing is educating the public on the source of infection, symptoms and prevention with a lot of reference to WHO and CDC resources.”

Centralized Ebola testing is occurring in two or three virology labs in the country, he says. Specimens do not come in from other countries.

Infected patients pose a significant risk to health care workers. More doctors and nurses have been stricken than during any previous Ebola outbreak. Pathologists and laboratory staff are at risk from handling specimens that come to the laboratory. Dr. Iliyasu stresses the importance of “universal precautions, including following strict infection control measures. Also, safe burial practices of the deceased must be adhered to.”

When asked what's needed to help the fight against Ebola on the ground, Dr. Ogunbiyi mentions basic supplies, personal protective equipment, suits that are cooler in the heat, more training in infection control measures and more crematoriums.

Dr. Iliyasu says, “I suspect the outbreak will worsen before getting better. However, a widespread epidemic is less likely, since disease is only spread by direct contact with secretions of an infected individual, not airborne. Transmission is only possible once a patient is symptomatic. Since the virus produces symptoms relatively quickly, it is easy to identify and quarantine those infected. Dead bodies must be cremated.”

Both admit there is a “lot of uncertainty about what will happen in Nigeria. People should remain vigilant and monitor the news.” The crisis has brought to light issues which need urgent attention; among a great many others, the region needs more pathologists.

Dr. Iliyasu and Ogunbiyi believe that the outbreak can be contained. If that is the case, Nigeria, will have much to teach the rest of the word about emerging pathogens and their containment.