Thought Leadership

SimEx: Fine-tuning Nigeria’s response to potential disease outbreaks

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Editor’s Note: This week in Abuja the Federal Ministry of Health (FMOH) alongside the World Health Organisation (WHO), the Nigeria Centre for Disease Control (NCDC) and the National Primary Health Care Development Agency (NPHCDA), launched the EYE Strategy to eliminate Yellow Fever, with Dr. Tedros Adhanom Ghebreyesus, Director General of WHO, present. A few weeks ago in Lagos, the West Africa Health Organisation (WAHO), supported by the NCDC and other partners, carried out the first ever Yellow Fever full scale simulated exercise in Nigeria, and probably the first ever infectious disease outbreak simulated exercise in West Africa, to test the country & the region’s disease response and notification system, and observe where potential gaps might be. The Nigeria Health Watch team attended the exercise and joined a team that went to the Nigerian-Benin border to watch how health officials would respond if someone tried to cross the border with symptoms of yellow fever. 

The Seme border between Nigeria and Republic of Benin is probably one of the most popular land borders in Nigeria. The level of trade and enterprise at this point of entry makes it one of the most commercially busy checkpoints in Western Africa. An unceasing sea of pedestrians go across the border in both directions, with officers in uniform & plain clothes occasionally stopping passers-by to question them for their documents. Goods- consumables, cars and containers – are ferried through the border in quick succession after being cleared by an army of well-fed border officials as well as a group commonly called “agberos” – local touts who hustle at the border. To successfully go through the Nigerian end of the Seme border, you would have to go past a minimum of 7 checkpoints; all of which require a little bit of ‘legal tender’ before you can continue your trip.

Today we arrive at the border with a mixed team of observers, to see what happens when someone tries to cross into Nigeria with an illness, as part of the Yellow Fever Simulation Exercise that was organized by the West Africa Health Organisation (WAHO), with support from the Nigeria Centre for Disease Control (NCDC), Africa Centre for Disease Control (Africa CDC) and other partners. An actor, Tuoyo, has been inserted at the border, to try and make his way into Nigeria from Benin, while observers and evaluators are watching closely, from a safe distance, taking note of every action.

When Tuoyo, the SimEx actor, collapsed, he was surrounded by a crowd of health officers. Photo credit: Nigeria Health Watch

We are told that, save for a few easily managed road accidents, the Seme Land Border rarely experiences medical emergencies. Therefore, the sight of Tuoyo collapsing under the relentless heat of the March afternoon sun disrupted activities at the border checkpoint. He was immediately given the customary treatment. The crowd surrounded him, raucous voices yelling out different suggestions of resuscitation techniques to be administered, with everybody jostling to see but doing nothing to help. Tuoyo then showed signs of vomiting and this sent the border officials running to make phone calls to their superiors and to the closest ambulance service they could get.

A simulation exercise is an activity that places participants in a made-up situation requiring them to function in the capacity expected of them in a real event. It is conducted to promote preparedness and evaluate an organization’s ability to respond to situations by testing policies, standard operating procedures, and personnel training.  Tuoyo’s part in the exercise involved him mimicking Yellow Fever symptoms enough to convince border health officers that this situation was worthy of notifying the appropriate authorities at once, thereby activating the next stage of emergency response and disease notification.

Yellow fever is an acute viral hemorrhagic disease transmitted by infected mosquitoes. The “yellow” in the name refers to the jaundice that affects some patients. Symptoms include fever, headache, jaundice, muscle pain, nausea, vomiting and fatigue. The virus is endemic in tropical areas of Africa and Central and South America. Large epidemics of yellow fever occur when infected people introduce the virus into heavily populated areas with high mosquito density and where most people have little or no immunity due to lack of vaccination. In these conditions, infected mosquitoes of the Aedes aegypti specie transmit the virus from person to person.

Evaluators and observers observing the actions of the health officers from a distance. Photo credit: Nigeria Health Watch

Accelerated urbanization, deforestation, and population movement in and out of cities and across porous borders – combined with high population density, low population immunity, and limited mosquito control resources — puts Nigeria at imminent risk for widespread and deadly yellow fever outbreaks, especially in urban areas. It was against this backdrop that the simulation exercise was carried out in 10 locations in Lagos State.

The simulation exercise started with an opening ceremony at the Radisson Blu Hotel in Ikeja, Lagos State on March 12th, 2018. In attendance were representatives from the World Health Organisation (WHO), Africa Centres for Disease Control and Prevention (Africa CDC), Centres for Disease Control and Prevention (CDC), Preparedness and Response (P&R), GIZUnited States Agency for International Development (USAID),and Economic Community of West African States (ECOWAS). The participants were greeted with goodwill messages from WHO, World Bank and West Africa Health Organisation (WAHO).

This was followed by an address from Dr. Chikwe Ihekweazu, CEO, Nigeria Centre for Disease Control. He explained that there was an ongoing outbreak of Yellow fever in Angola & Brazil which suggests that we should be on the alert, especially as Nigeria has an extremely low vaccination coverage. He emphasised that the level of preparedness has to be ascertained and tested especially to promote efficient collaboration amongst various players. He also said that in case of an outbreak, response should be in a “command and control” manner. “Conducting a SIMEX in Lagos presents us with the biggest opportunity and the biggest risk,” Ihekweazu said, adding that, “Only states that have experienced big outbreaks like Ebola can appreciate this exercise.”

Panelists at the Yellow Fever SimeEx spoke about the impact that the exercise would have across the ECOWAS region. Photo credit: Nigeria Health Watch

Immediately after the opening ceremony was a press briefing which had a panel consisting of Dr Simon Antara (AFENET), Dr. Carlos Brito of WAHO, Professor Babatunde Salako, Representative of the Minister for Health and CEO of the Nigerian Institute for Medical Research, Professor Stanley Okolo, Director General, WAHO, Dr. Jide Idris, Lagos State Commissioner for Health, Dr. Chikwe Ihekweazu, and Dr. Mary Stevens, Regional Coordinator, WHO Africa. The panelists spoke about the impact this exercise would have across the ECOWAS region.

Dr. Okolo explained that, “This exercise will enable us identify our strengths & weaknesses, as well as gaps to be filled to strengthen our health security system. WAHO remains fully supportive in strengthening member countries’ capacities.” Lagos Commissioner for Health Dr. Jide Idris mentioned that funding the health sector has to be increased because, “If we do not prepare for disease outbreaks, then we have a failed system. This Yellow Fever simulation exercise is therefore a very important activity.”

For the exercise, participants were split into 10 groups, each comprising evaluators, observers and actors, for the 10 selected sites of the simulation exercise. The sites ranged from the Lagos University Teaching Hospital (LUTH), to private clinics in Shomolu LGA, from the Murtala Mohammed International Airport to the Seme Land Border.

Health officers seen wearing face masks and gloves at the Seme Border. Photo credit: Nigeria Health Watch

At the Seme Border, health officers were seen putting on latex gloves and face masks while going about their activities; with some also washing their hands after coming in contact with the casualty. A secondary screening facility where cases like Tuoyo’s could be treated was also available. One noticeable shortcoming was the absence of an ambulance at the border. Emeka Chukwuemeka, an observer from Pro-health International, added that, the secondary screening room was a recent development as there was none available two years ago.“In all, the simulation exercise was able to achieve its objective” Chukwuemeka said, “… as opposed to the table-top exercises that just address theoretical assertions, this exercise has been more revealing.” The Seme-Border simulation ended with Tuoyo being taken to the General Hospital, Badagry, and temporarily suspected of having Yellow Fever.

During the simulation exercise, observers and evaluators identified strong points, lapses, challenges and opportunities that face the first line responders for early detection and quick communication of communicable diseases. Dr. Bathondoli Kabali from the WHO Afro Region, noted that, “All the agents appeared already informed and briefed about the simulation exercise and prepared accordingly with Public Health Emergency Contingency Plan (PHECP) copies in hands.”

This pre-knowledge had some effect on the SimEx. For instance, the observers and evaluators were easily identified at some of the sites of the SimEx, thereby eliciting actions of thorough & proper behaviour, such as checking of body temperatures using infrared thermometers. This, they didn’t do to thousands of passers-by going through the border but focused on just the observers. Also, some of the observed agents possibly exaggerated their services by going beyond what they would usually do or neglected certain routines because they knew that it is only a simulation.

Still, Dr. Ngibo Mubeta Fernandes from the Ministry of Health in Cape Verde, an observer, said, “Nigeria has to be congratulated for taking on a big challenge of putting together such a crucial and challenging exercise…. especially in a region where there is a consistent occurrence of disease outbreaks”. She further stated that the information gotten from this exercise would be “extremely helpful” in other countries in West Africa, especially in evaluating their preparedness towards checkmating public health events that could put their states at risk of an epidemic. Simon Bell, the lead evaluator from WHO, said to the SimEx Coordinators, “Really quite impressive what you have chosen to do here, and the ambition you have displayed. You should be quite pleased at what you have been able to do in this exercise.”

Evaluators and observers at the Seme border, during the debriefing of health officers. Photo credit: Nigeria Health Watch

In addition, Mrs Tomisin Tawose, the Lagos State Business Manager for InStrat Global Health Solutions (InStrat GHS), pointed out that the exercise was a good platform to aggregate the ecosystem of Public Health, to assess Nigeria’s emergency preparedness & response, in the event of a potential outbreak. InStrat GHS was a member of the Technical Working Group for this exercise, possibly because of its extensive work in data management and communication in the area of disease notification. InStrat GHS has been able to come up with a communication system, named the Early Warning Outbreak Recognition System (EWORS), capable of bridging the gap present in the communication channels in disease notification. EWORS utilizes satellite technology to ensure timely and qualitative communication of information about red flag diseases.

This event had the necessary ingredients of foresight, proper planning and the collective input of all stakeholders in the Health sector. We hope that partners left the exercise with a better understanding of the importance of team work in maintaining a healthy nation. According to Mrs. Olubunmi Ojo, of the NCDC, who was part of the simulation exercise organising technical working group, “Every citizen is a surveillance officer and we all have a role to play in safe-guarding the nation from diseases.”

Dr. Ike Anya of EpiAfric, who worked with Mrs Ojo and Dr. Lokossou of WAHO as lead coordinators of the exercise expressed gratitude at the opportunity to help design and deliver the exercise. He said, “I hope that the capacity building and learning that all those involved in planning and delivering the exercise have gained will help embed a culture of regular testing and exercising across the West African region, thus strengthening our preparedness and response mechanisms.”

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