Special Afri-Dev.Info Editorial
Ebola In Nigeria:
Premature School Resumption Involving Up to 80 million Children, Adolescents, Students & Teachers is High-Risk Strategy – For Children, Parents, & ECOWAS Sub-region
- 42 day no Ebola case period should have been respected.
- Weak health systems will not be able to cope if strategy backfires.
- Teachers cannot be converted to emergency health workers based on 3 weeks training.
- Ebola can still be transmitted in semen weeks after recovery – Sexual health education & commodities crucial to response.
- Liberia epidemic was worsened by premature relaxation of vigilance.
Has the Nigerian Ministry of Education taken a high-risk decision to bring forward re-opening of primary and secondary schools before the country’s Ebola outbreak is certifiably over?
The evidence indicates that this may be so.
Two full incubation periods (21 days x 2 / 42 days) without cases is the global health standard for declaring an Ebola outbreak over in a particular location.
Going by the official Ministry of Health Ebola update (of 1st September) – “the total number of cases of EVD in Nigeria stands at sixteen (16); the number of contacts under surveillance in Lagos stands at 72 while in Port Harcourt, the total number of contacts under surveillance stands at 199” – i.e. for a minimum of 21 days. The update further confirmed that “No contact in Port Harcourt has completed the 21 day observation period”. The Ministry of Health has also warned that it is likely there will be more confirmed cases of Ebola
Yet – on the 5th of September, the Ministry of Education announced that it has reversed its earlier decision (of 26th August) to postpone schools resumption till the 13th of October – and announced that schools would now re-open sooner – on the 22nd of September.
This negated a key pillar of the 26 August announcement that the Minister of Education and Commissioners of Education from the 36 states of the federation “will meet on 23rd September to review the situation in all states”.
What has prompted this apparently hasty review?
Would it not have been much safer – to wait for some time after the outcomes of the minimum 21 day incubation period covering the last batch of persons placed under surveillance – before reviewing the date for school resumption?
There Is Far Too Much At Stake For Questions Not To Be Asked.
Moving millions of children and adolescents within and across 36 states before the Ebola outbreak is fully under control may turn out to be an unwise decision.
The percentage of Nigerian population under 15 years of age is estimated at 44.23%, and although not every child is in school, this reflects in the country’s school population.
The total population of students in Nigeria surpasses the combined population of Guinea, Liberia and Sierra Leone where the current Ebola epidemic has been declared by experts as out of control: Pre-primary (ages 3 to 5) – population of Nigerian students is estimated at 15.9 million; Primary (ages 6 to 11) 27.04 million; Secondary (ages 12 to 17) 21.8 million; and Tertiary (ages 18 years and above) 15.3 million.
The populations of Guinea, Liberia and Sierra Leone are: 11.4 million; 4.1 million; and 5.9 million respectively.
Throwing about 80 million Nigerian children, adolescents, and young adults – (across an estimated 100,000 or more schools) into a potential Ebola mix, at a time when an abundance of caution is crucial – can hardly be described as a low, or even medium risk strategy.
If the Ministry of Education strategy goes horribly wrong – all the hard work of the Lagos, Rivers State and Federal Ministry of Health in containing the outbreak could be undone, with serious consequences for Nigeria, ECOWAS and all of Africa.
Is the Call for Caution Misplaced?
The evidence from Liberia and Sierra Leone where there have been riots, disruption to food production, manufacturing, mining, education, retail; and announcements of nationwide lock downs suggests not.
To quote the Deputy director of US Centre for Disease Controls National Centre for Emerging Zoonotic and Infectious Diseases:
“If there was no cases identified after today, we would still be committed to waiting 42 days from today to declare the outbreak fully over. The concern is that the outbreak can be reseeded much like a forest fire, with sparks from one tree reseeding it. That is clearly what happened in Liberia”.
Liberia was a situation they did not have any new cases for more than 21 days in the first wave of the outbreak and they were reseeded by cases coming across the border. Until we can identify and interrupt every chain of transmission, we will not be able to control the outbreak.”
Some Luck, Courage, Sacrifice and Efforts of Health Officials Have So Far Contained the Ebola Outbreak in Nigeria
In Nigeria, all 18 cases (so far) in the transmission chain are linked to a single person who travelled from Liberia to Lagos on 20 July. A combination of circumstances, incredible courage by two brave women – a doctor and nurse (now dead from Ebola) – that identified the index case and restrained him – and round the clock work by health officials and partners has so far ensured that – the transmission chain has been traceable and contained.
Among the contacts of the index case, one person knowingly evaded surveillance and travelled to Port Harcourt (to seek private treatment) triggering another chain of transmission, which killed the doctor that treated him. The doctor in turn infected his wife (also a doctor) and she helped alert the authorities. The involvement of health workers affected, and their ability to recognise the situation, has so far been key to halting a disaster in the making.
If there is an Ebola outbreak in Nigeria’s massive 80 million strong school population after the 22nd of September, can the health system cope with tracing, containment and treatment? The evidence indicates that the answer is a resounding NO. To put this in context Nigeria has only 4.1 doctors per 10,000 of the population (an estimated 58,363 doctors) – way below the 23 per 10,000 required for successful primary health care interventions.
And if schools shut down again after a new outbreak involving children and adolescents – and millions of students are reshuffled back home including across 36 states – what happens?
The Question Then Has To Be Asked – Why Has the Ministry of Education Reversed Its Earlier Decision Re-Open Schools In October?
Even basic disease prevention in Nigerian schools is a challenge as majority of schools are notorious for their lack of water and sanitation facilities, including lack of personal hygiene facilities for female students
The Ministry of Education directive that – “at least two (2) staff in each school, both Public and Private, are trained by appropriate health workers on how to handle any suspected case of Ebola” by 15th September – is ill informed. Even doctors with 6 – 7 years of training cannot identify Ebola just by looking at patients with early symptoms that could be anything from Malaria to Typhoid fever. (See appendix to Editorial for questions about the precautionary measures directed by the Ministry of Education)
The WHO listed Ebola symptoms include: fever, intense weakness, muscle pain, headache and sore throat – followed by vomiting, diarrhoea, rash, impaired kidney and liver function. To these the Nigerian Ministry of Information Facebook page has ominously added “red eyes, cold, depression and confusion” – as symptoms of Ebola. The potential for chaos when schools resume can only be imagined.
Importantly, the WHO underlines that other diseases to be ruled out before a diagnosis of Ebola can be made include: malaria, typhoid fever, cholera, plague, rickettsiosis, relapsing fever, meningitis, and hepatitis to mention a few. How can a teacher with 3 weeks ‘Ebola training’ and no diagnostic equipment on site manage this? And if they suspect it is Ebola what do they do? There is no effective states or national ambulance service to call.
Even without Ebola, a look at some annual and cumulative health indicators for children, adolescents and young adults in Nigeria demonstrates the country’s healthcare system is already inadequate, with successive Ministers of Health struggling to perform miracles with insufficient resources
- Distribution of causes of death in children under 5 years include: Malaria – 20%; Acute Respiratory Infections – 16%; Diarrhoea – 10%; HIV/AIDS – 3%; Measles – 1%.
- Only 31% of children under 5 years with Acute Respiratory Infection (ARI) symptoms are taken to health facilities.
- Only 38.1% of children under 5 years with diarrhoea receive oral rehydration therapy (ORT).
- Only 41.9% of children under 5 years with fever received treatment with any anti malarial.
- Only 18% of pregnant women living with HIV received antiretroviral for preventing mother to child transmission.
- Number of children living with HIV – 400,000.
- Polio vaccination coverage – 59%
- Measles cases – 6,447
Some other overall annual or cumulative health indicators for the general population – indicative of capacity to deal with Ebola outbreak:
- Malaria cases = 2,087,086 (2.08 million) / Malaria Deaths = 7,734
- People living with TB- 270,000 / TB Deaths, 27,000
- People living with HIV – 3,200,000 (3.2 million) / Treatment Coverage 20%
Nigeria’s HIV indicators are especially significant given that men who have recovered from Ebola can still transmit the virus through their semen for up to 7 weeks after recovery from illness. As immune systems are critical to survival of Ebola; sexual and reproductive health education and commodities are crucial for adolescents and young adults .
If the health care system is unable to cope as illustrated above in ‘normal times’, how can teachers be expected to manage an Ebola outbreak?
The federal government and the Ministry of Education need to re-consider the announcement to re-open schools on the 22nd of September – and to do this before the 22nd – especially if more cases of Ebola are detected.
No one hopes for the worst – but even as we hope for the best – we must make every effort, and take every precaution to prevent the worst. Ebola is currently a disease with no treatment and no vaccine.
If the Ministry of Education and government maintain the decision to re-open schools by the 22nd of September especially if there are more confirmed Ebola cases – the 21 days (Ebola incubation period) following September 22nd 2014 will be the most tension soaked and longest 21 days in Nigeria’s health and education history.
While schools cannot remain closed indefinitely, and we cannot rule out a separate Ebola outbreak in the future – The situation in Liberia and Sierra Leone demonstrates that waiting 21 to 42 days could make the difference between complete chaos, and a resolution of the present Ebola outbreak in Nigeria.
Statement Ends: For further information contact kindly contact us through email: media[a]afri-dev.net
Excerpts And Questions Arising – From Initial Ministry Of Education Announcement Postponing Schools Resumption Till 13th Of October
“All Primary and Secondary schools, both Public and Private are to remain closed until Monday 13th October, 2014 which is the new school resumption date for all schools throughout the Federation. This is to ensure that adequate preventive measures are put in place before the students report back to school.”
“All Summer Classes currently being conducted by some private schools should be suspended with immediate effect until 13th October, 2014.”
“All Private Primary and Secondary Schools must comply with the directives given under these preventive measures”
“All Tertiary Institutions are advised to suspend exchange of staff and students programs, visits and major International seminars and workshops until further notice. They are also to monitor the movement of foreign students in their campuses. They are to liaise with appropriate Government Health Institutions to organize and ensure effective sensitization program for all their teaching and non-teaching staff”
“The Minister of Education and all State Commissioners of Education will meet again on 23rd September, 2014 to review the situation in all States.”
The New Announcement of 5th September Negating This Previous One and Re-directing Schools to Re-open By 22nd September Raises Many Questions.
- What changed in the 10 days since the earlier announcement was made?
- Have all the precautionary conditions announce by the Minister of Education been met?
- Where those conditions adequate in the first instance?
Key Amongst The Precautionary Conditions Announced Where?
1). “ All State Ministries of Education are to immediately organize and ensure that at least two (2) staff in each school, both Public and Private, are trained by appropriate health workers on how to handle any suspected case of Ebola – and also embark on immediate sensitization of all Teaching and Non-Teaching Staff in all schools on preventive measures. This training of staff must be concluded not later than 15th September, 2014.”
- Has this training been concluded? Even if concluded is it sufficient?
2). “All State Ministries of Education should establish a Working and Monitoring Team for effective supervision of school activities before and after opening of schools.”
- Have these monitoring teams been put in place?
- What is the composition of these teams?
- What is their mandate and how will the monitoring be carried out?
- Are they empowered to make recommendations for school closure?
3). “Each State Ministry of Education should appoint a designated [Ebola] Desk Officer not later than 1st September, 2014, who should also receive appropriate training and who must report on daily basis to the Honourable Commissioner on situation in the schools. The names of such Desk Officers, their phone numbers and e-mail addresses should be communicated to the Headquarters of the Federal Ministry of Education not later than 1st September, 2014.”
- Have these desk officers been appointed?
- Who has been designated to train them?
- What is the composition of this training?
- Has the training been accomplished?
- Could any such training have been done in 6 days (between 26th August and 1st September)?
- Have their details been forwarded to the Federal Ministry of Education as of the 1st of September?
4). “All Primary and Secondary schools, both Public and Private should be provided with a minimum of two (2) appropriate/recommended Temperature Measuring Equipment by the State Ministries of Education. The State Ministries should determine the number of such equipment required and forward same to the Federal Ministry of Education not later than 1st September, 2014. The Federal Ministry of Education will liaise with the Federal Ministry of Health to ensure that appropriate equipment are procured.”
- Have all the 36 state Ministries of education determined the number of temperature measuring equipment to be procured in each state?
- Have the requests been forwarded to Federal Ministry of Education by the 1st of September?
- Has the order for them been placed? Will these be supplied and be in place by the 22nd of September?
- What about protective clothing?
i.e. WHO recommendation is that – “When in close contact (within 1 metre) of patients with Ebola, health-care workers should wear face protection (a face shield or a medical mask and goggles), a clean, non-sterile long-sleeved gown, and gloves (sterile gloves for some procedures).” Will these be provided in schools?
If the answer to any of these questions is No – then the Ministry of Education has failed even by the precautionary standards it set for itself.
Why take the risk of daily movement of a combined school population of about 80 million children, adolescents and young adults – including secondary school and higher education students that will travel within and between the 36 states of the country.
But Two Even Bigger And More Important Questions Should Be Answered.
- Why has the government and the Ministry of Education decided that it is not necessary to wait for the two full incubation periods (21 days x 2 / 42 days) without cases – which is the global health standard for declaring an Ebola outbreak over in a particular location?
- Is the decision to convert teachers to emergency health workers conditions appropriate?
Teachers are trained to teach, not be health workers. Should teaching staff be placed in the trenches to fight Ebola, or should health workers have been designated to assist schools?
The House of Representatives, the teaching unions and health workers unions and associations need to be brought into this discussion and unravel how and why this decision was taken, and if it should stand.