Ebola Crosses Borders as Africa CDC Claims Regional Role

Nigeria confirmed its first Ebola patient after testing the 42-year-old woman on Oct. 19. She developed symptoms on Oct. 6, raising questions about cross-border surveillance and which authority coordinates a regional response. The Ugandan-born woman lives in Abuja and is the wife of a diplomat. She returned to Nigeria on Oct. 3 after spending two and a half weeks in Kampala, with a two-hour stopover in Addis Ababa, Ethiopia.

She first went to a private hospital, believing she had malaria. Her condition failed to improve, and on Oct. 11 she entered a second private hospital. Nigerian health authorities said she was stable and responding to treatment. They had identified 44 contacts, although not all had been in close proximity to her.

Travel history and cross-border authority

Nigerian and Ugandan authorities gave differing accounts of whether the patient travelled to the Democratic Republic of the Congo. Uganda’s Ministry of Health called her a Nigerian national who had travelled to eastern Democratic Republic of the Congo for business and passed through Uganda on her way home. Ugandan authorities said the country had no active confirmed Ebola cases, and her transit did not establish where she caught the virus.

Nigeria’s health minister Muhammad Ali Pate said officials had not confirmed travel to Congo. “Our case did not have confirmed travel to DRC. So we presume it was likely picked in Uganda,” he said on state television. The World Health Organization said it hadn’t been informed whether the patient had travelled to Congo.

Africa Centres for Disease Control and Prevention Director-General Jean Kaseya asked the patient to give authorities her full travel and contact history, including whether she left Kampala, flew to the Democratic Republic of the Congo or met anyone who had come from there. “She has to disclose to the authorities,” Kaseya said. That information, he explained, would help Nigerian and Ugandan authorities establish how she was infected and identify possible transmission links.

Kaseya described how responsibility for a response shifts when an outbreak crosses national borders. “When we have an outbreak in one country, it is the sovereignty of the country. But when we have it in more than one country, it becomes the mandate of the Africa CDC,” he said. Africa CDC declared the outbreak a regional and continental concern on May 15, citing the risk of cross-border transmission.

Tracing the response and its funding

Kaseya said Nigeria wasn’t among the countries initially considered at risk because the outbreak was concentrated in eastern and central Africa. “It is now,” he said, adding that officials needed to redraw the risk assessment and that North and Southern Africa could also be at risk. The delayed test, he said, would complicate contact tracing: the patient had been in contact with health workers, family and friends. Ebola spreads through direct contact with bodily fluids of an infected person showing symptoms.

The outbreak comes from the Bundibugyo virus, a rare form of Ebola with no specifically approved licensed vaccine and no treatment. As of Oct. 19, the Democratic Republic of the Congo had recorded 9,552 confirmed cases and 4,602 related deaths, based on data through Oct. 18. Kenya reported nine confirmed cases, including one death, as of Oct. 20. Uganda recorded 20 cases between May and June, including 15 imported from Congo and five locally acquired among contacts and health workers linked to imported cases.

Funding oversight has also become a central issue for Africa CDC. Kaseya said $962 million had been disbursed from a $3 billion pledge made at a September meeting on the margins of the United Nations and G20 meetings. At a meeting with the Democratic Republic of the Congo government and partners, 19 of 92 partners attended. Partners said they had received about $220 million.

“If I see, out of $962 million disbursed, the government knows only about $220 million, what kind of government can accept to lead a response without knowing even how much they have, without knowing who's doing what and where?” Kaseya said. He said the issue was traceability, not a current allegation of fraud or mismanagement, and donors including the United States and European Union were providing information about recipients and amounts.

National response measures

Kaseya urged African governments to invest in their health systems and require nongovernmental organisations and donor-funded partners to report to national authorities and follow government-led plans. He said Africa CDC could blacklist partners that failed to account for outbreak funds. Nigeria’s president convened a task force on Wednesday, which decided to provide funding for the response, while Africa CDC called an Ebola crisis meeting of African heads of state.

Nigeria activated response measures after confirming its first Ebola case on Oct. 20. The Nigeria Centre for Disease Control and Prevention coordinated surveillance and other public health measures. WHO said it was supporting Nigeria with case investigation, contact tracing, laboratory testing, infection prevention and control, and protection of health workers and communities. WHO also urged Nigerians to remain calm: one imported case doesn’t by itself mean Nigeria is experiencing an Ebola outbreak.