1. This reported cases indicate the number of

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      Background: Morbidity and mortality rates of thediseaseThe most widespreadoutbreak of Ebola Virus Disease (EVD) since it was first experienced in 1976 was that of the West African epidemic that occurred from late 2013 through 2016causing major loss of life and disruption of socioeconomic activities in theregion. The outbreak is uncommon in terms of its duration, number of casesrecorded, fatality and geographical spread. Unlike previous outbreaks, whichlasted for a very short time, the recent case lasted for more than one year. Itoccurred mainly in the countries of Guinea, Liberia, and SierraLeone, the first casesbeing recorded in Guinea in December 2013, although EVD was not suspected untilmuch later in 2013 and not confirmed until March 2014. The disease later spreadto neighboring countries, Senegal and Mali, with minor outbreaks in Nigeria.(WHO Ebola Response Team, 2014).Ebola virus, a zoonoticinfection- an infectious disease that is transmissible from animals to humans-,causes a severe haemorrhagic fever in humans with high case fatality andsignificant epidemic potential as shown by the 2014–2016 West African outbreak.It severely threatened international public health systems in ways they havenever been challenged before.

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WestAfrica experienced the highest epidemic of the virus since the beginning of2014 infecting larger number than all other outbreaks combined as reported byWHO, 2016 where in total: Reported cases =28 646and Mortality case = 11 323. This reported casesindicate the number of people that were confirmed, probable and suspected to beinfected during the study period. However in epidemiology (study of thedistribution and determinants of health conditions), these reported case isoften used more casually to include proportions that are not truly infected. Onthe other hand, the mortality case indicates the occurrence of death from thereported case between 2014-2016. The virus caused significant mortality, withthe case fatality rate i.e the proportion of confirmed Ebola patients who diedfrom EVD slightly above 70%, while the rate among hospitalizedpatients was 57–59%.

 Although, small outbreaks occurred in Nigeria and Mali, and isolated cases were recorded in Senegal, the UnitedKingdom and Sardinia. In addition, imported cases led to secondary infection ofmedical workers in the UnitedStates and Spain but did not spread further. The number of casespeaked in October 2014 and then began to decline gradually, following thecommitment of substantial international resources.The high mortality rateassociated with Ebola threatens the ability to perform many interventions thatcould help contain the epidemic.

Indeed, due to fear of infection, the public werereluctant to engage in contact tracing (i.e locating persons who has beenexposed to the virus); infected persons are hesitant to present themselves fortreatment; and clinicians are frightened to provide care. In the first year,between October and November 2014, 72% of all reported patients with EVD wereisolated in Guinea, 20% in Liberia and 13% in Sierra Leone (UNDP, 2014).In addition, medical staff werereluctant about treating a highly transmissible infection for which there is novaccine, no specific therapy, and a high mortality (death) rate. As a result, apaucity of knowledge on the disease, combined with the fear produced by theepidemic, delayed the implementation of simple interventions to prevent deaths(Fowler et al.

, 2014).High mortality ratesrecorded fuelled fears surrounding the disease among both medical staff and thepopulation at large. As awareness of the existence and magnitude of theepidemic came months too late, the virus had spread considerably.It is occasionallytransferred to humans through body fluid contact with an infected patient, forexample contact with a cut or scratch on the surface of the skin (Beeching,2014) and it is also believed that a person can contract the disease only once.After a 1-21 day incubation period (the time interval from exposure to aninfectious agent to the onset of symptoms of the disease), the Ebola infectioncan present symptoms and initiate human-to-human transmission. The widespreadnature of the West African outbreak in 2014-2016 is thought to be related tothe highly mobile communities and dense population within the region.  2.      Factors responsible for the EbolaoutbreakCurrent state of health of a personcan be as a result of five major determinants.

This can be represented usingthe figure below:Figure1:Five social determinant of health (SDOH)The extent,severity, and demographic spread of this EVD outbreak have been attributed tovarious reasons, including poor health systems, urbanization, high povertyrate, lack of access to social services and high population mobility, all ofwhich are peculiar in the three main affected countries (Alexander et al., 2015; Kennedy & Nisbett,2015; Chan, 2014). All these reasons surrounds the SDOH illustrated in figure 1above. However some of the major factors contributing to the EVD outbreak areas discussed:2.

1  Physical environmentleading to disease transmissionInteraction with theindex case (the first case of patients coming to the attention of health authorities)in Guinea indicated that children regularly played near a tree with colony ofinsectivorous bats. The species of bats known to carry Ebola virus wereidentified close to where the index case lived. The source of 2014–2016 Ebola epidemichas therefore been reported to be Bats. (Mari et al., 2014).West Africa is characterizedby a high degree of population movement across exceptionally porous borders. Theextraordinary magnitude of the epidemic is therefore basically due topopulation density and high mobility (Kutzin & Sparkes, 2016).

Studies reportedthat mobility in these countries is seven times higher than elsewhere in theworld. This high mobility rate can be attributed to high poverty as peopletravel daily looking for work or means of sustainance. Hence, populationmovement created two significant hindrances to the disease control: Contacttracing is difficult to monitor.

Likewise as the situation in one country beganto improve, infected patients avoiding treatment from neighboring countries crossborder, thus reigniting transmission chains. In other words, as long as onecountry experienced intense transmission other countries remained at risk, nomatter how strong their own response measures had been. In addition, WestAfricans have relatives living in different countries, hence, traditionalcustom of returning home to a native village to die and be buried nearancestors is another dimension of population movement that carries anespecially high transmission risk.2.2  Poor health servicesGuinea, Liberia, andSierra Leone are among the poorest countries in the world, with recent historyof civil war and unrest that left basic health infrastructures severely damagedor destroyed and created a number of young citizens with little or noeducation. Basic infrastructures including road systems, transportationservices, and telecommunications are weak especially in rural area of thesecountries.

These problems greatly delayed the transportation of patients to healthcentres and of sample analysis to laboratories, the communication of alerts,reports, and calls for help, and public information campaigns.Inadequateinfrastructure in health systems, severe shortages of trained health workers,shortages of basic medicines and very weak health information and diseasesurveillance systems are peculiar challenges in the affected region (Dubois et al., 2015).

Before 2014, Liberia,Sierra Leone and Guinea have 88 496, 79 365 and 24 096 people per health centrerespectively, compared to 10 320 people per health centre in nearby Ghana. Inaddition, instead of the recommended one trained health care worker for every439 people, there was one health worker for 3 472, 5 319 and 1597peoplerespectively for these three countries. The insignificant number of workforcewas further diminished by the unprecedented number of health care workers infectedduring the outbreaks.

Nearly 700 were infected by year end of 2014 and morethan half of them died. Though the number of infected health care workers washigh at the early state of the outbreaks, but diminished as proper safetymeasure was put in place. In Liberia however, as cases began to decline and therisk was perceived to be lower, stringent measures for personal protectionlapsed.

Protective measures in the community, such as frequent hand hygiene andkeeping a safe distance from others, visibly declined. While in Sierra Leone,exhaustion among staff causes an increase in loss of health workers.   2.3  Culturalbeliefs and behavioural practicesAfrica as a whole is rich in culture.

Culturalbeliefs in the three countries have been similar to what has been seen duringprevious Ebola outbreaks in equatorial Africa. New cases of infection arisesdue to adherence to ancestral funeral and burial rites. Medical anthropologistshave, however, noted that funeral and burial practices in West Africa areexceptionally high-risk. Data available in August,as reported by Guinea’s Ministry of Health, indicated that 60% of cases in thatcountry could be linked to traditional burial and funeral practices. InNovember 2014, WHO staff in Sierra Leone estimated that 80% of cases in thatcountry were linked to these practices (WHO, 2015).

  In Liberia and Sierra Leone, where burialrites are reinforced by some secret societies, mourners are known to bathe inor anoint others with rinse water from the washing of corpses. In some cases,prominent members of these secret societies sleep near a highly infectiouscorpse for several nights, believing that doing so allows the transfer ofpowers.Compassion is anotherdeep-seated cultural trait: In West Africa, the virus spread through thenetworks that bind societies together in a culture that stresses compassionatecare for the ill and ceremonial care for their bodies if they die. Some doctorsare thought to have become infected when they rushed, unprotected, to aidpatients who collapsed in the hospital premises.

In addition, traditionalmedicine has a long history in Africa. Even prior to the outbreaks, poor accessto government-run health facilities made traditional medicine orself-medication the preferred health care option for many, especially the poor.Many extended cases have been traced to contact with a traditional healer orherbalist or attendance at their funerals.2.

4  Communityresistance, strikes by health care workers Controlefforts in all three countries was disrupted by community resistance, which hasmultiple causes. Fear and misperceptions about an unfamiliar disease have beenwell documented by medical anthropologists, who have also addressed the reasonswhy many refused to believe that Ebola was real. People and their ancestorshad been living in the same ecological environment for centuries, hunting thesame wild animals in the same forest areas, and had never before seen a diseaselike Ebola. Equally unfamiliar were the response measures, like disinfectinghouses, setting up barriers and fever checks, and the invasion by foreignersdressed in what looked like spacesuits, who took people to hospitals orbarricaded tent-like wards from which few returned.

A second source ofcommunity resistance arose from the inability of ambulance and burial teams torespond quickly to calls for help, with bodies sometimes left in the communityfor as long as 8 days. The communities will comply with official advice if itbenefits them. They are far less likely to comply if the result, likeuncollected bodies, causes visible harm. Strikes by hospital staffand burial teams have further impeded control efforts. Most strikes occurredafter staff were not paid for weeks or months, did not receive promised hazardpay, or were asked to work under unsafe conditions associated with the deathsof many colleagues.

2.5  PoorenlightenmentIn theface of early and persistent denial that EVD was real, health messages issuedto the public repeatedly emphasized that the disease was extremely serious anddeadly, and had no vaccine, treatment, or cure. These messages had the oppositeeffect even though it was intended to promote protective behaviours. If health carepractitioners declared that no cure to the virus, families preferred to carefor their loved ones at home. In their view, if death is almost inevitable, letthis happen as comfortable as possible at home, amid familiar and well-lovedfaces. Moreover, when patients were taken to treatment or quarantine, anxiousfamilies often received little or no information about the patient’s condition,outcome, or even the place of burial.

With time, and as entire households diedof the disease, communities began to understand that keeping patients in homescarried a high risk for care-givers. For unknown reasons thatmay include the stigma that surrounds this disease, the practice of hidingpatients in homes continued in some areas, even after abundant treatment bedsbecame available. The great stigma attached to Ebola explains why suspiciousdeaths are routinely tested for Ebola.

Bodies that test negative can be buriedin the traditional way, and families are freed from ostracism by the community.2.6  Spread byinternational air travel Theimportation of Ebola into Lagos, Nigeria on 20 July 2014 and Dallas, Texas on30 September, 2014 marked the first times that the virus entered a new countryvia air travellers. These events theoretically placed every city with aninternational airport at risk of an imported case. The imported cases, whichprovoked intense media coverage and public anxiety, brought home the realitythat all countries are at some degree of risk as long as intense virustransmission is occurring anywhere in the world – especially given theradically increased interdependence and interconnectedness that characterize thiscentury.

2.7  Gender dimensionGuinea provides a good example ofthe gender dimension of EVD epidemiology. The epidemic affects more women (53%)than men (47%), a disparity that could be explained by the role of women withinthe family as the primary care giver of the sick and thus more exposed toinfection (UN, 2014). In Liberia, there are more fatality cases among women(55.2%) than among men (44.2%). While in Sierra Leone, men and women are almostequally affected; around 50.6% of all confirmed cases were males and 49.

4%,females as at October 2014.Several factors explain the predominance of womenamong the victims. The first factor explains that the gender difference in thedeath rate is related to sociological aspects of affected communities. As careproviders, women are more likely to be exposed to the disease transmissionvectors such as vomit or other body fluids of an infected family member. Also,certain traditional practices and rituals for honoring the deceased that womentypically perform also pose an increased risk. 3.     RecommendationsBecause Ebola virusis spread mainly through contact with the body fluids of symptomatic patients,transmission can be stopped by a combination of early diagnosis, contacttracing, patient isolation and care, infection control, and safe burial.It is therefore veryimportant that Public health professionals focus on providing adequate educationregarding EVD and transmission not only in Africa but, massively, around theworld.

A regular program of communication on disease outbreak from publichealth officials is needed and should involve multiple outlets such as radio,television, and social media platforms. These communications should providefactual information concerning the management of high risk contagious disease suchas Ebola, tailored to the target population.Communities shouldcontinue to be engaged in addressing the routine health issues they face, notjust during crises.

In the long run, efforts need to focus on equipping localcommunities with the material and knowledge resources to respond to Ebola andto help build a surveillance infrastructure that can inform a strongerpost-epidemic structure.

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