|Year : 2014 | Volume
| Issue : 1 | Page : 1-5
Ebola viral disease in Nigeria: The panic and cultural threat
Odidika U J Umeora1, Nkechi Bridget Emma-Echiegu2, Maryjoanne Chinyem Umeora3, Nnennaya Ajayi4
1 Department of Obstetrics and Gynaecology, Federal Teaching Hospital, Abakaliki, Nigeria
2 Department of Sociology, Anthropology, Ebonyi State University, Abakaliki, Nigeria
3 Department of Pediatrics, Newark Beth Israel Hospital, Newark, New Jersey, USA
4 Department of Internal Medicine, Federal Teaching Hospital, Abakaliki, Nigeria
|Date of Web Publication||25-Aug-2014|
Dr. Odidika U J Umeora
Federal Teaching Hospital Abakaliki
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Umeora OU, Emma-Echiegu NB, Umeora MC, Ajayi N. Ebola viral disease in Nigeria: The panic and cultural threat. Afr J Med Health Sci 2014;13:1-5
|How to cite this URL:|
Umeora OU, Emma-Echiegu NB, Umeora MC, Ajayi N. Ebola viral disease in Nigeria: The panic and cultural threat. Afr J Med Health Sci [serial online] 2014 [cited 2019 Jan 19];13:1-5. Available from: http://www.ajmhs.org/text.asp?2014/13/1/1/139434
March 2014, the World Health Organization declared the outbreak of Ebola viral disease (EVD) in Guinea with extensions into Liberia. This is the first known outbreak in an urban settlement.  By mid August 2014, 10 cases have been reported so far in Nigeria with two deaths. The first case and death was from a visitor who flew in from Liberia. Ebola conjures fear. Palpable fear, panic and uncertainty seem to have taken over particularly the West African sub-region. This fear derives mainly from paucity of factual knowledge about it, reinforced by the realization that there is currently no vaccine or treatment for this fatal illness with case fatality rate of up to 90%. ,,, Further concern exists about the potential for exporting the virus from the outbreak regions to other countries, as well as the possibility of employing the virus as a bioweapon.  However, it must be noted that EVD is rare and ordinarily would not be of so much public health significance but for the sensationalistic reportage and lack of effective prophylactic or therapeutic measures.  Such reportage has been rife in Nigeria that panic has taken over and permeated every fabric of the Nigerian society. African customs and traditional practices are threatened. Charlatans and spiritualist dish out unscientific and unsubstantiated remedies and claims to cure. Unfortunately, the unwary public has fallen to this in fear and panic. The most celebrated was the employment of warm salt baths and salt drinks for prevention of EVD, to which some citizens hearkened with resultant untoward medical consequences.
It is on this note that AJMHS now rums an editorial on EVD mainly to create knowledgeable awareness among the population. In so doing also expound on the needful preventive and control measures, while evaluating the impact on African culture.
| The Agent|| |
Ebola virus (EBOV), named after the river EBOLA in the Democratic Republic of Congo (formerly Zaire), with the Marburg virus belongs to the filoviridae family. The name derives from "filum" - meaning "threadlike" in Latin. It is a thread-like, nonsegmented negative sense, single-stranded RNA virus. They are virulent, highly pathogenic, causing hemorrhagic fever and resulting in fulminant septic shock.  Infection is often fatal. Marburg outbreak in 1967 was the first to be experienced.  Thirty-one cases were reported with three other recurrences. ,, The Marburg outbreak was contained when the implicated culprits - monkeys were subjected to euthanasia. On the other hand, several outbreaks have been recorded for EBOV mainly in poor resource communities. The five known species of the virus derive their names from the locality of such outbreaks. The most widely recognized Ebola outbreak was in 1976 in Zaire. The causative agent was termed EBOV-Z and had a mortality rate of between 55% and 88%. ,, Since then many more outbreaks have been recorded including the latest in Guinea/Liberia.  EBOV-S was responsible for the outbreaks in Sudan and Uganda over the years and had a mortality rate of about 50%. , Another outbreak in Bundibugyo in Uganda was traceable to EBOV-B in 2007 and had a mortality of 30%.  One person, an ethnologist who performed a necropsy on a chimpazee, was involved in the Cote d'Ivoire outbreak by EBOV-CI in 1994.  EBOV-R was found in Reston 1989, Virginia and was suspected to have been imported via Chimpazees from the Philippines (17,18 MAY). , No one died in this episode.
| Transmission|| |
The natural reservoir for the virus for human transmission is largely unknown, and outbreaks are linked to contact with carcasses of gorillas, chimps and monkeys or exposure to bat droppings or eating fruit bats.  It is believed that most of the contacts are a direct result of human activities relating to deforestation, road construction, hunting, logging, camping and global warming. These activities get humans in direct contact with bats, gorillas, chimpanzees and monkeys. 
Human-to-human transfer occurs from direct contact with blood and body fluids of the infected.  There is a widespread involvement of the skin making it a dire source of infectivity.  Transfer can also occur following contact (touching) with cadaver and corpses. Though there is evidence that filiviridae may be stable in and transmissible in small aerosolized particles in experimental animals, if such occurs in humans, it is minor. , During the Kikwit (Democratic republic of Congo), outbreak, it was believed that aerosolized particles generated from a medical procedure (laparotomy on a patient with abdominal pain) was responsible for the transmission of the virus to all members of the surgical team.  Infection occurs through epithelial surfaces like the oropharynx and conjunctiva and inoculation via epidermal breaches in the skin.  Infection may be inadvertently transferred to these sites by tainted hands.  Contaminated clothes and linens of an infected person may also be sources of infection. 
It has also been noted that EBOV can persist in vaginal secretions as well as the seminal fluid for up to 3 months , hence can possibly be sexually transmitted.  It is possible that viral antigens or genomes may endure into the recuperation period, but long term infection is doubtful. 
| Pathophysiology and Features|| |
The incubation period for EBOV ranges from 2 to 21 days  with an average of 8-10 days. Inside the body, the virus replicates rapidly and targets endothelial cells, mononuclear phagocytes and hepatocytes. Once inside the macrophages or dendritic cells, it secretes the "EBOV secreted glycoprotein". This glycoprotein forms a trimeric complex, which then helps attach the virus to the endothelial cells. It further forms a complex dimer that interferes with signaling of the neutrophils and maturation of the dendritic cells. Dendritic cells are necessary for presentation of the particle to the immune system to elicit a response. Interference with their maturation means that the virus evades T-cell surveillance hence exciting severe infection without triggering immune response by an individual and overwhelms an individual's immune system.  Infected leucocytes serve as carriers of the virus to organs like the lymph nodes, liver, lungs, and spleen  where it causes extensive necrosis. Fever and other inflammatory symptoms and signs are produced when cell damage consequent upon viremia induces production of cytokines such as interferon-alpha, interleukin-6 and interleukin-8. Damage to the endothelial cells breaches vascular integrity and fluid leakage, whereas damage to hepatocytes may be a significant causation of shock and disseminated intravascular coagulopathy.  Adherence of the viral particles to the endothelium leading to thrombocytopenia noted by the third and fourth days may be contributory too to disseminated intravascular coagulopathy.
Acute disease commences with flu-like symptoms, then fever, weakness, headache, joint and muscle aches as well as abdominal pain, vomiting and diarrhea. Other symptoms include dysphagia, sore throat, chest pain, hiccups and shortness of breath. Patient may also present with cardiovascular shock. Death results in about nine days from shock. Cardiovascular collapse and multi organ dysfunction. ,,
| Management and Prognostication|| |
Currently, there is no approved vaccine or therapy for EBOV. Management is mainly supportive and containment. Supportive management comprises fluid and electrolyte replacement, oxygen therapy, analgesics, antibiotics and antifungals. Anticoagulants may be useful in early disease to prevent disseminated intravascular coagulation while procoagulants in late disease to combat it. However, there have been many experimental treatments available and even used during index outbreak by the United States Government. The Nigerian Government has also authorized the use of the same experimental serum within the country and declared it is not unethical. This agent ZMapp ® is serum composed of humanized antibodies against the EBOV surface antigen. The two USA citizens who received this seem to show positive signs of improvement. In 1999, seven out of eight victims who received serum from survivors survived.  Another drug, the Nano Silver did not pass the ethical test in Nigeria. Vaccines against the filoviruses are also at the experimental stage.
Apart from the convalescent serum, other experimental drugs include Favipiravir (7-705) which is active against RNA viruses,  Clomiphene and Toremiphene, these recognized Estrogen, receptor modulators are shown to inhibit viral programs of EBOV in infected mice,  but this action is thought to be accomplished through a different pathway than the standard Estrogen pathway. 
Positive prognostic factors are low viral load, recovery within the 2 nd week and appearance of antiviral specific antibodies.  High viral titers, severe intravascular volume depletion, shock, poor oxygenation, and metabolic derangement are poor prognosticators.
| Psychosocial and Economic Implications of Ebola|| |
There is no gainsaying that the fear of EVD has threatened the social and traditional fabric of Nigeria recently. Peoples' psyche has been affected with attendant behavioral modifications with regards to inter personal interactions within the society. In a comprehensive study on indigenous responses to an Ebola outbreak, Hewlett  a cultural anthropologist, focused on the actual perception of the outbreak by the community, in particular, specific cultural elements and local beliefs to ensure proper messages, confidence and close cooperation of the community.  He examined persons' or cultures' explanations and predictions regarding a particular illness. Providing care and treatment for a particular disease is often based on negotiating these different models. Furthermore, Dunn  also developed a simple framework for integrating anthropologic work into disease control efforts. This framework emphasizes identifying both health enhancing and health-lowering beliefs and practices of both the local, national and international communities. The data from the study showed that:
- Local, national and international actions contributed to the control of the outbreak of EVD like suspension of the following activities: Handshaking upon greeting, harmful cuts by traditional healers, schools and public funerals.
- All of the health-lowering activities in the community like omitting traditional healers who were willing and ready to mobilize communities for control efforts, taking blood samples for research only or blood taken without reporting results to persons or communities increased distrust of health care workers, taking bodies burial before family members could verify the death, led sick persons to hide from family and health workers; family members being afraid to take sick persons to hospital would militate against control of the outbreak.
The study clearly showed that cultural practices did indeed amplify the outbreak. Another important finding was that local people have beliefs and practices in place that can be useful to the local, national and international teams in the control of rapid epidemics such as EVD and other high fatalities.
Ebola viral disease brings with it significant amounts of fear and stigma driven by the communities belief that the outbreaks are often due to witchcraft and wrong doings by the victims and affected families. Fear is further fuelled when infection control techniques and restrictive practices such as quarantine and isolation employed to protect the public health. , Stigma has a well-known negative effect on the mental health of beneficiaries as well as disease prevention and control. ,, In an independent research, many survivors experienced an intense stigmatization.  Some were not allowed to return home; many had all their clothes burnt; some were abandoned by their spouses. Their children were told not to touch them, and wives were told to go back to their home villages. The discrimination also extended to family members who were regularly turned away from market places. The findings also indicated that women experienced greater discrimination than men.
Stigma can present major barriers to health care access, thereby reducing early detection and treatment and furthering the spread of disease. It enhances social marginalization often can lead to poverty and neglect, thereby increasing the susceptibility of the population to the entry and amplification of infectious diseases. A potentially stigmatized population may distrust health authorizes and resist cooperation during a public health emergency. Finally, Social stigma may distort public perceptions of risk, resulting in mass panic among citizens and the disproportionate allocation of health care resources by politicians and health professional. ,,
The need for trust building among the public and Government and care providers' transparency from the very beginning cannot be over emphasized; clear and factual information must be provided; the unknown risks of infection can exacerbate stigmatization and create undue alarm. 
Ebola viral disease results in obvious economic losses to the individuals, families and society at large. Businesses that thrive on social interactions may be affected. The Bushmeat industry in Nigeria is also receiving the hit as bush meats appear to have been implicated rightly or wrongly in EVD transmission. Many may avoid crowded places like clubs, amusement parks and stadiums and even churches. Revenue might be lost in the Tourism industry as well as public transportation, which might be affected. International trades and travels are not left out. Recently, Zambia barred flights from three heavily affected West African countries. The huge budget for health preventive measures also creates some drain in the economy.
| Prevention and Control|| |
Prevention of EVD is at two levels. First is to prevent the infection from entering the human population by avoiding contact with all known vectors of the disease like fruit bats, monkeys/apes and antelopes. The public should be educated to avoid sick, dead or dying wild animals as these are potential sources of the EBOV. Fruits with holes in them should not be eaten because the hole may have been made by bats and thus, the fruits are potentially infected. 
The second aspect is the prevention of secondary spread within the human population. Avoidance of contact with the body fluids of infected persons is key here. Such body fluids include blood, urine, feces, saliva, tears, semen, vaginal fluids, sweat and breast milk of infected persons. Dead bodies of victims are highly infectious and should be handled and disposed of only by designated and well informed personnel who must also be well protected with appropriate personal protective equipments (PPEs). This precaution should be in place both at home and in the hospital. 
Control measures  during epidemics include:
- Active case identification and isolation of patients from the community to prevent continued virus spread.
- Identifying contacts of ill or deceased persons and tracking the contacts daily for the entire incubation period of 21 days.
- Investigation of retrospective and current cases to document all historic and ongoing chains of virus transmission
- Identifying deaths in the community and using safe burial practices
- Daily reporting of cases.
Health-care personnel must be well educated on safe infection control practices to prevent transmission in the health-care settings with the attendant disastrous consequences. Early recognition and identification of patients with potential EVD is critical. Infection prevention and control measures in the hospital should include:
- Patient placement: Patients should be placed in a single room (containing a private bathroom) with the door closed. Where available, negative pressure rooms are recommended.
- Health-care provider protection: Health-care providers should wear gloves (fluid resistant or impermeable), shoe covers, eye protection (goggles, face shield), and face mask. Additional PPE might be required in a certain situation (e.g. copious amount of blood, other body fluids, or feces present in the environment), including double gloving, disposable shoe covers and leg coverings.
- Aerosol generating procedures: Avoid aerosol generating procedures. If performing these procedures, PPE should include respiratory protection (N95 filtering respirator or higher) and the procedure should be performed in the airborne isolation room.
- Environmental infection control: Diligent environmental cleaning and disinfection and safe handling of potentially contaminated materials is paramount. Appropriate disinfectants for EBOV and other filoviruses 10% sodium hypochlorite (bleach) solution, or hospital grade quaternary ammonium or phenolic products. Health-care providers are performing environmental cleaning and disinfection should wear recommended PPE. 
| Conclusion|| |
Ebola viral disease is a fatal disease with currently no effective cure or prophylaxis but does not call for panic or stigmatization. Transmission involves contact with body fluids and secretions from infected individuals. Personal hygiene, good public health practices and safety measures confer some protection. Containment and supportive therapy are important to manage individual cases, while the outbreak burns out. Medical and emergency preparedness rather than panic are advocated. Robust qualitative research using the explanatory model should be funded and undertaken to evaluate population/communities' belief and perception of the causes and control of EVD, as well as the attendant cultural threats. Such research will generate ideas that will aid in better EVD control.
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