Formulating an Effective National Response to Ebola in Nigeria

Abstract
Today, there are dozens of deadly diseases in the world, but the Ebola virus disease (alternatively “EVD” or “Ebola”) is among the most virulent and lethal. Although intensive research is underway, there is no cure currently available for Ebola and the death toll attributable to this disease continues to increase. To date, there have been nearly 30,000 cases of Ebola infections that caused more than 11,000 deaths, primarily in West Africa, but the disease has the potential to spread worldwide unless first responders, emergency management managers and the health care community take aggressive steps to identify infections and contain outbreaks. The main purpose of this study is to provide a systematic and critical review of the relevant juried, scholarly and governmental literature about the Ebola virus disease to create an awareness manual that is targeted at educating Nigerian citizens concerning this disease. A secondary purpose of this study is to identify gaps in the existing literature concerning optimal strategies for responding to Ebola outbreaks in order to recommend further areas of study.
An effective preparedness strategy for future Ebola Virus Disease outbreak in Nigeria: Public Awareness Approach
Chapter One: Introduction
Statement of the problem
In spite of increasingly aggressive efforts to identify a cure for the Ebola virus disease (Preston, 2014), outbreaks continue to occur, including an ongoing one in the Democratic Republic of the Congo (which has proven to be the most difficult to manage to date), each with the potential of escalating into a worldwide pandemic (Brown, 2015). Therefore, national and local emergency managers must develop a comprehensive understanding of the etiology of this disease, its course and what steps should be taken in response to confirmed cases in order to contain outbreaks when they occur and to educate citizens to prevent the spread of rumors that can further exacerbate the virulence and lethality of the Ebola disease virus (Allam, 2014).
Purpose of the study
The overarching purpose of this study was to provide a systematic and critical review of the relevant peer-reviewed, scholarly and governmental literature concerning Ebola in order to develop an awareness manual for educating the Nigerian citizen on Ebola virus disease. A secondary purpose of this study was to identify any gaps in the current body of scholarship concerning optimal strategies for responding to Ebola outbreaks in order to recommend further areas of study.
Significance of the problem
Unlike many other deadly diseases that continue to plague humankind, Ebola is in a category almost by itself in terms of its lethality. Indeed, Ebola infections typically kill between 25% and 90% of its victims, and it is not surprising that the public generally reacts to even the mention of this disease with dread and terror (Ebola outbreak, 2019). The largest outbreak of Ebola occurred in West Africa during the period between 2014 and 2016, but the second-largest outbreak is still ongoing in the Democratic Republic of Congo despite efforts on the part of the international health care community to contain it (Ebola, 2019). In fact, the outbreak in the Democratic Republic of Congo was all the more noteworthy because the country had a comprehensive preparedness plan already in place (Hancock,2019).
While many countries of the world remain directly unaffected by Ebola, the potential for this deadly disease to spread beyond the borders of the African continent are pronounced, especially due to the ease with which people can travel long distances today (Hood, 2015). Moreover, the Ebola disease virus has been shown to be able to cross national borders with relative ease, and its impact on the nations of Africa has been severe. For instance, according to the U.S. Centers for Disease Control and Prevention (CDC)< “A total of 28,616 cases of EVD and 11,310 deaths were reported in Guinea, Liberia, and Sierra Leone. There were an additional 36 cases and 15 deaths that occurred when the outbreak spread outside of these three countries” (Ebola outbreak, 2019). The fear and dread that are associated with Ebola are due in large part to the fact that there is no cure for the disease and misinformation and rumors abound concerning its effects (Ebola, 2019), a troubling situation that directly relates to the rationale in support of this study as described below.
Rationale of the study
Developing effective responses to the Ebola virus disease requires a series of multifaceted interventions, and all are essential for containing outbreaks of the disease (Ebola, 2019). The elements of effective responses include isolating infected victims, providing them with the best palliative care possible and identifying any new victims and repeating these interventions (Ebola, 2019). Other elements of effective responses to Ebola include the prevention of further infections by the disease by performing safe but respectful burials of deceased victims, and ensuring that affected health care facilities, ambulances and victims’ homes are decontaminated (Ebola, 2019).
While these steps can help contain an outbreak, they do not stop them from occurring in the first place. Therefore, while the search for a cure for the Ebola virus disease continue, it is vitally important for national and local emergency management teams to formulate effective response interventions to minimize the transmission of the disease, including educating citizens concerning the Ebola disease virus to prevent the spread of misinformation that could adversely affect the ability of emergency managers to achieve this objective.
Chapter Two: Review of the Relevant Literature
Chapter Introduction
This chapter provides a review of the relevant literature concerning the Ebola virus disease, including transmission methods, symptoms, diagnosis, and current treatment strategies. In addition, this chapter provides an analysis concerning ways to identify optimal emergency management strategies for Ebola outbreaks in Nigeria.
Overview of the Ebola virus disease
Cause of the Ebola virus disease
The Ebola virus disease is caused by an infection from a host of viruses that are included in the genus, Ebolavirus: Ebola virus and the species, Zaire ebolavirus (What is Ebola virus disease?, 2019). One of the more challenging aspects of Ebola is its virulence which facilitates transmission from person to person or animal to person. For instance, according to the CDC (2019), “Ebola virus disease is a rare and deadly disease in people and nonhuman primates. The viruses that cause Ebola are located mainly in sub-Saharan Africa. People can get Ebola through direct contact with an infected animal (bat or nonhuman primate) or a sick or dead person infected with Ebola virus” (Ebola virus disease, 2019, para. 2).
Because many people in West Africa come into contact with animals, including the common practice of eating so-called “bush meat,” including fruit bats which are the only known natural reservoir for the disease. In this regard, Holakouie-Naieni and Ahmadvand (2015) report that, “Although the current epidemic of Ebola virus is propagated by human to human transmission, it is hypothesized that transmission from reservoir to human has likely occurred by consuming ‘bush meat’ or handling an infected animal” (p. 1670). Consequently, the opportunities to contract the Ebola virus disease are especially pronounced in many African nations, including Nigeria. At present, there are five different strains of the Ebola virus which are named for the locations where the strains were first identified: Ivory Coast, Bundibugyo, Reston, Zaire, and Sudan (Ebola, 2019). The foregoing issues have significant implications for emergency management professionals and these issues are discussed further below at they apply in general.
Implications for emergency management
Because Ebola infections can be caused by contact with the bodily secretions of infected individuals, person, it is vitally important for first responders and health care practitioners – in fact anyone who comes into contact with people who are infected by the Ebola virus disease – to wear appropriate protective clothing and gear to avoid becoming infected themselves (Ebola, 2019). In addition, it is also important to note that it is possible for Ebola to be transmitted from pregnant women to their babies in utero, as well as during the babies’ delivery or by contact with bodily fluids from the mother, including breast milk (Ebola, 2019). It is also important for emergency managers to know that the Ebola virus disease is not transmitted through water or air as well as from newly infected people that have not developed any of the various symptoms of the disease (Ebola, 2019).
Although the majority of the cases of Ebola infection have occurred in remote regions of African countries (numbering fewer than 100 individual cases each), it is also important to take preventive steps when and if the infected victims reach health care facilities. For example, the international organization, Doctors without Borders (2019) counsels that, “During an outbreak, Ebola virus can spread quickly within health care facilities. Proper infection control in health centers is therefore vital to reduce risks for other patients, caregivers, and health workers” (para. 5). In sum, anyone coming into contact or providing health care services for infected victims of the Ebola virus disease must take precautions including most particularly the use of protective clothing and gear. In addition, from an emergency management perspective, it is also important for practitioners to fully comprehend the various symptoms that are associated with the Ebola disease virus to help identify victims at the earliest opportunity and these issues are discussed further below.
Symptoms and diagnosis of the Ebola virus disease
One of the more challenging aspects of diagnosing Ebola is the amount of time that may elapse from first exposure to the development of any discernible symptoms which can occur at any point ranging from just 2 days up to 3 weeks with an average of 14 days prior to the onset of discernible symptoms (Allam & Vonka, 2015). Although the disease tends to manifest itself in various ways in different patients, most victims share many of the same symptoms of Ebola disease infection. For instance, the clinicians at Doctors without Borders report that, “Ebola usually begins with a sudden onset of fever, weakness, muscle pain, headache, and sore throat. This is often followed by vomiting, diarrhea, and abdominal pain, which may progress to severe disease with altered mental status, shock, multi-organ failure, and sometimes abnormal bleeding” (Ebola, 2019, para. 6).
In addition, some of the other types of symptoms that are known to be associated with Ebola infections include problems swallowing and breathing, hiccups, red eyes and, chest pains (Ebola, 2019). The primary symptoms that are associated with infections by the Ebola virus disease are depicted in Figure 1 below.
Figure 1. Common symptoms of Ebola
Source: http://slu.adam.com/graphics/images/en/17160.jpg
Further challenging the early diagnosis of Ebola infection is the fact that the above-described symptoms are also common to a number of other serious diseases such as viral or bacterial infections of the intestines like typhoid fever, leptospirosis, influenza, yellow fever, dengue and malaria (Ebola, 2019). Therefore, it is also essential to ensure that people that are suspected of having contracting Ebola have appropriate screening samples tested in laboratories to confirm the diagnosis in order to provide them with treatment for their symptoms (Ebola, 2019). Laboratory testing for the diagnosis of Ebola. Such laboratory tests use testing methods that are capable of detecting the genetic material of Ebola. In the past, these types of tests required specialized medical technicians and modern laboratories which were frequently located great distances from outbreak zones (Ebola, 2019).
These significant constraints meant that health care practitioners, patients and family members were required to wait an inordinate amount of time in order to receive the test results for the Ebola virus. Following the end of the West African epidemic, however, an innovative test was developed using a small GeneXpert machine (see Figure 2 below) that facilitates the testing of patients for Ebola infections closer to outbreak zones (Ebola, 2019).
Figure 2. GeneXpert testing machine
Source: https://secureservercdn.net/50.62.173.69/9aa.913.myftpupload.com/wp-content/uploads/ 2018/07/omni-300x279-300x279.png
As a direct result of the GeneXpert innovation, testing for the Ebola virus disease has been simplified and the waiting time for receiving results has been reduced from several days to just a few hours, an improvement that has particular significance for responding to the ongoing outbreak in the Democratic Republic of the Congo (Ebola, 2019). It is important to note, however, that this simplified testing regimen lacks the same level of rigor of laboratory testing and any test results that indicate Ebola infection should be repeated after 72 hours for confirmation (Ebola, 2019).
Following the confirmation of an Ebola virus disease infection, it is essential for first responders to react quickly in order to contain any potential outbreak. Notwithstanding this essential need, it is also important to take the needs of patients and the communities in which they live into account when formulating an effective response to potential Ebola outbreaks (Ebola, 2019). This means that every situation demands a unique response, but some of the common features that characterize an effective response to the identification of new Ebola infection cases include the following:
· Care and isolation of patients, to prevent further spread and save lives;
· Community engagement and health promotion, to build community understanding of Ebola and participation in implementing necessary interventions;
· Environmental decontamination (such as spraying homes of patients) and safe, dignified burials of those who died from Ebola;
· Surveillance of affected and at-risk communities, to identify possible cases early;
· Contact tracing, to find and test anyone who had recent contact with a new Ebola patient;
· Supporting existing health structures to identify and refer potential Ebola patients and to maintain effective infection control; and,
· Vaccinations – although these are currently available, additional research and testing are required before vaccinations can be deployed on a wholesale basis in an infected region (Ebola, 2019).
Even after an outbreak has been successfully contained, however, the work of the emergency management team is not yet complete since it is also essential to ensure that effective surveillance protocols are in place to identify any additional potential cases of Ebola infections (Ebola, 2019). The World Health Organization (WHO) classifies an Ebola outbreak as being over only after 42 full days (or two incubation periods) have elapsed without any new confirmed cases of Ebola infections (Outbreak preparedness, 2019). Since many developing nations in Africa may lack the resources that are needed to achieve all of the foregoing interventions, assistance from the international community in helping them prepare for Ebola outbreaks also represents a timely and valuable investment in public health resources (Sirleaf, 2018).
Because there are no cures that are available for the Ebola virus disease, the treatment to date has largely focused on palliation of symptoms such as controlling pain, reducing fevers and the frequency of vomiting and diarrhea. In addition, other common palliative care treatments for Ebola victims include a rigorous hydration regimen to prevent dehydration and shock due to uncontrolled vomiting and diarrhea (Ebola, 2019). In those cases where patients remain alert, are not vomiting and are capable of actively participating in their own care after being infected by the Ebola virus disease, the hydration regimen may simply consist of providing them with rehydration drinks; in other cases, however, intravenous replenishment of fluids may be necessary (Ebola, 2019). In addition, therapeutic foods, vitamins and anti-anxiety medications can also help infected patients following infections by Ebola (Ebola, 2019).
There are studies currently underway that promise to expand this limited set of interventions to include more effective medications for treating the symptoms of Ebola and perhaps even provide an outright cure, but at present the foregoing steps are regarded as best evidence-based practices in the health care community (Ebola, 2019). Other steps that are considered absolutely essential for the provision of an effective response to potential Ebola outbreaks is the timely dissemination of accurate information about the disease to populations at risk and these issues are discussed further below.
Importance of timely and accurate information about Ebola
There are some valuable lessons learned from past outbreaks of Ebola that can help inform responses by emergency management managers today. For example, during the Ebola outbreak in Sierra Leone, Liberia and Guinea in 2014, there was global media attention focused on these countries and what steps were being taken by the international community and local health care teams to contain it. In the process, a great deal of misinformation about the disease was provided global audiences to the point where near-panic ensued. The fact that so many people were infected (more than 28,500 confirmed infections) and lives lost (more than 11,000 people died during this outbreak) made the disease sound even scarier than it truly is (Van Tongeron & Hook, 2016).
The lessons learned from the 2014 outbreak underscored the need for accurate information in order to prevent an isolated case of Ebola infection from becoming a full-blown epidemic. Indeed, some indication of the rapidity with which the Ebola virus disease can spread can be discerned from the spike shown in Figure 3 below showing the respective number of new cases of Ebola in Guinea, Liberia and Sierra Leone during the outbreak that lasted from March 24, 2015 through April 13, 2016.
Figure 3. The frequency of new cases in Guinea, Liberia, and Sierra Leone during the Ebola Outbreak from March 25, 2014 to April 13, 2016
Source: https://www.cdc.gov/vhf/ebola/images/epi-graphs/epi-graph-1.jpg

Shortly after the Guinea, Liberia and Sierra outbreak depicted in Figure 3 above, the U.S. Centers for Disease Control and Prevention (CDC) confirmed the first case of infection by the Ebola virus disease within the continental United States in September 2014, and the mainstream media responded by emphasizing the threat of a corresponding epidemic in America (Patwardhan & Raghunath, 2014). For example, according to Van Tongeron and Hook (2016), “For several weeks, the American media was dominated by warnings about a potential U.S. Ebola outbreak. With such widespread media coverage and the announcement of three additional confirmed cases, Americans grew increasingly panicked about the possibility of such an outbreak” (p. 133).
During an era when global transportation is increasingly available to people from all countries (with a few notable exceptions such as North Korea), it is not surprising that Americans – as well as citizens of other developed nations – were panicked by the threat of an Ebola epidemic, and the U.S. government responded by implementing a number of security measures, including strengthening border and airport security procedures, that were intended to detect and prevent such an eventuality, despite the lack of any evidence that such as threat was real (Van Tongeron & Hook, 2016).
The fact that many of these initiatives have a direct impact on American citizens who willingly accepted them underscores the severity of the public concern. In this regard, Van Tongeron and Hook (2016) note that, “By mid-October 2014, countless Americans felt vulnerable and concerned about their own lives. Concern about a U.S. Ebola outbreak became rampant, serving as a reminder of mortality, despite every indication that the risk of Ebola spreading in the U.S. was remote” (p. 134). Although the high-profile media coverage of the few cases that did occur in the United States did not help to dissuade American citizens that there was no need for panicking, the U.S. government attempted to reassure people that they were safe. In fact, then-President Barack Obama conveyed four goals to fight the Ebola virus disease on September 16, 2014 as follows:
1. Control the outbreak;
2. Address the ripple effects of local economies and communities;
3. Coordinate a broader global response; and,
4. Urgently build up a public health system in these countries (Lightsey, 2016).
Notwithstanding these comprehensive security measures and reassurances from the federal government, a majority of Americans remained concerned that the Ebola virus disease represented a direct threat to citizens in the United States and called from even stricter controls notwithstanding cautions by the health care community that additional security measures would hamper efforts to contain it. In this regard, Van Tongeron and Hook (2016) report that, “[In October 2014], 91% of Americans supported stricter airport screening procedures and 67% of Americans supported restricting travel to and from Ebola-affected West African countries, despite health officials' warnings that such isolationist measures would likely make the epidemic even harder to fight” (p. 134).
Against this backdrop, it is easier to understand the importance of disseminating timely and accurate information about diseases to refute rumors and misinformation, including most especially Ebola, to all stakeholders, particularly those that are at highest risk such as citizens of West African countries (Brand & Stela, 2014). Emergency management managers can play an important role in this area in ways that can reduce the adverse effects of the disease as well as help prevent future recurrences. For instance, according to Wigmore (2016):
Analyzing and contextualizing Ebola rumors is important because they show that although social mobilization, sensitization and an effective health response was important in the short-term, it was and is the more long-term and deeply ingrained social, political and historical problems that the international community needs to grapple with to ensure that Ebola outbreaks are controlled in the future. (p. 191)
These observations have special salience for emergency management teams and managers in Nigeria today who are faced with the potential for the Ebola virus disease to spread within their borders as discussed further below.

Identifying optimal emergency management strategies for Ebola in Nigeria
According to the World Health Organization (2019), Nigeria experienced its first confirmed case of Ebola virus disease infection in July 2016 when an air passenger returned from visiting his sister who ultimately died of the disease in Liberia. This victim began exhibited the symptoms of Ebola, such as vomiting during his flight to Nigeria, upon his arrival in the airport and yet again in the car that transported him to a local hospital where he informed the medical care staff that he had contracted malaria (Successful Ebola responses in Nigeria, Senegal and Mali, 2016).
The events that followed this misrepresentation of the victim’s actual disease clearly demonstrated the importance of screening patients for Ebola when they return from areas with known outbreaks of the disease. For instance, the World Health Organization notes that, “The protocol officer who escorted him later died of Ebola. As malaria is not transmitted from person to person, no staff at the hospital took protective precautions. Over the coming days, nine doctors and nurses became infected and four of them died” (Successful Ebola responses in Nigeria, Senegal and Mali, 2016, para. 2). Although none of the passengers that were on the return flight to Nigeria developed Ebola infections, it is clear that the lethality of the Ebola disease virus demands the accurate and timely dissemination of information so that first responders, emergency management teams, health care providers and citizens fully understand what is at stake but without causing undue alarm or panic in the process.
Certainly, time is of the absolute essence when responding to suspected cases of Ebola, but it is also vitally important for first response teams and/or health care practitioners to take the precautions noted above, including most especially wearing appropriate protective clothing and gear. Likewise, it is also important for national authorities to implement surveillance programs to identify potential hotspots of infectious activity among animals populations that are known carriers of the Ebola virus disease. For instance, outbreaks of Ebola are known to take place among antelope and non-human primates prior to or during a human outbreak. In this regard,
· Before Taï National Forest outbreak (1994), the chimpanzee population in the area decreased by half; and,
· Before and during Gabon outbreak (2001), 64 dead gorillas, chimpanzees, and antelope were discovered (Ebola, 2019).
In Nigeria, the potential for the spread of Ebola is heightened when local residents kill and butcher these animals for food, and once a single human is infected, the risk of an uncontrolled outbreak is very real indeed. Therefore, monitoring animal populations can help researchers predict a possible outbreak in a given region of Nigeria, thereby providing them with the time needed to deploy medical services to the area. At present, though, more than half (57%) of Nigeria’s population of more than 203 million people live in rural regions of the country (Nigeria people, 2019), meaning that there will inevitably be significant challenges in responding to outbreaks in these areas.
Moreover, even in the urban areas of Nigeria, formulating an effective response to Ebola infections can be difficult, constraints that further highlight the need for health care authorities to communicate accurate and timely information to a nation’s citizens as well as the world at large. For example, the World Health Organization emphasizes that:
When confirmation of Ebola virus was announced on 23 July [2014], the news rocked public health communities all around the world. No one believed that effective contact tracing could be undertaken in a chaotic and densely populated city like Lagos, with many poor people living in crowded slums and a population that swelled and ebbed every day as people came to the city looking for work or returned home when unsuccessful. Many envisioned an urban apocalypse, with Nigeria seeding outbreaks in several other countries, as had happened in the past with the poliovirus (Successful Ebola responses in Nigeria, Senegal and Mali, 2016, para. 7)
As noted above, people are scared of Ebola not only because of the potential for a veritable pandemic to occur, but also due to misunderstandings and misinformation about how the disease is spread and the risk the disease represents to them personally. To its credit, the Nigerian government, in collaboration with the World Health Organization, took immediate steps to not only effectively contain this potential outbreak, but to provide accurate information to citizens concerning warning signs of the disease and what steps they should take if they believed they were infected.
The Nigerian government launched a house-to-house information campaign and communicated with the public through local radio stations in the dialects spoken in various regions of the country (Successful Ebola responses in Nigeria, Senegal and Mali, 2016). In addition, existing resources that were being used for polio surveillance including global positioning systems for mapping purposes were adapted to focus on the Ebola disease. Moreover, the country’s political leadership also established isolation facilities and a fully equipped emergency operations center to coordinate the work by specially trained health care staff for diagnosing the disease.
This was no small undertaking by any measure, but the successful outcome of the Nigerian’s government’s intervention in this situation made it clear that providing all citizens with the information they needed during this crisis was just as important as the medical services that were provided by community health workers to victims. In fact, the Nigerian government achieved 100% contact tracing in Lagos during this episode (Successful Ebola responses in Nigeria, Senegal and Mali, 2016). Given the profound constraints that were involved, this was a remarkable achievement, but it would not have been possible without community health care workers.
The 2014 incident clearly underscored the need for a cadre of well trained and knowledgeable community health care workers who can “take the message about Ebola to the streets.” For example, according to Shuaib and Gunnala (2014), community health workers in Nigeria played an essential role in containing the Ebola virus disease. In this regard, Shuaib and Gunnala (2014) report that specially trained community health workers “worked with community leaders, going house to house to provide important information about Ebola and searching for active cases and contacts, and they helped local religious leaders to expand their education and outreach strategies, especially in efforts to reduce transmission during funerals and burials” (p. 867).
Beyond the foregoing measures, community health workers in Nigeria also served other important roles such as data collection for aggregation, providing citizens with information concerning culturally appropriate protective practices, and essentially helped prevent a full-blown Ebola outbreak. This achievement was all the more noteworthy given Nigeria’s large population and dense urban areas which could have made the outbreak far worse than that experienced in West African countries (Perry & Dhillon, 2016). In sum, then, Nigeria mounted an immediate response, including a high-profile community information campaign, to the first case of Ebola identified in 2014 that proved highly effective in reducing public anxiety and improving the ability of the nation’s network of responders to deliver the medical services that were needed in a timely fashion.
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