Ebola Outbreak – Influencing Social And Politicoeconomic Dynamics And Determinants

Finnish Red Cross/Maria Santto Rinsing Ebola protective gear in Beni, Democratic Republic of the Congo. (31 May 2019).

Ebola is a Zoonosis – Scientist (Farmer and Mukherjee, 2018) describe it as it has spring to human from animal hosts – which is caused by a filovirus (a thread like virus that causes internal and external bleeding).

In 1976 it was initially represented in rural Congo, not far from the Ebola River, as an acute onset condition characterized by symptoms of fatigue, accompanied by fever and abdominal pain.

Because of this, Ebola represents a pressing global health crisis, resulting in a peak epidemic that expose the need to forge fruitful alliances across boundaries and disciplines, and the degree to which all human lives are equally respected.

In West Africa, the 2013/14 Ebola virus pandemic (EVD) has an outcome amplified as defined in more instances and deaths than all previous EVD outbreaks (Shears & O’Dempsey, 2015).

Especially high rate of infection and mortality in healthcare workers (HCWs) has been recorded (Shears & O’Dempsey, 2015).

As a result, the destructive effect of Ebola is unparalleled, affecting over 28,000 people and contributing to over 11,000 deaths of infected individuals (Moon et al., 2015) and halting national health systems.

The outbreak of Ebola 2013/14 was officially confirmed to the World Health Organization (WHO) on an outbreak of Ebola virus disease (EVD) in Guinea on March 23, 2014, although other researchers say that the outbreaks began in October 2013 (La Torre et al., 2014).

On August 8, nearly five months later, the WHO declared the epidemic of international concern as a public health emergency (La Torre et al., 2014; WHO, 2014).

The Ebola outbreak in West Africa in 2014, which mostly affected Guinea, Sierra Leone and Liberia, and some sparing cases in some other nations, in the number of cases, surpassed all previous Ebola outbreaks.

Prior to the 2014 outbreak, there were 20 major outbreaks of Ebola virus disease in Sub-Saharan Africa, the largest being that in Uganda in 2000, with 425 cases and a 53% mortality rate.

Following the first outbreaks in Sudan and Zaire in 1976, Ftika et al (2013) also found that transmission in healthcare facilities among caregivers/healthcare staff has been a major priority.

The phenomena acted as amplifiers that enabled the spread of the culture (Shears & O’Dempsey, 2015). La Toure et al (2014) also found that mortality rates after Ebola infection are 25 percent in primates (a chimpanzee population in Cote d’Ivoire in the 1990s).

Alternatively, bats are known to be the best choice for the virus reservoir, acting as the backdrop for constant contact between humans with the ecosystem and wildlife.

Fruit bats may serve as a source of infection, since they become asymptomatic, even infected with Ebola. Another argument about the transfer of the infection from bats to humans is suggestive of this.

As suggested by (Leroy et al., 2009), this occurrence connects the outbreak of Ebola in humans due to the ingestion of bat meat. The major reasons for the high incidence rate are the lack of funding for infection control.

Ebola Zaire (ZEBOV), occurring in outbreaks in the DRC, Gabon, and the Republic of the Congo, Ebola Sudan (SEBOV), occurring in southern Sudan and Uganda, Ebola Bundibugyo (BEBOV), occurring in Uganda and DRC, Ebola Tai Forest, occurring in a single case in Cote D’Ivoire, and Ebola Reston, are five strains of Ebola virus described( Matua et al., 2015) which has occurred in non-human, laboratory primates linked to the Philippines, with a small number of asymptomatic human cases.

WHO (2014), Leroy (2014) and Matua et al. (2015) recorded that ZEBOV rates range from 60 percent to 90 percent, taking into account the virus pathogenicity, SEBOV strain led to case fatality rates of 40-60 percent, while the BEBOV strain contributes to 25 percent fatality rates.

Matua et al. (2015) noted that in up to 90 percent of infected patients, the virus causes acute fever and death, frequently associated with hemorrhagic symptoms.

In a single non-fatal human case, the CIEBOV subtype was implicated. As a result of multi-organ and multi-system failure and hypovolemic shock, the virus is thus considered very infectious.

The high fatality rate, 60 percent to 90 percent of the recent outbreak in 2013/14 as indicated by the wider spectrum (Rajak et al., 2015; Matua et al., 2015), was based on the time of diagnosis, sympathetic drug accessibility.

Infected persons normally die 6-9 weeks after the first indications but differences in death rates have been detected between epidemic and during an epidemic (Rajak et al., 2015).

In other perspective, data from (Shiwani et al., 2016 ; Taylor et al., 2016) revealed that in 97 (male) survivors of Ebola virus disease, viral RNA was detected in 37% of patients, with 18 months being the longest gap between active disease and detection.

The international spread of the virus across borders, which includes the possible use of the viral isolates as a possible tool for bioterrorism make EVD an important public health concern of global proportions (Matua et al., 2015; WHO, 2014). This eventually raise the Ebola outbreaks to be associated with widespread fear.

Rajak et al., (2015) presented that the disease has an incubation period of 2-21 days (average 4-10 days) followed by its associated symptoms. The general reproductive number (R0) of 2014 Ebola outbreak was estimated at between 1.5–2.5 for the most affected countries – Sierra Leone, Liberia and DR Congo ( Althaus, 2014; Fisman et al., 2014;).

However (Althaus et al., 2015) provide a contrasting perspective into Nigeria that, the first phase of the EVD outbreak in Nigeria can be considered a severe diffusing event providing an assumption that, the probability that a singular individual generates ≥ 9 cases would be 2.6%. And this could be associated to Nigeria’s population and community arrangement and architecture.

Kilmarx et al. (2014) argue that Ebola outbreak was more common among health workforce in the West Africa country-Sierra Leone. Base on the number of HCWs reported in 2009 as a denominator for HCWs compare to infection rates in the general population aged ≥15 years, Ebola incidence rate in HCWs and non-HCWs is approximately 100-fold higher in Sierra Leone and this is the estimated confirmed cases and this is confirmed by data from (Kilmarx et al., 2014).

Kilmarx et al had indicated that for about 159 (80%) confirmed HCW Ebola cases with data on funeral attendance, 13.8% had attended a funeral, compared with 32.3% in non-HCW. Funeral attendant is common and embrace by most communities in West Africa hence as a social norm, it also contributed to the severe outbreak among the West African Countries.

As a result the health workers force death by selected countries follows that Eight hundred and eighty one healthcare workers were infected during the 2014 Ebola outbreak and 513 died due to the disease (Shiwani et al., 2016).

The healthcare workforce in Liberia, Sierra Leone and Guinea was reduced by 8%, 7% and 1%, respectively (Shiwani et al., 2016; CDC, 2015). In Sierra Leone, accordingly, experienced a drastic 23% decrease in the delivery of health care services.

EBOLA OUTBREAK AND SOCIAL HEALTH DETERMINANT
Nukunu et al., 2020 has pointed out that sub-Saharan Africa faces evidential difficulty in its ability to respond to health crisis.

The assessment went further noting almost the entire African continent as “least prepared” to treat the sick and protect health care workers, and claim most countries lack the logistical equipment and practices in infection control, although in the case of Covid-19, Africa continent seems to have recorded the least infection rate. Nukunu et al therefore iterated that, majority of Sub-Sahara African countries have outdated equipment and considered inadequacy in infrastructure to deal with a global pandemic hence may contribute to it spread.

(Nukunu et al., 2020) has argue again that in Africa the concept of solitude hence social distancing is not of common norms and that most residence and communities were not properly plan and as such about 56 per cent of Africa’s urban population live in slums where it is not possible to follow proper hand hygiene rule, social/physical distancing.

Residents often engage in casual jobs that call for contact with others, and staying at their abodes is not an option in times of outbreaks.

On rapid assessment of Ebola infection prevention and control needs in six districts, in Sierra Leone, (Pathmanathan, et al., 2014) suggested that Health system gaps that exist which has been identified were deficiency or absence of; skilled health care staff, personal protective equipment (PPE), safe patient transport, and standardized infection prevention control rules.

This constraint fall within the general socioeconomic, cultural and environmental conditions health determinant as prescribed by Dalghren & Whitehead (1991) health determinant model and also agrees with Barton & Grant (2006) model which focuses on Build environment.

Farmer & Mukherjee (2018) observe that the most at risk group contracting the disease are those who are general caregivers – and not only nurses and doctors, but mothers and sisters.

Farmer et al again emphasized that, about 75 percent of those afflicted with Ebola are women who are largely care givers as defined by socio-cultural practices. It has been presented by (WHO, 2018) as cited by (Okeke, 2019) that, in an anthropological survey on the socio-economic impact of Ebola, across all ages were affected nonetheless, the active population (15-40 years) were the majority of the cases with women (50.8%) being more affected compare to men (49.2%) and the significant case rate among women is because in ‘social and community’ layers, of health determinant, caregivers are mostly women.

Since the Ebola virus (EV) disease is ideated to be of zoonotic origin, different researches have tried to identify the reservoir of EV.

Primates were considered as rather unlikely to be the reservoir (La Toure et al., 2014; Nakayama & Saijo., 2013) as it was observed that they were susceptible to the development of the disease while infected. Other findings by (Galas, 2014) have shown some evidence that fruit bats may be the reservoir of the Zaire Ebola Virus.

This conclusion was arrived after a discovery of three tree-roosting species: Hypsignathus monostrosus, Epomops franqueti, and Myonycteris torquata having natural infection identified by the viral RNA and antibodies (Galas, 2014).

Galas again identify that, with respect to Ebola virus susceptibility, several reviews of available evidence does not reveal any known natural resistance for Ebola Virus infection. Hence making everyone susceptible to the virus infection.

The only way to mitigate the spread of the Ebola virus infection is through reliability of vaccine. Yet vaccine development has delayed over the years. While Ebola virus is not a new epidemic, it is inexplicable that there has not been focus on vaccine development in the past 40 Years until the development of Zmapp vaccine triggered by the 2013/2014 Ebola outbreak (John, 2017).

Other vaccines which were in trials namely Glaxo Smith Kline’s cAd3 and rVSV (recombinant vesicular stomatitis virus) from New Link Genetics and the Public Health Agency of Canada (Donovan, 2014 and Kanapathipillai et al., 2014) and during 2015 it was tested in Guinea revealing advanced protection against the Ebola virus (Okeke, 2019) which even delayed.

Although not totally licence except for experimental use only, It’s reported by (John, 2017) that scientists began the vaccine trials for Ebola virus on primates decades ago yet (Grady, 2014) iterated that, the research was stopped due to lack of funds and identified that, there are several other scientific, social, demographic and political factors pertaining to the delays in vaccine development.

The work of (John, 2017) justifies that, scientific complexity of the virus is a key reason for the delay as there is no clarity of the underlying pathogenicity of the Ebola virus disease.

In floaty to the global social determinants of health (SDH) (Eshetu and Eshetu, 2011; John, 2017) has indicated that in poverty-stricken nations as compare to developed nations, there is evidential health disparity.

(John, 2017) further argue that the Ebola outbreak was severe and the widespread and prolonged duration taken to contain the virus in the West African countries have been due to the continued civil war, in countries like Liberia and Sierra Leone and such countries were not recovering.

This phenomenon severely crippled their health and economic resources amidst having had only one doctor for every 100,000 people before the epidemic outbreak (Rothstein, 2015).

Wilkinson (2003 ) has clearly signify that poverty may be the primary factor that is responsible for poor health and untimely disease control in Africa as there is lack of basic needs and primary health settings.

Other factors that promoted the fast and wide spread of the Ebola is Poverty central channel to ill-health, illiteracy, unemployment, poor sanitation, starvation and lack of access to basic health care services (Eshetu and Woldesenbet, 2011).

This is further compounded by the Social and cultural practices such as hand shaking, customary burial and funeral methods. And consumption of bush meat as it’s evident the consumption of bat among the natives of the Liberia (John, 2017).

The Guinea’s Ministry of Health, has linked 60% of cases in the country could be to traditional burial and funeral practices. WHO domain in Sierra Leone estimated that 80% of cases in that country were also linked to the funeral practices.

Example is some mourners anoint others with rinse water from the washing of corpses (WHO, 2018). Patronage of traditional healers hitherto the usual primary caregivers prior to the occurrence of Ebola continued.

This is because traditional healers have been part of the system for centries. In the case of Ebola, their pseudo-science practices undermine the benefit of early presentation to the hospital and hence propagating the spread of the virus (Okeke, 2019).

Others also thought that the disease was caused by “cursed untruthful hunters’’ (CDC, 2017). Others denied the existence of the virus and unfamiliarity with the virus and its control measures including disinfecting houses and lack of trust also fuel the spread of Ebola virus disease (Troncoso, 2015).

(WHO, 2018; CDC, 2017; Okeke, 2019) has indicated that individual lifestyle of the most affected population contributed to the dissemination of the Virus and (John, 2017) research supported that majority of the rural populace engaged in hunting of bats, monkeys and other wild primates for food called “bush meat”.

The spread of Ebola virus from animal species to human occurs in the events of native dish preparation when animal body fluids touch humans.

This findings was supported by (Okeke, 2019), where she identify that, corpses/cadavers have high viral loads, such customary funeral practices ensue by observance of washing and touching of corpse often promotes multiple widespread since it main manner of infection in human is through direct contact with a symptomatic or dead cases.

ECONOMIC DETERMINANTS
Okeke (2019) has reported that poverty also facilitated the spread of the disease. Nonetheless, it’s worthy to note that, Communities have been quick to learn and adapt practices to reduce transmission of the virus as accounted by (Shelley-Egan and Dratwa, 2019; Leach, 2015; Richards et al., 2015) that, communities in the three countries learned about the realities of Ebola, they began to undertake their own safe care, isolation just as communities that have longer experience with Ebola, example being DR Congo and Uganda, have done already for over 10years.

Okeke further reported that the outbreak had a more significant proportion of the population live beneath poverty level across the affected countries hence as an example; impoverishment rate magnified by 2.2, 5.5 and 13.8 per cent in Guinea, Liberia and Sierra Leone respectively and (WHO, 2018) explain that food security as indicated by the prevalence of under-nutrition was negatively affected with an increase in percentages of 4.2, 4.1 and 1.7 in Liberia, Sierra Leone and Guinea respectively in 2016.

To further elaborate on socio-economic layers as a determining factor which affected Ebola control, Ebola has destroyed much of the progress achieved through considerable political, social and financial efforts by local and international authorities after several civil unrest in especially Liberia and Sierra Leone. This has greatly slows down development and economic improvement.

On the onset, Ebola pandemic was though to be a sanitary situation contrary to it being only human-centered, and the effects in the future on political stability, socioeconomic activities and education were unattended. The 3 countries were labelled to lose at least US$2.2 billion in 2015 as forecasted by the World Bank due to the epidemic.

The economy of Sierra Leone economy dwelled by 23.5% due non operation of the mining sector. The cost of recovery from the Ebola far outstrip the total amount of aid received by the three countries in the past, and is calculated to be of US$812 million for Liberia, US$844 million for Sierra Leone and US$2,890 million for Guinea for the 2015 to 2017 period.

RACIAL CONTRIBUTING FACTORS OF EBOLA SPREAD
Among the Global ecosystem layer, there was racial divisiveness that accounted for the lack of harmony among the West African countries and the Westerners.

(Shelley-Egan and Dratwa, 2019) highlighted the socially divisive racial preferences. Trust was also lost as WHO delayed to respond to the outbreak.

Shelley-Egan et al recounted that Sierra Leone’s top Ebola doctor, Dr. Sheik Humarr Khan, died of the disease in late July 2014, while being considered for evacuation to a European country, and while a dose of Zmapp was available.

(Sanders et al. 2015) confirmed that the WHO disallowed another infected doctor in Sierra Leone, Dr. Olivet Buck, to leave the country or to fund an evacuation, the WHO accounted that it would work to provide Buck with “the best care possible” in Sierra Leone. Consequently, Buck died during September 2014.

This perceived socially divisive “optics of racial preferences’’ and demeanour by the WHO officials however is justify, as it allowed the concern and relief about the evacuation and treatment of western healthcare personnel (Shelley-Egan, 2019) and raised questions about how the world responds to the Ebola crisis and to those working on the ground to stop its spread (Sanders, 2015).

The international issue was “sternly divided along colonial (and quasi-colonial lines)”. France assumed responsibility for Guinea, the United States for Liberia and Britain for Sierra Leone.

Wilkinson and Fairhead opinioned that “Perhaps there was something qualitatively different in the styles of foreign assistance each country received through their ex-colonial power”

PUBLIC HEALTH FOCUS FOR FUTURE INTERVENTIONS

In future to mitigate Ebola and in perspective, pandemic at Social and familial level, it is crucial to create awareness to avoid consumption of bush meat and contact with infected animals.

This should be carried out through targeted local languages at community levels (Frieden, 2014). Coupled with awareness, at community plane, it is significant to have culturally appropriate education delivered to the local community about the perils of customary burials and required when handling cadavers.

This has been exemplified by Nigeria, within Africa, Nigeria has paved the way in eradicating Ebola by were it makes awareness about the effects of Ebola in newspapers, magazines, social media and almost every office being mandated to install sanitizers to maintain good hygiene, therefore showing other countries to make use of the limited resources (Mordi, 2014).

I also proposed ‘’reactive’’ and ‘pre-emptive’ approach to manage future Ebola epidemic as also suggested by (Mutua et al 2015).

The “reactive”, approach containment efforts aimed at halting the spread of existing outbreaks. Hence for better outcome, a suggested addition of “pre-emptive” strategies also need to be initiated.

Therefore, largely, implementing both “reactive” and “pre-emptive” strategies is more likely to lead to better epidemic preparedness and response at individual, community, institutional, and government levels, resulting in timely containment of future Ebola outbreaks.

The context to fixing health inequalities which developed as a result of the outbreak, the affected countries should work to resolving the social and economic inequity by establishing poverty alleviating interventions through strategic partnership and coordinations. (Eshetu, 2011).

The Africa Centre for disease control and Prevention should jointly work with the ECOWAS regional body to set up response and data management centres at various dedicated health/infectious diseases management centres.

The collection of data and it distribution will inform timely response and decision making easier hence making resources mobilization possible.

Environment control of possible reservoir such as the fruit bats should be advocated. This advocacy should include banned by the various West African state government in markets and for culinary purpose and prohibited.

This act could be tactically enforce using traditional community by-laws and believe systems tailored to their understanding. It is strongly recommended that better cooking rather than removal of the bats as food items may be more rewarding (Nwabuko, 2018).

In addition, there should be a joint health and epidemic preparedness coordination among the West Africa states government centrally and strategically coordinated. The various governments should also invest in core capacity building, training and logistics.

There should be upgrade of existing infrastructure while investing in public health and infectious diseases research.

Dr. Promise Edem Nukunu, MD (HM), BSc. Dentl
He was an intern at Noguchi Memorial Institute for Medical Research (NMIMR) and currently serves as volunteer Scientist for SARS-CoV-2 at NMIMR.

Edem Promise is a member of the Medical Journalists’ Association – Ghana and a member of the World Federation of Science Journalists as well as a member of the Global Emerging-Pathogen Treatment (GET) Consortium. (PLUS Faculty). Reach out to him via correspondent e-mail: penukunu@st.ug.edu.gh

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By. P. Edem Nukunu

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