Ebola virus: current realities and myths

By Akinyinka Akinyoade[1] and Bisola Adebayo[2]

At the end of September 2014, twenty-four hours after the US government cautioned the Nigerian government not to be hasty in declaring the West African country Ebola-free, the US discovered Ebola victims on its own shores in Texas. This source of Ebola in the US was not from the mediatized deliberate airlifting of victims from ground-zero of the epidemic in Sierra Leone, 7000 km away, to Atlanta and Charlotte (USA) for treatment in high-class medical facility, as was done last August. This time it was a man, Mr. T. Duncan, who returned home after visiting Liberia to the warm embrace of his family in Texas. Within another twenty-four hours, more than eighty persons who had been in contact with the Liberian-American had been quarantined in a bid to cut of opportunities of spread of the disease. The scenario is reminiscent of how the disease got into Nigeria before it was brought under control. A Liberian-American had flown into Nigeria, with him Ebola, last July. By the time he passed away, he left in his wake seven persons dead (five were health workers), scores infected, and over 900 direct and indirect contacts to index case. They could all be contacted, some were quarantined across the two states where over 20 million people are living in the densely populated urban areas of Lagos and Port Harcourt.

This article goes beyond giving statistical updates of the spread of the Ebola virus; it highlights socio-cultural as well as medical issues surrounding the current outbreak in West Africa and elsewhere.

Levity of decision-making, borne out of ignorance

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• Photo: Gabriele François Casini/MSF

The dreaded Ebola Virus Disease which is now causing so much panic worldwide is, however, not a new pain. It affected hundreds in the Democratic Republic of Congo (DRC) in the 1970s. The current outbreak in Liberia and Sierra Leone in West Africa was traced to an index case in Guinea. From this epicenter it found its way to Nigeria, Ghana, France, UK, Germany and USA - suspected and actual cases. In July 2014, the critical illness of a Dr. Patrick Sawyer before leaving Liberia for Nigeria was not a secret to himself, nor to his family, his country or his employer. Upon discovering that he had had physical contact with his sister around the time she died of the disease, ArcelorMittal, the iron mining company which employed Sawyer, suspended him from work (9 July, 2014) and referred him to the Liberian Health Ministry for testing and close observation for the mandatory 21-day period. But Liberia’s Deputy Finance Minister for Fiscal Affairs, Sebastian Muah, gave Sawyer clearance to travel to Nigeria for an ECOWAS (Economic Community of West African States) meeting at the time he was supposedly under close medical observation. Isolation for treatment is alien to West Africa, whatever the reason; it is easily translated as ostracism from the community before death, so to speak. Such was the levity of decision-making, borne out of ignorance, perhaps out of a misunderstanding of the nature of an Ebola infection. It could be taken for malaria, flu etc. Indeed, up till now, there is no cure or vaccine. Nigeria questioned why an infected person was officially cleared to fly into Nigeria by a Liberia Government Minister who ought to have known better. Mrs Decontee Sawyer, the late Patrick Sawyer’s widow, purportedly declared that her husband went to Nigeria in search of a cure for his illness, in the backdrop of the inefficiencies of Liberia’s health care system. The pre-Ebola health status of Liberia showed the country already had enough public health and sanitation problems to contend with. It ranks very low on the human development index (HDI), at position 175 out of 187 countries.

Aggressive identification, isolation, and treatment of infected persons

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• From: Reliefweb

The Ebola-origin notwithstanding, Nigeria decided first to curtail and contain the spread of Ebola without bothering about conspiracy theories surrounding the quasi officially supported sending of an Ebola-infected person into Nigeria. The curtailment was robust and decisive. The population of Lagos State is more than those of the current Ebola epidemic epicenters Guinea, Sierra Leone and Liberia together. Aggressive identification, isolation, and treatment of infected persons and persons contacted by index and secondary cases, led to hundreds of people being quarantined and eight fatalities. Proportion-wise, it was a 2% fatality rate compared to existing accounts of nearly 55-70% (depending on whose account) of the current epidemic in the other countries.

The speed of the spread of the recent emergence in parts of West Africa has been devastating in volume but not in proportion. The BBC on 2 October published a calculated rate of five infections per hour in Sierra Leone, 7400 being infected (and they are still counting) and 3439 fatalities in West Africa. In the past, fatalities were recorded to have reached 90% in DRC, Uganda and elsewhere. The survival rate recently has improved to 45% due to early detection and awareness campaigns. But the epidemic has decimated the ranks of health workers and others who have had direct and indirect contact with infected persons. It is a real threat that should not be treated with the usual levity with which we treat so many other things.

Rotimi Fasan, commented - as far back as 13 August - in Nigeria’s Daily Vanguard, that our response to the disease needs to be more diligent. To give Ebola room in Lagos, with its almost 16 million people living in close quarters, is to court annihilation. To allow it take root in any other part of the world is to court disaster in unprecedented scale. In the backdrop of Nigeria’s relatively higher success in containing Ebola, the US authorities have followed a similar path of decisive action in Texas.

Virus not easy to identify

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• From: International SOS

Lubna Abdel Aziz of Al Ahram Egyptian Weekly submitted that the “Ebola virus is not easy to identify. No wonder there is considerable alarm and tribulation in the US, over the very first ever Ebola-infected patients on their soil. First discovered in 1976, its origin remains a mystery though some believe the fruit bat is the culprit. Its incubation period of only two to 21 days, makes it highly infectious but not highly contagious, because it is not airborne. It can only be transferred through bodily fluid, that is through sweat, vomit, diarrhea, blood, urine or semen. The virus however can stay alive for several days, so it can still be contracted from contaminated surfaces, such as bedding, clothes, door-knobs etc. Nonetheless, it can only get into your body through an opening, a cut or a scratch or by touching food and eating it, hence the minimal contagion.” Early symptoms of the disease include fever, sore throat, fatigue and headaches – all flu-like. It gets worse as other symptoms like vomiting, diarrhoea and loss of appetite sets in. This may escalate to internal and external bleeding (from skin rash), resulting in excessive loss of blood, organ failure and death.

Some infected people are able to survive when provided with supportive care to prevent dehydration. Recovery time is quick and complete for some, and while it remains a serious public health risk, it is a disease that can be contained through public health measures around better sanitation and hygiene. The Zmapp experimental drug developed in the US has helped some victims so far; others, like the Spanish priest who also got infected and was administered the same drug, did not live to tell his tale. Drug or vaccine intervention is still some way off. The West African Post-graduate College of Pharmacists (WAPCP) recently organized a symposium to canvass for precautionary measures on Ebola, in order to prevent the spread. Precautionary methods may include: frequent hand washing with soap and clean water; culling infected animals to reduce animal to human contact; close supervision of burial or disposure of animal remains; avoid crowd gatherings; avoid traditional burial rituals such as embalming bodies; wearing gloves and appropriate protective equipment when taking care of ill patients. No matter the love there is for loved ones, first symptoms should be reported to health care centres and patients isolated for treatment.

The social impact of the epidemic

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• From: CDC

The impact of the Ebola epidemic is more than epidemiological, and that is where the fear rattles the population more than one can imagine. Socio-cultural issues are part of the drivers for the outbreak, but also form a substantial part of the interventions to contain it. Socio-cultural issues are also arising from the current outbreak.

Firstly, irrespective of national medical advances, an index case that is not identified quickly has the probability of infecting thousands at frightening exponential speed.

Secondly, an easy route of transmission is an innocent handshake (sweaty palm of an infected person joining with the palm of a friend who had earlier been accidentally pricked). Now, handshaking has been indirectly banned. Four days after the first death from the Ebola virus was recorded in Rivers State (Nigeria), Governor Amaechi strongly advised: “Please, no more handshake, keep your hands in your pocket until we contain the disease”. In West Africa, handshaking does not only represent greetings; it is camaraderie, respect, agreement, and conspiratorial friendship, ending with a snap of two middle fingers by the greeters. The social soul is now seen as a possible route of transmission of the dreadful disease. It is like advising two friends or foes in Holland not to greet each other anymore with the perfunctory three pecks at the cheek level. Or telling Americans not to high-five anymore. Horror of horrors.

Thirdly, citizens of Guinea, Sierra Leone and Liberia are fast becoming international pariahs – Saudi Arabia recently banned Muslim pilgrims from those countries from performing the Hajj, so as to ensure stress-free pilgrimage for other faithfuls from all over the world. This year, there will be no new Alhajis or Alhajas (depending on local title appellations given to successful pilgrims) in those three countries – perhaps this year could be their last on earth for other reasons, unfortunately, the chance to perform Hajj is gone for life. No pun intended.

Fourthly, due to the uncertain nature of recognizing what is indeed an Ebola infection, patients struck with other disease conditions similar to or confused with Ebola, get rejected at medical facilities and eventually suffer the consequences. Such was the case of the Udo man in Ovia South West Local Government Area of Edo State (Nigeria) who died of bleeding from peptic ulcer, as medical officials rejected his plea for treatment upon the confusion that the man probably harbored the Ebola virus. The community was panic-stricken and people fled home, causing refugee-like situations in other communities; it was a herculean effort by the Edo State government to defuse the situation.

Fifthly, salt prices surged as the public bought salt in large quantities. Salt+water+sugar solution is used as oral rehydration therapy (ORT) to put Ebola patients on their way to recovery. Rumours had it that if one bathes with salty water, chances of getting the disease substantially reduce. Thus the scramble for salt; thus the rise in market prices of salt in Nigeria.

Sixthly, foodstuff prices rose in Sierra Leone as the government implemented a 3-day stay at home order in September, in order to track hidden cases. Even worse, the government of Cote d’Ivoire gave shoot-at-sight orders to border police to curtail immigration across land borders with Liberia. In Liberia itself, armed military personnel were drafted to seal off suspected communities. So much for the ECOWAS protocol on free movement of persons in the sub-region.

Seventhly, the Ebola virus outbreak occurred in Nigeria during the long school vacation period (July-August). In the wake of Patrick Sawyer’s entry into the country, the Nigerian government had rallied into action, mobilizing health and material resources to respond to the emergency. Energy was expended on creating awareness among the public, tracking and putting infected persons into quarantine in designated centres. The federal government went further to order immediate closure of all summer schools and postponement of resumption dates of regular schools in order to stem the tide of the Ebola virus. This was to minimize the risk of spreading Ebola among the very vulnerable demographic group of children, who could not be trusted to maintain the same high level of hygiene or precaution as adults would in a public health system. Private school owners were peeved; this announcement had direct implications for their incomes; they called for government to cancel the decision on extended closure. But common sense prevailed that, though their means of livelihood were in danger, it was expedient not to sacrifice safety on the altar of economic considerations.

Low transmission rate compared to airborne diseases

The disease has triggered a lot of speculation and fear. This recent 2014 outbreak across Africa is said to be the largest outbreak yet, affecting countries like Liberia, Sierra Leone, Guinea and Nigeria. It has recorded the highest number of cases and deaths. But comparatively, the transmission rate is considered low compared to airborne diseases such as tuberculosis and influenza. Health workers and family members of the infected are considered to be at highest risk of contracting the disease.

According to media sources, Dr. Liise-Anne Pirofski, based at the Albert Einstein College of Medicine in New York, does not “see Ebola as the biggest infectious-disease worry”. The flu is still a major killer in the United States. Methicillin-resistant Staphylococcus aureus (MRSA), a strain of staph bacteria that does not respond to the antibiotics traditionally used to treat  a flu infection, can still be acquired even in advanced health-care provider settings. MRSA is still capable of causing life-threatening infections, particularly in hospital patients. Also, the US record 820,000 new cases of gonorrhea yearly, 30% of which are resistant to existing drugs. Resistant bacteria are an urgent threat. While they rarely kill infected persons, conditions such as pelvic inflammation and infertility can result from untreated gonorrhea in women, as can the life-threatening condition called disseminated gonococcal infection, which is characterized by arthritis, inflammation of the tissue covering tendons, and dermatitis. 

Successful contact tracing

Dr Bisola Adebayo, Senior Registrar in the Department of Community Health and Primary Health Care at Lagos State University Teaching Hospital, and currently drafted to the Ebola Emergency Operations Centre (EEOC) in Lagos, points out some of the obstacles the EEOC had to contend with. They include: fast-tracked training of health care workers who were not up to the level of the required knowledge about the Ebola Virus Disease, as shown in initial operation research in Nigeria; radio and TV jingles had to be stepped up as it was noticed that most people could not recall the helpline number off hand; sub-national differentials in level of awareness and understanding of the phenomenon, which made contact tracing initially difficult (many believed that the disease was not real). The social mobilisation team of the EEOC has been adapting messages to the public according to their findings; Nigeria’s National Orientation Agency (NOA) was used for getting sensitization messages across. Factors contributing to the success of contact tracing was the high level of reliance on the use of doctors, nurses or residents in the Nigeria Field Epidemiology and Laboratory Training program for contact tracing, as well as the high level of partnership and collaboration between the Nigerian Center for Disease Control (NCDC), Médecins Sans Frontières (MSF), the Association of Public Health Physicians of Nigeria (APHPN), the Red Cross, the WHO and  the US Center for Disease Control and Prevention. The latter is now in the eye of the Ebola storm in the US.

Akinyinka Akinyoade and Bisola Adebayo/ASCLeiden, 9 October 2014

Visit the ASC information portal on the 2014 outbreak of Ebola in Africa.