i

KNOWLEDGE, PERCEPTION AND BELIEF OF EBOLA VIRUS DISEASE

(EVD) AMONG THE RESIDENTS OF PALLADAN, ZARIA.

BY

MUSA, IKO

(U07MD1104)

A FINAL YEAR PROJECT SUBMITTED TO THE DEPARTMENT OF

COMMUNITY MEDICINE, IN PARTIAL FULFILMENT FOR THE

AWARD OF THE MBBS DEGREE BY THE AHMADU BELLO

UNIVERSITY, ZARIA.

JANUARY 2015.

ii

DECLARATION

I hereby declare that this project was written by me and it is the product of my research work.

All sources of my information and where applicable other writers’ view have been duly

acknowledge in form of references.

MUSA, IKO ________________________

U07MD1104 sign/date

iii

CERTIFICATION

I certify that this research work was carried out by MUSA IKO (U07MD1104) under my direct

supervision.

___________________ ________________________

DR. IBRAHIM DANGANA Sign/Date

(Project Supervisor)

iv

DEDICATION

This piece of work is dedicated to my beloved late father Mr. Musa Wundu

v

ACKNOWLEDGEMENT

I return all praise, honour and glory to the Almighty God who has been my strength and fortress

all these years and who has seen me through this great work. I deeply appreciate my supervisor,

Dr Ibrahim Dangana, for his unreserved commitment, tutorship and guidance throughout this

work. May God bless you sir.

To my sweet mother, Mrs. Deborah Musa, my elder sisters (Amina Musa, Ladi Musa), my

beloved brothers (Samuel, Joshua, Rufus and Benjamin) and my beloved sisters (Amina, Ladi,

Nana, Jummai) for your support and prayers, I wouldn’t have come this far. I love you all!

To my friends: Abednego Audu, Babangida Shalli, Emmanuel S. Peter, Emmanuel Yohanna,

Shettima Isa, Emmanuel Japheth, Wankari Nggurum, My mentor and friend-Barrister Ibrahim

Wabekwa, my love Rhoda Hussaine, thanks for your patience. You are more than just friends to

me. Thanks for your contributions. Space will not permit me to mention everyone who has

contributed directly or indirectly to making this work a success, my God rewards every one of

you.

vi

LIST OF ABBREVIATION AND ACRONYMS

Abbreviation Definition

BEBOV Bundibugyo ebola virus

BSL-4 Biosafety level 4

CDC Centre for disease prevention and control

DRC Democratic republic of Congo

ELISA Enzyme link immunoabsorbent assay

EMRO WHO regional office for the Eastern Mediterranean

EURO WHO regional office Europe

EVD Ebola virus diseases

FOCUS 1000 Facilitating and Organizing Communities for

Sustainable Development

GP Glycoprotein

HCWs Health care workers

HSPH Harvard school of public health

IgG Immunoglobulin G

IgM Immunoglobulin M

IHR International health regulations

MVD Marburg virus disease

NHP Non-human primate

PCR Polymerase chain reaction

PHEIC Public health emergency of international, concern

PPE Personal protective equipment

RESTV Reston Ebola virus

RT-PCR Reverse transcriptase Polymerase chain reaction

SEBOV Sudan Ebola virus

TNF Tumor necrosis factor

UNICEF United

Nations Children’s Fund (UNICEF)

VHF Viral hemorrhagic fever

VP Viral structural protein

WHO World health organization

ZEBOV Zaire Ebola virus

vii

TABLE OF CONTENTS

Title page……………………………………………………………i

Declaration………………………………………………………….ii

Certification ..………………………………………………………iii

Dedication ……….…………………………………………………iv

Acknowledgement ………...………………………………………..v

List of acronyms and abbreviation………………………………….vi

Table of contents………………...………………………………….vii

List of tables………..………………………………………………ix

List of figures……………………………………………………….xi

Abstract ……………………………………………………...……..xii

CHAPTER ONE

Introduction………………………………………………...….1

Problem statement…………………………………………..…3

Justification for the study………………………………..…….4

Aim and objectives…………………………………….………5

CHAPTER TWO

Literature review………………………………………………6

Introduction……………………………………………………6

Epidemiology………………………………………………….7

Pathogenesis………………………………………………….13

Clinical features………………………………………………14

Diagnosis and differential diagnosis…………………………15

Management …………………………………………………17

Public knowledge of EVD and its

transmission…………………………………………………..18

Perception and belief of ebola virus disease………………....19

Prevention and control……………………………………….21

viii

CHAPTER THREE

Methodology………………………………………………..…………..28

Background of study area……………………………...………………..28

Study design……………………………………………………………..30

Study population…………………………………………………………30

Sampling technique….……………………………………...……………30

Sample size determination………………………………………………30

Data collection method...………………………………………………..32

Data analysis…………………………………………………………….32

Ethical considerations…………………………………………………...33

Limitations of the study…………………………………………………33

CHAPTER FOUR

Result …………………………………………………………………..35

Introduction……………………………………………………………35

Socio-Demographic Characteristics…………………………………...35

Knowledge of Ebola Virus Disease (EVD)……………………………33

Perception and Belief of Ebola Virus Disease (EVD)…………………42

Relationship Analysis………………………………………………….45

CHAPTER FIVE

Discussion……………………………………………………………..48

Conclusion …………………………………………………………….51

Recommendations …………………………………………………….51

References……………………………………………………..………53

Appendix ………………………………………………………….…..58

ix

LIST OF TABLES

Table 4.1: socio-demographic characteristics of the respondents ……………..35

Table 4.2: Sex distribution of respondents ……………………………………...35

Table 4.3: Marital Status of the Respondents ………………………………….35

Table 4.4: Religion of Respondents……………………………………………..36

Table 4.5: Ethnicity of the Respondents ……………………………………...36

Table 4.6: Educational Status of the respondents……………………………36

Table 4.7: Occupation of the Respondents…………………………………...37

Table 4.8: Percentage of knowledge of the cause of EVD ……………………39

Table 4.9 Percentage of knowledge of the cause of EVD ……………………..40

Table 4.10: Knowledge Regarding Cure of EVD………………………………41

Table 4.11: Prevention with Personal Protective Clothing …………………...42

Table 4.12. Number of family members respondents that drank or bathe with salt water

……………………………………………………………………………..45

Table 4.13: Cross tabulation between the highest level of education of the respondents and

those who drank or bathe with salt water ………………..45

Table 4.14: Cross tabulation of health worker’s advice and those who drank or bathe

with salt wate……………………………………………………………………….46

Table 4.15: friend’s advice and those who drank or bathe with salt water…….46

x

Table 4.16: Cross tabulation of gender and those who drank or bathe with salt water

………………………………………………………………………………………..47

xi

LIST OF FIGURES

Figure 4.1 Percentage of the awareness of Ebola virus disease…………………38

Figure 4.2. Incubation period of Ebola virus disease……………………………38

Figure 4.3. Source of information ………………………………………………..39

Figure 4.4 Percentage of the respondents knows about mode of transmission of

EVD………………………………………………………………………..…….40

Figure 4.5. Knowledge of the symptoms of EVD……………………………….41

Figure 4.6. The perception and belief of the cause of Ebola virus disease ……..42

Figure 4.7. Perception and belief towards prevention of Ebola virus disease…..43

Figure 4.8. Behavioural change adapted toward prevention of EVD……………43

Figure 4.9. Who advised the respondent to drink or bathe with salt water……..44

Figure 4.10. Means through which respondents were advised to take or bathe with salt

water……………………………………………………………………………..44

xii

ABSTRACT

BACKGROUND

Ebola virus disease (EVD), previously known as Ebola haemorrhagic fever, is a serious, often

fatal illness in humans. EVD is caused by the Ebola virus, a filovirus that is thought to be

harboured by specific arboreal bat species in the affected regions. Ebola is transmitted through

direct contact with a sick person’s blood or body fluids, such as urine, saliva, faeces, vomit, and

semen. The fear and lack of correct and adequate knowledge about Ebola virus disease has led

many people to use different method of prevention which does not have a link to the disease mode

of transmission and pathogenesis

AIM

To assess the knowledge, perception and belief of Ebola virus disease among the residents of

Palladan, Zaria

METHODOLOGY

A cross sectional descriptive study was carried out among 152 residents of Palladan who are

randomly selected using multistage sampling technique. A pre-tested structured interviewer

administered questionnaire was used for data collection. Data was analysed using Statistical

Package for Social Sciences (SPSS®) software version 21 and Microsoft® Excel® 2013.

RESULT.

Out of 152 respondent, nearly half of the respondents were male (51%) and female (49%) who

are within the age group 18-24 years (50.7%) majority were Hausa (52.6%) Muslim (59.9%) the

respondents. Also 46.7% of the respondent had secondary education. The awareness of Ebola

virus disease is generally high: nearly everyone has heard of EVD (98%) and 74.5% believe EVD

xiii

ever exist in Nigeria where majority of the respondent heard of EVD through Television (38.8%),

and by radio (32.9%). Bats, monkey, chimpanzee, and wild animals are mostly associated with

the cause of EVD (79.7%) and (26.3%) of the respondents link the cause of EVD to a micro-

organism. Respondents with no or low level of education 2.8% and 6.3% respectively were less

likely to associate the cause of ebola virus disease to microorganism (virus). There is low

misconception that EVD could be transmitted by mosquitoes (10.1%), by air (15.4%), and (3.4%)

of the respondents believe that EVD is caused by gods, witchcraft, evildoing, or curse. There was

significant change in behaviour and practice 70% towards prevention of EVD also was positive

perception towards key prevention of Ebola virus disease where 88%, 91.9%, 79.9% of the

respondents believe in quarantine of contacts safe burial practices and wearing of protective

respectively clothing as a means of prevention respectively of EVD. There is no statistical

relationship between bathing with or drinking salt water and level of education however there is

significant statistical relationship between friend’s advice and those who drank or bathed with

salt water for the prevention of EVD during EVD outbreak in Nigeria.

CONCLUSION

Although majority of the respondents have a good knowledge and perception of the cause, means

of transmission, symptoms ways of prevention of Ebola virus disease, there is some

misconception of regarding the practice of prevention of EVD. Majority of the respondents

believe EVD had been transmitted in Nigeria. The good knowledge and perception of EVD as

well as the belief that it ever exist in Nigeria could be responsible for the significant change in

behaviour of the respondents towards EVD prevention.

1

CHAPTER ONE

1.0 INTRODUCTION

1.1 Background

Ebola virus disease (EVD), previously known as Ebola haemorrhagic fever, is a

serious, often fatal illness in humans. Ebola was first recognized in 1976 in two concurrent

outbreaks, in Nzara, Sudan, and in Yambuku, Democratic Republic of Congo, near the Ebola

River, from which the disease gets its name.1 The natural reservoir host of Ebola virus is not

known. However, based on evidence and the nature of other similar viruses, researchers

believe that Ebola virus is animal-borne, with bats probably being the most likely reservoir.2,

3

EVD is caused by the Ebola virus, a filovirus that is thought to be harboured by

specific arboreal bat species in the affected regions.4 Five strains of Ebola virus, which are

genetically and antigenically distinct, have been identified over the years. These include the

Tai Forest, Reston, Sudan, Zaire and Bundibudyo viruses (Bundibudyo virus was identified

for the first time during an outbreak in Uganda in 2008).4 The latter three strains have been

associated with sizeable outbreaks in sub-Saharan Africa, with mortality rates of 30 - 90%.3

These viruses differ in geographical spread, and the Zaire Ebola virus has been associated

with the most fatal outbreaks to date.5 The 2014 outbreak of Ebola virus in West Africa is

caused by a variant of Zaire Ebolavirus with 97% sequence identity to strains isolated from

the Democratic Republic of Congo and Gabon, suggesting a parallel evolution of this virus in

the affected area as opposed to introduction from these endemic areas.4

EVD is a severe acute viral illness often characterized by the sudden onset of

fever, intense weakness, muscle pain, headache and sore throat. This is followed by

vomiting, diarrhoea, rash, impaired kidney and liver function, and in some cases, both

internal and external bleeding occur.1, 6 Other viral haemorrhagic fevers include dengue,

2

yellow fever, Lassa and South American arena viral haemorrhagic fevers, Congo-Crimean

haemorrhagic fever, Rift Valley fever, and haemorrhagic fever with renal syndrome.7-9

Ebola is transmitted through direct contact with a sick person’s blood or body fluids,

such as urine, saliva, faeces, vomit, and semen.8 It is also spread through contact with

contaminated objects (like syringes) or infected animals. In Africa, infection has been

documented through the handling of infected chimpanzees, gorillas, fruit bats, monkeys,

forest antelope and porcupines found ill or dead in the rainforest.1, 5, 8 The incubation period

for EVD ranges from 2 to 21 days, with an average of 8-10 days.2, 5 Burial ceremonies in

which mourners have direct contact with the body of the deceased person can also play a role

in the transmission of Ebola. Men who have recovered from the disease can still transmit the

virus through their semen for up to 7 weeks after recovery from illness.5, 8

Ebola virus disease can be diagnosed definitively by enzyme-linked immunosorbent

assay (ELISA), antigen detection tests, serum neutralization test, reverse transcriptase

polymerase chain reaction (RT-PCR) assay and, virus isolation by cell culture.5, 8

Currently, there is no approved vaccine or therapy for EVD. However experimental treatment

with two new drugs, ZMapp and Nano Silver is available. Concern for a filoviral infection

must not deter an immediate assessment of treatable and more common causes of a febrile

illness among travellers, such as malaria, typhoid fever, leptospirosis, borelliosis, septicaemic

plague, tick typhus, and dysentery.7 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.5, 8, 9

Outbreak control relies on applying a package of interventions, namely case

management, surveillance and contact tracing, a good laboratory service, safe burials and

social mobilisation.5 Raising awareness of risk factors for Ebola infection and protective

3

measures that individuals can take is an effective way to reduce human transmission. These

preventive measures include: avoiding direct contact with blood, saliva, vomit, urine and

other bodily fluids of people with EVD or unknown illnesses; avoiding close contact with

wild animals and avoid handling wild meat; reducing the risk of human-to-human

transmission from direct or close contact with people with Ebola symptoms, particularly with

their bodily fluids.10, 11 Gloves and appropriate personal protective equipment should be worn

when taking care of ill patients at home. Regular hand washing is required after visiting

patients in hospital, as well as after taking care of patients at home; Outbreak containment

measures including prompt and safe burial of the dead, identifying people who may have

been in contact with someone infected with Ebola, monitoring the health of contacts for 21

days.5, 10

1.2 PROBLEM STATEMENT

Ebola virus disease (EVD) is one of the most feared diseases known to mankind. This is

because of the high mortality rate (up to 90%) associated with the disease, and also its

propensity for person-to-person spread through close contact with infected tissues and body

fluids of affected persons, particularly in the unprotected home-care setting and during

preparation of bodies for burial, while spread is amplified in hospitals with poor infection

control practices. Healthcare providers caring for Ebola patients and the family and friends in

close contact with Ebola patients are at the highest risk of getting sick because they may

come in contact with the blood or body fluids of sick patients.10, 12

Four West African countries (Liberia, Sierra Leone, Guinea, and Nigeria) are in the

midst of the largest Ebola outbreak the world has seen.13 The World Health Organization

(WHO) declared it an outbreak in March 2014. On August 6, 2014, the WHO, based on the

4

recommendations of its Emergency Committee, declared the current outbreak a Public Health

Emergency of International Concern (PHEIC).1, 14 On 30 September 2014, the first travel-

associated case of Ebola was reported in the United States.10, 15 An individual who travelled

from Liberia to Dallas, Texas first developed clinical findings consistent with Ebola virus

disease approximately five days after arriving in the United States.15

According to Nigeria’s Minister of Health, Professor C. O. Onyebuchi, immigration

from the countries hit by the disease has increased the threat of its spread to Nigeria. He

pointed out that apart from the cases reported in some West African countries like Liberia

and Ghana, “Ebola has been moving eastward towards Nigeria as well and we are already

facing danger from Central African Republic”.16 Three patterns of transmission have been

identified by WHO: in rural communities, facilitated by strong cultural practices and

traditional beliefs; in densely populated peri-urban communities; and cross-border

transmission. In addition, the situation is being driven by the failure to gain trust and

community support that is essential to effectively trace, monitor or isolate contacts of EVD

patients.11 Inadequate treatment facilities and insufficient human resources continue to

worsen the problems of control measures.11

1.3 JUSTIFICATION

The fear and lack of correct and adequate knowledge about Ebola virus disease has led many

people to use different method of prevention which does not have a link to the disease mode

of transmission and pathogenesis. Among such methods used by the general public include

bathing with hot-water and salt, chewing bitter kola-nut and raw onions with resultant

untoward medical consequences.8, 17 Effective prevention and control strategies have been

undermined by fear, mistrust and misinformation within affected communities, leading some

to believe that medical staff have brought the virus to the country.2, 17 This has resulted in

5

people refusing to cooperate with medical personnel, helping patients escape isolation wards,

and exhibiting hostile behaviour.2 Community perceptions, fears and reluctance to co-operate

can be especially problematic, and communication barriers must be bridged by well-designed

and understandable health messages.4

The virus has claimed more than 6,055 lives so far, and experts say a key part of fighting

the disease is to make sure people are armed with the facts.17 Locals are presumed to

subscribe to alternative disease models rooted in “traditional healing,” believe in sorcery

or the supernatural as the cause of the disease, or generally hold “misconceptions”

about its aetiology.18 Therefore, conducting this research will help in determining the

misconception about the cause, transmission and prevention of this disease.

1.5 OBJECTIVES

1.5.1 General objectives

To assess the knowledge, perception and belief of Ebola virus disease among the residents of

Palladan, Zaria

1.5.2 Specific objectives

1. To assess perception of the residents of Palladan Zaria on Ebola virus disease

2. To assess the knowledge regarding the origin, cause and transmission of Ebola virus

disease

3. To assess the knowledge of the residents of Palladan Zaria on the prevention of Ebola

virus disease

4. To determine beliefs that enhance or are detrimental to the prevention and control of

Ebola virus disease

5. To assess the practice regarding the prevention of Ebola virus disease

6

CHAPTER TWO

2.0 LITERATURE REVIEW

2.1 INTRODUCTION

Ebola virus is regarded as the prototype pathogen of viral haemorrhagic fever, causing

severe disease and high case-fatality rates.19 Ebola virus, named after the river Ebola in the

Democratic Republic of Congo (formerly Zaire), with the Marburg virus belongs to the

Filoviridae family.8 Since the first documented EVD outbreak in Zaïre or the Democratic

Republic of Congo in 1976, five species of the genus Ebola virus (Filoviridae family) have

been identified from samples collected from humans and non-human primates during

outbreaks of the disease: Zaïre ebolavirus (ZEBOV), Sudan ebolavirus (SEBOV), Reston

ebolavirus (RESTV), Taï Forest ebolavirus (TEBVO) and Bundibugyo ebolavirus

(BEBOV).8

Ebola virus and Marburg virus constitute the family Filoviridae in the order of

Mononegavirales. The Ebola virus is a lipid-enveloped, nonsegmented negative sense,

single-stranded RNA filovirus. The name derives from “filum” — meaning “threadlike” in

Latin. Tissue culture-derived virions can appear as either long filamentous particles (with

branching) reaching up to 14 turn in length, or as shorter forms that can fold back upon

themselves to give '6', 'U', or circular appearances when examined by transmission electron

microscopy.4, 19

This high fatality, combined with the absence of treatment and vaccination options,

makes Ebola virus an important public health pathogen and bio-threat pathogen of category

A.20

7

2.2 EPIDEMIOLOGY

The 2014 Ebola outbreak in West Africa is the largest and most complicated that the

world has ever seen.9 The disease has nevertheless remained rare since its initial description

in 1976, with no more than 2000 cases diagnosed before 2014.8 Since the latest outbreak

was first identified in the forested regions of south eastern Guinea on 1st March 2014,

it has spread to Liberia, Sierra Leone, and Nigeria and has now been declared by the

World Health Organization as a “public health emergency of international concern”.

The filoviruses were first recognized in 1967, when the inadvertent importation of

infected monkeys from Uganda into Germany and Yugoslavia resulted in explosive outbreaks

of severe illness among vaccine plant workers who came into direct contact with the animals

by killing them, removing their kidneys, or preparing primary cell cultures for polio vaccine

production.21 Since that time, with the exception of a few accidental laboratory infections, all

cases of filoviral disease have occurred in sub-Saharan Africa. The frequency of recognized

outbreaks has been increasing since 1990.12

The current 2014 outbreak, by far the largest outbreak of Ebola virus disease ever

recorded is currently occurring in West Africa with the Zaire species of the virus.20 Although

most previous Ebola outbreaks occurred in Central Africa, this outbreak started in the West

African nation of Guinea in late 2013 and was confirmed by the World Health Organization

in March 2014.22 The initial case was a two-year-old child in Guinea, who developed fever,

vomiting, and black stools, without other evidence of haemorrhage.23 The outbreak

subsequently spread to Liberia, Sierra Leone, Nigeria, and Senegal. The case-fatality rate has

been estimated to be approximately 90 percent.9 The magnitude of the outbreak, especially in

Liberia and Sierra Leone, has probably been underestimated; this is due in part to individuals

with Ebola virus disease being cared for outside the hospital setting.21, 24 As at 3rd December

8

2014, a total of 17,145 confirmed, probable, and suspected cases of Ebola virus disease

(EVD) have been reported in five affected countries (Guinea, Liberia, Mali, Sierra Leone,

and the United States of America) and three previously affected countries (Nigeria, Senegal

and Spain). Similarly, as at 5th December 2014, there had been 6,070 deaths of individuals

from the disease.25 The outbreaks of EVD in Senegal and Nigeria were declared over on 17

October and 19 October 2014, respectively.26 Following the WHO Ebola Response Roadmap

structure, country reports fall into two categories: those with widespread and intense

transmission (Guinea, Liberia, and Sierra Leone); those with an initial case or cases, or with

localized transmission (Nigeria, Senegal, Spain, and the United States of America).25, 27 An

overview of the situation in the Democratic Republic of the Congo, where a separate,

unrelated outbreak of EVD is occurring, were also provided in the WHO Ebola Response

Roadmap structure document.25

2.2.1 Countries with Widespread and Intense Transmission

As at 5th December 2014, A total of 17,111 confirmed, probable, and suspected cases and

6,055 deaths have been reported from EVD by the Ministries of Health of Liberia, Guinea

and Sierra Leone.25 Similarly, within this period, 622 health-care workers (HCWs) are

known to have developed EVD (106 in Guinea, 361 in Liberia, 11 in Nigeria and 138 in

Sierra Leone, 1 in Spain, 2 in Mali and 3 in the United States of America).20 The number of

HCWs that have died as a result of EVD infection were 346 (59 in Guinea, 174 in Liberia, 5

in Nigeria, 108 in Sierra Leone).25 Investigations into health-care workers (HCWs) exposures

are ongoing.

2.2.2 Countries with an Initial Case or Cases, Or with Localized Transmission

As at 5th December 2014, five countries (Mali, Nigeria, Senegal, Spain, and the United States

of America have reported a case or cases imported from a country with widespread and

9

intense transmission. In Nigeria, there have been 20 cases and eight deaths, while in Senegal,

there has been one case.25

A total of 8 cases (7 confirmed and 1 probable), including 6 deaths (5 confirmed, 1

probable), have now been reported in Mali. All identified contacts connected with the

initial case have now completed 21 day follow-up.

In Spain, more than 42 days have now passed since the HCW infected while caring for a

patient with EVD in Madrid tested negative twice and was discharged from hospital,

therefore the outbreak in this country has now been declared over.

In the United States of America, there have been 4 cases of EVD and 1 death. One HCW in

New York and 2 HCWs in Texas have tested negative for EVD twice and have been released

from hospital. All contacts in the country have completed the 21-day follow-up period.

In Nigeria, there were 20 cases and 8 deaths. In Senegal, there was 1 case and no deaths.

However, following a successful response in both countries, the outbreaks of EVD in

Senegal and Nigeria were declared over on 17 October and 19 October 2014,

respectively.20, 25

The Ebola virus was imported into Nigeria by a late Liberian-born American, Patrick

Sawyer, who arrived Lagos on the 20th of July 2014 and died five days later after

being diagnosed with the Ebola virus at First Consultants Hospital in Obalende, Lagos

State.1, 8 The President of Nigeria, Goodluck Ebele Jonathan declared a national

emergency on Ebola and approved 1.9 billion Naira intervention fund to combat the

outbreak of the virus.28 Likewise, the Anambra State Ministry of Health on 31st July

announced that there are concerns in the State that the disease may have infiltrated

10

the State through a corpse brought in from Liberia and deposited at Apex Mortuary in

Nkwelle Ezunaka.1 However, subsequent findings confirmed otherwise.

As at 9 October 2014, and following a retrospective review of cases, there have been

68 cases (38 confirmed,28 probable, 2 suspected) of Ebola virus disease (EVD) reported in

the Democratic Republic of the Congo, including eight among HCWs.25 In total, 49 deaths

have been reported, including eight among HCWs. 852 contacts have now completed 21-day

follow-up. All of the 269 contacts currently being monitored, were seen on 9 October, the last

date for which data has been reported. The last confirmed case was isolated on 4 October.

This outbreak is unrelated to that affecting Guinea, Liberia, Nigeria, Sierra Leone, Spain, and

the United States of America.25

Ebola virus disease has no sexual predilection, but men and women differ with respect

to the manner in which direct exposure occurs.29 Men, by the nature of their work exposure in

forest and savanna regions, may be at increased risk of acquiring a primary infection from

gathering “bush meat” (primate carcasses) for food, as well as an unknown vector or vectors.

Evidence from Africa and the Philippines is compatible with bats being a principal vector of

Ebola virus. Because women provide much of the direct care for ill family members and are

involved in the preparation of the bodies of the deceased, they may be at increased risk of

acquiring Ebola virus infection through their participation in these activities. However, men

and women who are medical healthcare providers seem to share a high and equal risk of

infection.29 Although most cases of Ebola virus infection have occurred in sub-Saharan

Africa, most patients have been black. However, no evidence exists for a specific racial

predilection.30

2.2.3 Viral Reservoirs

11

The reservoir hosts of the various species of Filoviruses have not been identified. The viruses

could be maintained in small mammals, possibly rodents or bats, although wild primates

might also acquire the virus through contact with the maintenance host, there is no evidence

that they are other than accidental hosts.31 However, non-human primates have an

important role in transmitting the pathogen to human beings, because several recent

outbreaks began when hunters encountered a sick or dead animal in the forest and took it

home for consumption. Although there is serological evidence that some wild primates have

survived infection with Zaire Ebola virus, the mortality rate among great apes is high enough

to threaten their survival in some regions of Africa and could warn of a further increase in

human disease.32 Perhaps the greatest mysteries regarding the filoviruses are the identity of

their natural reservoir and the mode of transmission from the reservoir to wild apes and

humans.31 Bats have long headed the list of suspects, because they have been present in large

numbers at the sites of several filovirus outbreaks and are known to maintain other

pathogenic RNA viruses, such as rabies. Epidemiologic data have suggested a strong link

between exposure to bats and subsequent filoviral disease.19

2.2.4 Transmission

Infections with Ebola virus are acute, with is no carrier state.33 Because the natural reservoir

of the virus is unknown, the manner in which the virus first appears in a human at the start of

an outbreak has not been determined.22 However, researchers have hypothesized that the first

patient becomes infected through contact with an infected animal. Ebola is introduced into

the human population through close contact with the blood, secretions, organs or other bodily

fluids of infected animals.5 In Africa, infection has been documented through the handling of

infected chimpanzees, gorillas, fruit bats, monkeys, forest antelope and porcupines found ill

or dead or in the rainforest.1, 5, 8

12

Person-to-person transmission occurs through direct contact of broken skin or

unprotected mucous membranes with virus-containing body fluids (e.g., blood, vomitus,

urine, faeces, semen, and probably sweat) from a person who has developed signs and

symptoms of illness.5, 8 One type of direct contact that leads to transmission is the ritual

washing of Ebola victims at funerals.31 An epidemiologic study found that family members

were only at risk of infection if they had physical contact with sick individuals or their body

fluids, or helped to prepare a corpse for burial.34 Infection apparently results from entry of

virus through breaks in the skin or the mucous membranes of the mouth or eyes.9 Even

though aerosolised filoviruses are highly infectious for non-human primates in the

laboratory, transmission patterns during epidemics indicate that the virus does not spread

naturally among human beings by the respiratory route, which suggests that it is not

efficiently aerosolised by people.19 Airborne transmission has only been reported among

healthcare workers who were exposed to aerosols generated during medical procedures.19

There is no evidence that insects have any role in disease transmission.30 Among

workers in contact with monkeys or pigs infected with Reston Ebola virus (RESTV), several

infections have been documented in people who were clinically asymptomatic. Thus, RESTV

appears less capable of causing disease in humans than other Ebola species.35 Human

infection with Ebola virus can occur through contact with wild animals (e.g., hunting,

butchering, and preparing meat from infected animals).20, 36 Other potential routes of

transmission include the following: accidental infection of workers in any Biosafety-Level-4

(BSL-4) facility where these viruses are being studied, Use of filoviruses as biological

weapons.31, 37 There is no evidence to date that filoviruses are carried by mosquitoes or other

biting arthropods.19

13

2.3 PATHOGENESIS

Ebola virus has a nonsegmented negative-stranded RNA genome containing 7

structural and regulatory genes.38 The Ebola genome codes for 4 virion structural proteins

(VP30, VP35, nucleoprotein, and a polymerase protein [L]) and 3 membrane-associated

proteins (VP40, glycoprotein [GP], and VP24).39 The GP gene is positioned fourth from the

3′ end of the 7 linearly arranged genes. The sGP binds to neutrophil CD16b, a neutrophil-

specific Fc g receptor III, and inhibits early neutrophil activation.33 The sGP also may be

responsible for the profound lymphopenia that characterizes Ebola infection. Thus, sGP is

believed to play pivotal roles in the ability of Ebola to prevent an early and effective host

immune response.29

Ebola virus act both directly and indirectly to disable antigen-specific immune

responses.31 Dendritic cells, which have primary responsibility for the initiation of adaptive

immune responses, are a major site of filoviral replication. In vitro studies have shown that

infected cells fail to undergo maturation and are unable to present antigens to naive

lymphocytes, potentially explaining why patients dying from Ebola virus disease do not

develop antibodies to the virus.40 Adaptive immunity is also impaired by the massive loss of

lymphocytes that accompanies lethal Ebola virus infection.4 Lymphocytes remain uninfected,

but undergo "bystander" apoptosis, presumably induced by inflammatory mediators and/or

the loss of support signals from dendritic cells. A detailed study of infected but asymptomatic

individuals revealed that they had an early (4-6 days after infection) and vigorous

immunologic response with production of interleukin (IL)–1β, IL-6, and tumour necrosis

factor (TNF), resulting in enhanced cell-mediated and humoral-mediated immunity.29 In

patients who eventually died, proinflammatory cytokines were not detected even after 2-3

days of symptomatic infection. A second, somewhat larger (120-150 kd) GP, transmembrane

14

glycoprotein, is incorporated into the Ebola virion and binds to endothelial cells but not to

neutrophils. Ebola virus is known to invade, replicate in, and destroy endothelial cells.19, 36

Destruction of endothelial surfaces is associated with disseminated intravascular coagulation,

and this may contribute to the haemorrhagic manifestations that characterize many, but not

all, Ebola infections.7, 37

Clinical infection in human and nonhuman primates is associated with rapid and

extensive viral replication in all tissues.41 Viral replication is accompanied by widespread and

severe focal necrosis. The most severe necrosis occurs in the liver, and this is associated with

the formation of Councilman-like bodies similar to those seen in yellow fever.31 In fatal

infections, the host’s tissues and blood contain large numbers of Ebola virions, and the tissues

and body fluids are highly infectious. In vitro studies have shown that infected cells fail to

undergo maturation and are unable to present antigens to naive lymphocytes, potentially

explaining why patients dying from Ebola hemorrhagic fever do not develop antibodies to the

virus.23, 35

2.4 CLINICAL FEATURES

The onset of the disease is abrupt after an incubation period of 2-21 days. The clinical

features can be divided into four main phases as follows:30

Phase A. Influenza–like syndrome: The onset is abrupt with non-specific symptoms or signs

such as high fever, headache, arthralgia, myalgia, sore throat, and malaise with nausea.

Phase B. Acute (day1–6): Persistent fever not responding to antimalarial drugs or to

antibiotics, headache, and intense fatigue, followed by diarrhoea and abdominal pain,

anorexia and vomiting.

15

Phase C. Pseudo-remission (day 7–8): During this phase the patient feels better and seeks

food. The health situation presents with some improvement. Some patients may recover

during this phase and survive from the disease.

Phase D. Aggravation (day 9): In many if not most cases, the health status gets worse.

The following symptoms may be observed also: respiratory disorders: dyspnoea, throat and

chest pain, cough, hiccups; symptoms of haemorrhagic diathesis: bloody diarrhoea,

haematemesis, conjunctival injection, gingival bleeding, nosebleeds and bleeding at the site

of injection consistent with disseminated intravascular coagulation; skin manifestations:

petaechiae (not so obvious on black skin), purpura (morbiliform skin rash); neuro-psychiatric

manifestations: prostration, delirium, confusion, coma; cardio-vascular distress and

hypovolaemic shock (death).19, 30 From these clinical manifestations it is obvious that EVD

may mimic many other tropical diseases like malaria, typhoid fever or yellow fever at the

start of the disease. In most outbreaks, recognition of the disease is delayed because

physicians are not accustomed to this new illness and the symptoms are generally non-

specific. Outside the epidemic context, it appears quite impossible to recognise the first Ebola

case in an outbreak on clinical grounds only. Suspicion of EVD is only possible later during

the aggravation phase.30

2.5 DIAGNOSIS AND DIFFERENTIAL DIAGNOSIS

Ebola virus disease presents as a viral prodrome with a high potential for differential

diagnosis, especially early in outbreaks.7 The initial diagnosis of this syndrome is based on

clinical assessment. Therefore, proper contingency plans should be developed. Early

laboratory confirmation of suspected clinical haemorrhagic fever cases is essential to

implement appropriate control measures. In Africa, laboratory confirmation of Ebola cases

has been challenging and early recognition of the first outbreaks were severely hampered as a

16

result. Because the disease was poorly known or rare, laboratory investigations were oriented

towards the more common, endemic pathogens in the area.2

Ebola virus disease can be suspected in acute febrile patients with the symptoms

described and with a history of travel to an endemic area, if they present with fever and

constitutional symptoms. Identification might be difficult because severe and acute febrile

diseases can have a wide range of causes in areas endemic for Ebola virus, with the most

prominent being malaria and typhoid fever followed by others such as shigellosis,

meningococcal septicaemia, plague, leptospirosis, anthrax, relapsing fever, typhus, murine

typhus, yellow fever, Chikungunya fever, and fulminant viral hepatitis.2, 6, 7

Laboratory diagnosis for EVD is generally done in national and international

reference centres, which should be contacted immediately on suspicion for advice on

sampling, sample preparation, and sample transport.19 Laboratory diagnosis of Ebola virus is

achieved in two ways: measurement of host specific immune responses to infection and

detection of viral particles, or particle components in infected individuals.19 Currently, RT-

PCR and antigen detection ELISA are the primary assays to diagnose an acute infection.19, 37

Viral antigen and nucleic acid can be detected in blood from day 3 up to 7–16 days after

onset of symptoms.3 For antibody detection the most generally used assays are direct IgG and

IgM ELISAs and IgM capture ELISA. IgM antibodies can appear as early as days post onset

of symptoms and disappear between 30 and 168 days after infection and IgG-specific

antibodies develop between day 6 and 18 days after onset and persist for many years.38, 42

IgM or rising IgG titre constitutes a strong presumptive diagnosis while decreasing IgM, or

increasing IgG titres (four-fold), or both, in successive paired serum samples are highly

suggestive of a recent infection.19, 29, 31 All these assays can be done on materials that have

been rendered non-infectious. An efficient way to inactivate the virus for antigen and

antibody detection is the use of gamma irradiation from a cobalt-60 source or heat

17

inactivation.19 Similarly, the nucleic acid can be amplified by purification of the virus RNA

from materials treated with guanidinium isothiocyanate—a chemical chaotrope that denatures

the proteins of the virus and renders the sample non-infectious.3 Provision of basic on-site

diagnostics, including confounding differential diagnosis, could help with the management of

patients specifically and with an outbreak in general. The development of truly portable real-

time thermocyclers and simple serological assays appropriate for field use has made the

provision of a field diagnostic laboratory a reasonable undertaking.19, 30, 40 However, the

launch of diagnostic support in remote areas of equatorial Africa can be logistically and

technically difficult since these regions are austere environments with cultural differences

and sometimes hostile behaviour.19

2.6 MANAGEMENT

Managing Ebola patients in the African setting is a major challenge because there is no

effective antiviral drug and no specific vaccine available. Only supportive care could be

administered, to sustain cardiac and renal functions with prudent use of perfusion. Oral

rehydration was recommended but sometimes not realistic because of throat pain, vomiting

and intense fatigue.5, 8

Supportive management comprises fluid and electrolyte replacement, oxygen therapy,

analgesics, antibiotics and antifungals.20, 34 Anticoagulants may be useful in early disease to

prevent disseminated intravascular coagulation (DIC) while procoagulants in late disease to

combat it.43 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.8 This agent ZMapp® is serum composed of humanized antibodies against the

Ebola virus surface antigen. The two USA citizens who received this seem to show positive

18

signs of improvement. In 1999, seven out of eight victims who received serum from survivors

survived.8 Another drug, the Nano Silver did not pass the ethical test in Nigeria. Vaccines

against the Filoviruses are also at the experimental stage.1, 8 Apart from the convalescent

serum, other experimental drugs include Favipiravir which is active against RNA viruses,

Clomiphene and Toremiphene, these recognized oestrogen, receptor modulators are shown to

inhibit viral programs of Ebola virus in infected mice, but this action is thought to be

accomplished through a different pathway than the standard oestrogen pathway.19

In an Ebola outbreak in Kikwit, Congo, human convalescent blood was used for

passive immunisation to treat patients that had been infected naturally with Zaire Ebola virus;

seven out of eight patients who received blood transfusion from convalescent Ebola patients

survived.23 Such experiments, unfortunately, have not been repeated in further outbreaks

because in vitro studies showed that antibodies against Ebola had no neutralising activities.23

In addition, although monoclonal antibodies to the glycoprotein of Ebola virus showed

protective and therapeutic properties in mice, they failed to protect non-human primate

(NHP) and since Ebola virus is generally considered as a potential biological weapon, it is

urgent to develop effective antiviral drugs and vaccines.10 The ideal is to develop a candidate

vaccine able to confer interspecies cross-protection against Zaïre ebolavirus (ZEBOV),

Sudan ebolavirus (SEBOV), Bundibugyo ebolavirus (BEBOV) and unknown Ebola virus

species.19

2.7 PUBLIC KNOWLEDGE OF EVD AND ITS TRANSMISSION.

In a study conducted in Sierra Leone by Catholic Relief Services in conjunction with United

Nations Children’s Fund (UNICEF) and Facilitating and Organising Communities for

Sustainable Development (FOCUS 1000) a non-governmental organization on the public

knowledge, attitude and practice of Ebola virus disease found out that everyone in Sierra

19

Leone has heard of Ebola and nearly everyone believes that it exists in the country (97%) and

approximately, 77% of respondents have heard of someone who survived Ebola while 53%

know the number to call to report suspected EVD cases or ask questions about the disease.44

Also a study conducted by the NOIPolls Limited in partnership with EpiAfric; an

Abuja based public health consulting firm in which 1006 respondents were interviewed in

the survey, they found out that 83% of the respondents affirmed that it spreads “by

exchange of body fluids”, whereas 7% believe it spreads “by air” while 4% each stated

that it is spread via “contact with infected bats (animal)” and “by mosquitoes”.1

In the United States, the Harvard School of Public Health (HSPH) poll found people

with less education are more likely to be concerned about an outbreak in the U.S. (less than

high school 50% vs. some college 36% vs. college graduate or more 24%). People with less

education are also more concerned they or their family will get sick with Ebola (less than

high school 37% vs. some college 22% vs. college graduate or more 14%).45 Perhaps related,

those with less education are also less likely to be following the news about the Ebola

outbreak in West Africa closely (total 63%; less than high school 57% and some college 62%

vs. college graduate or more 73%). Two-thirds of people (68%) surveyed believe Ebola

spreads “easily” (“very easily” or “somewhat easily”) from those who are sick with it.45 This

perception may contrast with Center for Disease Control and prevention, World Health

Organization, and other health experts who note that Ebola is not an airborne illness, and is

transmitted through direct contact with infected bodily fluids, infected objects, or infected

animals.

2.8 PERCEPTION AND BELIEF OF EBOLA VIRUS DISEASE

Ebola brings fear, panic and uncertainty which seem to have taken over the West

African sub-region. This fear derives mainly from paucity of factual knowledge about it,

20

reinforced by the realization that there is currently no vaccine or treatment for this fatal

illness with case fatality rate of up to 90%.8 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. Such reportage has been rife in Nigeria that panic has

taken over the Nigerian society.8, 46 African customs and traditional practices are threatened.

Charlatans and spiritualist dish out unscientific and unsubstantiated remedies and claims to

cure. Unfortunately, the unsuspecting public has fallen to this in fear and panic. The most

celebrated in Nigeria was the employment of warm salt baths and salt drinks for prevention

of EVD, to which some citizens hearkened with resultant untoward medical consequences.8,

17, 47

There is no denying that the fear of EVD has threatened the social and traditional

fabric of Nigeria recently. Peoples’ psyche has been affected with attendant behavioural

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.23 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. 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: Handshakes upon greeting, harmful cuts by

traditional healers, schools and public funerals.

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

21

be useful to the local, national and international teams in the control of rapid epidemics such

as EVD and other viral haemorrhagic fevers. 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

are employed to protect the public health.46, 48

2.9 PREVENTION AND CONTROL

The concepts of prevention as enunciated by Leavell and Clark49 can be approach as follows:

2.9.1 Primordial Prevention

It came from a Latin word ‘primordium’ means beginning. It means prevention at a stage,

when the risk factors have not yet developed. Primordial prevention is aimed to eliminate the

development of risk factors, it is targeted at total population or selected groups and achieved

through public health policy and health promotion.49, 50 In October 2014 California issues

quarantine policy for Ebola exposure that anyone arriving in California from an Ebola-

affected area and who has had personal contact with a person infected with the deadly virus

will be quarantined for 21 days, based on an order issued by the state's public health director.

Airline crews are trained to spot the symptoms of Ebola in passengers flying from places

where the virus is found.

2.9.2 Primary Prevention

The process of primary prevention is limited to the period before the onset of clinical

disease in an individual. Thus activities directed to prevent the occurrence of disease in

human populations fall in this category. These activities are related to health promotion and

specific protection. Primary prevention of EVD is at two levels.

22

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 are educated to avoid sick, dead or dying wild animals as these are potential sources of

the EVD. 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.8

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, faeces, 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 equipment (PPE). This precaution should be in place

both at home and in the hospital.8, 51 Improve health-related behaviours among at-risk and

vulnerable groups by promoting and strengthening standard infection prevention and

control practices within the community; e.g. regular hand washing, food safety, etc.15

Previously, the usefulness of an Ebola virus vaccine was disputed, because of the

disease’s rarity, little interest by industry, and the potential cost.31 Frequent outbreaks in the

past decade, several imported cases of EVD and laboratory exposures, and the potential

misuse of Ebola virus as a bio-threat agent has changed that view. Vaccine development is

part of many nations’ efforts in response to the public health threat posed by emerging or re-

emerging bio-threat pathogens such as Ebola virus. A protective vaccine would be very

valuable not only for at risk medical personnel, first responders, military personnel, and

researchers, but also for targeted vaccination in affected populations, especially during

outbreaks, for use in a so-called ring vaccination strategy. Currently, vaccine candidates to be

considered should show efficacy in at least two animal models of the disease including non-

23

human primates, the gold standard animal model for viral haemorrhagic fever caused by

several pathogens such as Ebola virus.22 Only a few vaccine platforms have passed these

requirements and are considered for further investigation and perhaps for clinical trials. These

vaccine candidates are based on recombinant technologies that use either generated

replication-deficient or attenuated replication competent platforms. Among the replication-

deficient platforms, human adenovirus-type-5 vectors have been the first successful strategies

to protect non-human primates from lethal Ebola virus challenge.19

Originally a DNA prime(glycoprotein and nucleoprotein) adenovirus

boost(glycoprotein) approach was used, which was subsequently replaced with an accelerated

approach of one immunisation with a recombinant adenovirus expressing the Zaire Ebola

virus glycoprotein 28 days before challenge.19 The approach has been further developed by

others by use of a multivalent adenovirus technology for the development of a pan

Filoviruses vaccine that provides protection against several Filoviruses species. The

adenovirus platform seems safe and robust but is weakened by pre-existing immunity in the

world population and its failure in an HIV/AIDS trial.7 The second successful approach with

replication-deficient platforms is based on Ebola virus-like particles generated by

coexpression of the viral matrix protein (VP40),nucleoprotein, and glycoprotein.32 This

approach seems to best address safety issues but might need adjuvant and still needs booster

immunisation for efficacy in non-human primates, which is not favourable for emergency

use. Other issues are associated with the costs and production of the virus-like particle (VLP)

vaccines compared with viral vector-based platforms. Reverse genetics has generated the first

new generation inactivated Ebola virus vaccine by deletion of an essential gene rendering the

resulting virus replication deficient.29 This technology allows large-scale production, but

remaining safety issues still need to be addressed for potential future use of this technology in

generation of promising vaccine candidates.

24

Generally, live attenuated viruses are more advantageous than non-replicating

vaccines because of ease of production and their potent stimulation of innate and adaptive

(humoural and cellular) immune responses. However, this idea does not seem feasible for

Ebola virus because of difficulties in ensuring the safety of live attenuated Ebola virus

strains. However, live attenuated recombinant Ebola virus vaccine vectors have been

developed on the basis of the background of less virulent viral systems such as vesicular

stomatitis virus111 and human parainfluenza virus.8 The system based on vesicular

stomatitis virus has shown tremendous efficacy in non-human primates including both

prophylactic and post exposure treatment situations.4 These potent vaccine platforms are

associated with safety issues despite having a clean record in laboratory animals including

immune-deficient animals. As with adenovirus vectors, pre-existing immunity might be an

issue with the human parainfluenza virus platform but is negligible for vesicular stomatitis

virus. Vaccine platforms of human parainfluenza and vesicular stomatitis viruses might have

potential for delivery without use of needles.37 Despite good to excellent protective efficacy

in animals, correlates and mechanisms of protection have not been well defined for most of

the vaccine candidates mentioned above. On the basis of present data, antibody responses, T-

cell proliferation, and cytotoxic-T-lymphocyte responses show that antibody and T-helper

cell memory are essential for protection, and that cell-mediated immunity, although possibly

important, is not an absolute requirement. Total antibody response is thought to be a correlate

for protection for Ebola virus vaccines. Finally, a multivalent preventive vaccine is clearly

needed to provide protection against all species of Ebola viruses, and such a vaccine will

possibly need at least three components of immune response.

25

2.9.3 Secondary Prevention

Secondary prevention comes into play after the disease process has been initiated in

the human host. The aim of such an approach is to minimize the spread of disease and to

reduce the serious consequences. This is achieved through early diagnosis and treatment.

Early diagnosis and prompt treatment of EVD offers benefits to the affected individuals as

well as to their families and the community.50 It helps to reduce the transmission of infection

and, hence, is considered as a method of prevention. It include early diagnosis and treatment

of EVD as depicted above. Epidemiological investigation, surveillance and laboratory testing

subcommittee should be set up and train mobile epidemiological surveillance teams and

ensure that the training of the teams includes essential communication skills and in-depth

knowledge about the disease and prevention measures.52 Such teams must: Adopt a case

definition adapted to the local context of the epidemic; actively search for cases and

investigate each reported case; for each suspected, probable, or confirmed case, draw up a list

of contacts and monitor them over a period of 21 days; Publish daily epidemiological

information in the form of a situation report; After consultation with the national reference

laboratory and partners, deploy a mobile field laboratory, if required; Link up and coordinate

human and wildlife epidemic surveillance; Collect the technical data that is necessary to

declare the end of the epidemic.

2.9.4 Tertiary Prevention

Tertiary prevention acts at the stage where disease has got established in the individual. It is a

costly venture, though recent efforts at community based rehabilitation have tried to bring

down the costs. Tertiary prevention can be applied at the last two levels of prevention. These

are: Disability limitation and Rehabilitation.49 Rehabilitation is an extremely costly venture.

The aim of rehabilitation is to reintegrate the affected individual in the community by

26

optimizing his functional ability. It involves psychological, vocational and social and

educational intervention.

Comprehensive public education campaigns should be conducted to address social

stigma and exclusion of former patients and health-care workers resulting from the public’s

potentially excessive fear of contagion, contamination, or any other commonly held belief.52

Encourage activities that facilitate the social inclusion of the bereaved, orphans,

widows, and widowers as well as organizing recreational activities and encourage children’s

return to school.52

2.9.5 Control Measures

Control measures during epidemics8, 51 include:

1. Active case identification and isolation of patients from the community to prevent

continued virus spread.

2. Identifying contacts of ill or deceased persons and tracking the contacts daily for the

entire incubation period of 21 days.

3. Investigation of retrospective and current cases to document all historic and ongoing

chains of virus transmission

4. Identifying deaths in the community and using safe burial practices

5. 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 potentiated disease is critical.

Infection prevention and control measures in the hospital5, 8, 51 should include:

27

1. Patient placement: Patients should be placed in a single room (containing a private

bathroom) with the door closed. Where available, negative pressured rooms are

recommended.

2. Health-care provider protection: Health-care providers should wear gloves (fluid

resistant or impermeable), shoe covers, eye protection (goggles, face shield), and

facemask. Additional PPE might be required in a certain situation (e.g. copious

amount of blood, other body fluids, or faeces present in the environment), including

double gloving, disposable shoe covers and leg coverings. Floors and horizontal work

surfaces should be cleaned at least once a day; Cleaning should always be carried out

from “clean” areas to “dirty” areas, in order to avoid contaminant transfer.52

3. Aerosol generating procedures: Avoid aerosol generating procedures. If performing

these procedures, PPE should include respiratory protection (N-95 filtering respirator

or higher) and the procedure should be performed in the airborne isolation room.

4. Environmental infection control: Diligent environmental cleaning and disinfection

and safe handling of potentially contaminated materials is paramount. Appropriate

disinfectants for Ebola virus 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. Clothes, beddings etc. that are not disposable by incineration are

usually soaked in boiled water and disinfectants before washing.

28

CHAPTER THREE

3.0 METHODOLOGY

3.1 BACKGROUND OF THE STUDY AREA

Zaria is a major city in Kaduna State in North-Western Nigeria, as well as being a

Local Government Area. It was one of the original seven Hausa city-states. The 2006 Census

population was 1,500,000. Zaria, initially known as Zazau, was also the capital of the Hausa

kingdom of Zazzau. However, human settlement predates the rise of Zazzau, as the region,

like some of its neighbors, had a history of sedentary Hausa settlement, with institutional but

pre-capitalist market exchange and farming.52 In the late 1450s, Islam arrived in Zaria by the

way of its sister Habe cities, Kano and Katsina. Along with Islam, trade also flourished

between the cities as traders brought camel caravans filled with salt in exchange for slaves

and grain. Between the fifteenth and sixteenth century the kingdom became a tributary state

of the Songhai Empire. In 1805 it was captured by the Fulani during the Fulani Jihad. British

forces led by Frederick Lugard took the city in 1901.52, 53

Zaria's economy is primarily based on agriculture. Staples are guinea corn and millet,

and cash crops include cotton, groundnuts and tobacco. The city is considered by some to be

a main center of Hausa agriculture. Not only is Zaria a market town for the surrounding area,

it is the home of numerous artisans, from traditional crafts like leather work, dyeing and cap

making, to tinkers, print shops and furniture makers. Zaria is also the center of a textile

industry that for over 200 years has made elaborately hand-embroidered robes that are worn

by men throughout Nigeria and West Africa.54

Zaria is situated within the Sahel savannah characterized by a tropical, continental

climate with extensive dry season (October-May), during this period, a cold weather is

29

usually experienced due to North-Easterly wind (the Harmatan) which controls the tropical

continental air mass coming in from the Sahara. Its weather prevails over most parts of the

country. Temperatures get as low as 100 at night and as high as 400 in the afternoons. In

March and April, hot but dry weather is encountered, trailed by a sweeping-in of tropical

maritime air mass from the Atlantic Ocean which displaces the North-Easterly winds.52, 53

It is located between longitude 11°04′N 7°42′E, and latitude 11.067°N 7.700°E. Area

of economic importance include farming and education, hence it can easily be referred to as

“educational town”, being home to various academic institutions like the prestigious Ahmadu

Bello University Zaria (ABU)- the largest university in Nigeria and the second largest on the

African continent. The institution is very prominent in the fields of Agriculture, Science,

Finance, Medicine and Law. Zaria is also the base for the Nigerian College of Aviation

Technology, Federal college of education, Nuhu Bamali Polytechnic, National Research

Institute for Chemical Technology and Barewa College.53

Palladan is a suburb of Zaria, and is one of the eleven district wards in Sabon Gari

Local Government Area. The population of Palladan is 26487 as of 2006 census.52 Palladan is

divided into the predominant religion is Islam with Christian minority, while the major tribe

is Hausa/Fulani. Others include Yoruba, Bajju, Kadara. The majority of the inhabitants are

businessmen and women and petty traders. They also engaged in farming smelting and

smiting of iron, pottery and dying, others include military personnel, artisans lectures and

teachers as well.53, 54

30

3.2 STUDY DESIGN

This is a cross sectional descriptive study to assess the knowledge, perception and belief of

Ebola virus disease among the residents of Palladan, Zaria.

3.3 STUDY POPULATION

The study population consist of adult male and female residents of Palladan Zaria, who are

above the age of 18 years irrespective of their gender, religion, or ethnic backgrounds and

who have been living in Palladan for at least 1year.

3.4 INCLUSION CRITERIA.

1) Adult individuals that have been residents in Palladan for at least one year.

2) All resident of Palladan above the age of 18 years

3.5 EXCLUSION CRITERIA

1) Individuals residing in Palladan for less than a year.

2) Individuals less than 18 years of age.

3) Individual who do not want to be included in the study.

3.6 SAMPLE SIZE DETERMINATION

The following formula was used to calculate the sample size,

n=𝑧2𝑝𝑞

𝑑2

Where n = minimum sample size

d = desired degree of precision = 0.05

31

p= proportion of individuals with good knowledge, perception and belief of Ebola

virus disease

q = complementary probability =1-p

z = standard normal deviate taken as 1.96 in correspondence to 95% confidence

interval

Where n = sample size

z = 1.96

p = 90% (proportion of respondent who indicated Ebola virus disease spread through

exchange of body fluids in a study conducted in Nigeria by the NOIPolls Limited in

collaboration with EpiAFRIC, Abuja)

q = 1-0.90

n = 1.962×0.90×(1−0.90).

0.052

n = 0.3457

0.0025

n = 138.3

n ≅ 138

Attrition rate = 10% of 138

≅ 14

The desired sample size was 152 (sum of estimated sample size and attrition rate)

32

3.7 SAMPLING TECHNIQUE

A multistage sampling technique was employed.

Stage 1. The Palladan ward was divided into 4 using main the road that passed through the

middle of the town and by another Railway that cut across the main road. The sample size

152 was then divided by 4, to obtained 38.

Stage 2. The number of houses in each quarter were numbered, out of which only 7

houses were selected from each of the quadrant using a systematic probability

sampling technique.

Stage 3. In each of the houses selected, at least 5 questionnaire were administered using

a random table balloting technique until the required sample size was obtained.

3.8 DATA COLLECTION METHOD

Data was collected using a structured interviewer administered questionnaires. The questions

were structured in such a way to reflect the objectives of the study. Sections on the

questionnaire sought to collect information on: Socio-demographic characteristics (section

A); knowledge of Ebola virus disease (section B); and perception and belief of Ebola virus

disease (section C). The questionnaire was pre-tested in Baye community that has the same

socio-demographics with the study community. Data was collected over the period of 3rd to

5th December 2014 by the Researcher and 4 trained research assistants.

33

3.9 DATA ANALYSIS

The data collected from the study was checked for errors and then edited accordingly. It was

then entered, validated and analysed using the Statistical Package for Social Sciences

(SPSS®) software version 21. For the descriptive aspect of the analysis, frequency

distributions were generated. For all categorical variables, means and standard deviations and

other descriptive measures were determined. Frequency tables and graphs were constructed to

represent quantitative data, while qualitative data was represented with charts by using

the software programme Microsoft® Excel® 2013. Chi-square test was applied for comparison

of proportions and for evaluating associations of categorical variables in contingency

tables. Statistical significance was said to be achieved where p values were equal to or less than

0.05.

3.11 ETHICAL ISSUES

1) Permission was obtained from the department of community medicine, Ahmadu

Bello University Teaching Hospital to embark on the study as well as verbal

consent from the district head ‘Mai Anguwa’ of Palladan Community before

entering the community to carry out the study.

2) Verbal consent was sought and obtained from the eligible respondents after assuring

them that all information obtained would be kept confidential

3.11 LIMITATIONS OF THE STUDY

1) Due to time and financial constraints, a larger sample could not be used which could

have been a better representation of the population.

34

2) Some of the respondents did not cooperate to be questioned because according to them,

for the past few years they have not gained anything from the results of such studies.

3) Barriers to entry of males into some houses for cultural reasons also hinder effective

sampling of the population.

4) Refusal to participate in the study

35

CHAPTER FOUR

4.0 RESULT

4.1 INTRODUCTION

A total of 152 questionnaires were administered and all questionnaires were filled and

returned in Palladan community from 3rd to 5th December, 2014. All questionnaires were

analysed and the results of the finding are shown below.

4.2 SOCIO-DEMOGRAPHIC CHARACTERISTICS

Table 4.1: Showing distribution of socio-demographic characteristics of the respondents

Age Group(years) Frequency Percent

18-24 77 50.7

25-45 40 26.3

46-64 27 17.8

>65 8 5.3

Total 152 100

Majority of the respondents were between the age group 18-24 years (50.7%)

Table 4.2: Sex distribution of respondents

Sex Frequency Percent

Male 100 65.8

Female 52 34.2

Total 152 100

Most of the respondent (65.8%) are male and 34.2% are female.

Table 4.3: Marital Status of the Respondents

36

Marital Status Frequency Percent

Married 58 38.2

Divorced 2 1.3

Widow/widower 2 1.3

Single 90 59.2

Total 152 100

38.2% of the respondents were married, while 59.2% of them were single.

Table 4.4: Religion of Respondents

Religion Frequency Percent

Islam 91 59.9

Christianity 60 39.5

Others 1 0.7

Total 152 100

Majority of the respondents (59.9%) were Muslim and 39.5% were Christian.

Table 4.5: Ethnicity of the Respondents

Ethnicity Frequency Percent

Hausa 80 52.6

Yoruba 25 16.4

Igbo 14 9.2

Others 33 21.7

Total 152 100

Majority of the respondents (52.6%) were Hausa and other tribes account for 21.7%

Table 4.6: Educational Status of the respondents

37

Educational status Frequency Percent

Quranic 13 8.6

Primary 8 5.3

Secondary 71 46.7

Tertiary 56 36.8

None 1 0.7

Others 3 2

Total 152 100

Most of the respondents (46.7%) had secondary education as their highest level of

education. 5.3% and 36.8% of them had Primary and tertiary levels of education

respectively. 0.7% had no formal education

Table 4.7: Occupation of the Respondents

Occupation Frequency Percent

Farming 4 2.6

Petty Trader 16 10.5

Artisan 8 5.3

Business 34 22.4

Civil servant 12 7.9

Student 78 51.3

Total 152 100

Majority of the respondents (51.3%) were student, 22.4% are doing business and a few

(2.6%) of them were farmers

38

4.3 KNOWLEDGE OF EBOLA VIRUS DISEASE (EVD)

Figure 4.1 Percentage of the awareness of Ebola virus disease. 98 % of the respondent

have heard of Ebola virus disease and only minority (2%) have not heard of Ebola virus

disease

Figure 4.2. Incubation period of Ebola virus disease

Majority of the respondent (64.7%) recognised 2-21 days as an incubation period of EVD

98

2

Yes No

16.7

64.7

10

3.3

5.3

10 days 2-21 days 10-15 days 5 days None of the above

39

Figure 4.3. Source of information

Majority of the respondent (38.8% and 32.9%) heard of EVD through television and radio

respectively and few (7.9%) of them heard EVD through religious institution

(Mosque/Church)

Table 4.8: Percentage of knowledge of the cause of EVD

Age group

(years)

Microorganism Bat/monkey/

chimpanzee

Evil

spirit

gods Witchcraft

Evil

doing/sin

Curse

18-24 11.2 39.5 3.3 7.2 1.9 0.7 2.6

25-45 7.2 22.4 1.3 4.6 0 0.7 0

46-64 5.9 13.8 3.9 1.3 0 0.7 1.3

>65 1.9 3.3 0.7 0.7 0 1.3 0

Television

RadioPublic

announcement

Mosque/Church

Mobliephone

InternetNewspa

per

Percentage 38.8 32.9 19.7 7.9 13.8 22.4 11.8

38.8

32.9

19.7

7.9

13.8

22.4

11.8

0

5

10

15

20

25

30

35

40

45

Per

cen

tage

Source of information on EVD

40

Table 4.9 Percentage of knowledge of the cause of EVD

Highest

level of

education

Microorganism Bat/monkey/

chimpanzee

Evil

spirit

gods Witchcraft

Evil

doing/sin

Curse

Quranic 3.4 4.6 1.9 1.3 0 2.6 0.7

Primary 2.1 3.9 0.7 1.3 0.7 0 0.7

Secondary 14.7 27.6 3.3 7.9 1.3 0 0

Tertiary 18.7 40.8 3.3 3.3 0 0.7 2.6

None 2.8 0.7 0 0 0 0 0

Others 0.8 1.3 0 0 0 0 0

Figure 4.4 Percentage of the respondents knows about mode of transmission of EVD

79.1% of the respondent believe that EVD can be transmitted through the exchange of body

fluids while 9.5% believe that it can be transmitted through other means such as hand

shaking, breast milk of infected person, eating bush meat.

10.115.4

79.1

9.5

0

10

20

30

40

50

60

70

80

90

By mosquitoes By air By exchange of bodyfluids

Others

per

cen

tage

41

Figure 4.5. Knowledge of the symptoms of EVD

Most of the respondents (60.1%) recognised fever as a symptom of EVD, 45.6% knew

gastrointestinal bleeding and 12.1% knew respiratory symptom as a manifestation of EVD.

Table 4.10: Knowledge Regarding Cure of EVD

Has cure Frequency Percent

Yes 84 56

No 66 44

Total 150 100

56% of the respondent believe EVD has cure while 44% believe otherwise

60.1

14.1

23.5

20.1

12.1

45.6

0

10

20

30

40

50

60

70

Fever Flu-likesymptoms

Haemorrhagicrash

Eyemanifestation

Respiratorysymptoms

GIT symptomse.g. bleeding

Percentage

42

Table 4.11: Prevention with Personal Protective Clothing

Prevented using personal

protective clothing

Frequency Percent

Yes 86 56.4

No 66 43.6

Total 152 100

56.4% of the respondents believe EVD can be prevented using personal protective clothing.

4.4 PERCEPTION AND BELIEF OF EBOLA VIRUS DISEASE (EVD)

Figure 4.6. The perception and belief of the cause of Ebola virus disease

Majority of the respondent (79.9%) attribute bat/monkey/chimpanzees as a cause of EVD.

9.4% and 14.1% of them attribute evil spirit and gods respectively as a cause of EVD while

minority of the respondent (2%) attribute witchcraft as a cause of EVD

9.414.1

2 3.4 4

79.9

0

10

20

30

40

50

60

70

80

90

per

cen

tage

43

Figure 4.7. Perception and belief towards prevention of Ebola virus disease

Most of the respondent (91.9% and 88%) believe EVD can be prevented by safe burial and

quarantine of contact respectively, while 23.2% believe in drinking or bathing with salt water

as well as 21.9% believe in bitter Kola

Figure 4.8. Behavioural change adapted toward prevention of EVD

Majority of the respondent (70%) have adapted washing hand with soap and water and

minority of them (2.1%) adapted drinking traditional herbs as a change in behaviour toward

prevention of EVD. 18% of them have not change their behaviour towards prevention of

EVD.

21.9

23.2

91.9

88

20.1

0 20 40 60 80 100

Bitter kola

Drinking salt water or bathing with it

Safe burial

Quarantine of contacts

Wearing of protective clothings

70

2.17.3 7.3

18

0

10

20

30

40

50

60

70

80

Wash hands withsoap and water

Drink traditionalherbs

Take antibiotics Wear gloves andprotective

clothing

None

per

cen

tage

Behavioural change adapted

44

Figure 4.9. Who advised the respondent to drink or bathe with salt water

Majority of the respondent (34.1%) were advised by a family member to drink or bathe with

salt water

Figure 4.10. Means through which respondents were advised to take or bathe with salt

water. Most of the respondent (39.3%) were advised through phone call and a minority

(2.2%) through a third party

3.7

20.9

34.1

5.2

0

5

10

15

20

25

30

35

40

Health worker A friend A family member Others

per

cen

tage

Source of advice on salt bathe and water as means of EVD prevention

39.3

9

11.9

2.23.8

Phone call Text message Face to face instruction Through a third party Others

45

Table 4.12. Number of family members respondents that drank or bathe with salt water

family members that drank or bathe with salt water Frequent Percentage

1 2 1.8

2 14 12.8

3 18 16.5

More than three 75 68.8

Total 109 100

Most of the family (68.8%) members that drank or bathe with salt water are more than three

4.5 RELATIONSHIP ANALYSIS

Table 4.13: Cross tabulation between the highest level of education of the respondents

and those who drank or bathe with salt water

Highest Level of education Drank or bathe with salt

water

Total

Yes No

Quranic 6 7 13

Primary 4 4 8

Secondary 31 25 56

Tertiary 40 31 71

None 0 1 1

Others 2 1 3

Total 83 69 152

χ2= 1.921 df = 5 α level of significance = 0.05

Comment: The chi-square analysis above shows that there is no relationship between

highest level of education and salt water drinking

46

Table 4.14: Cross tabulation of health worker’s advice and those who drank or bathe

with salt water

Health worker’s advice drank or bathe with salt water Total

Yes No

Yes 4 1 5

No 79 68 147

Total 83 69 152

χ2= 1.345 df = 1 α level of significance = 0.05

Comment: The chi-square analysis above shows that there is no relationship between health

worker’s advice and salt water drinking

Table 4.15: friend’s advice and those who drank or bathe with salt water

Friend’s advice Drank or bathe with salt water Total

Yes No

Yes 28 0 28

No 55 69 124

Total 83 69 152

χ2= 28.533 df = 1 α level of significance = 0.05

Comment: The chi-square analysis above shows that there is significant relationship between

friend’s advice and salt water drinking.

47

Table 4.16: Cross tabulation of gender and those who drank or bathe with salt water

Gender drank or bathe with salt water Total

Yes No

Male 48 52 100

Female 35 17 52

Total 83 69 152

χ2= 5.145 df = 1 α level of significance = 0.05

Comment: The chi-square analysis above shows that there is relationship between Gender

and salt water drinking.

48

CHAPTER FIVE

5.1 Discussion

The study was conducted among the residents of Palladan, Zaria. It assessed the

knowledge, perception and belief of Ebola virus disease. Out of 152 questionnaires

administered, 152 were returned and was subsequently analyzed. Response rate was therefore

100%. Out of the 152 respondents, 100 are male and female constitute the remaining 52

respondents with male to female ratio of 2:1. This is a slightly higher male to female

proportion compared to a study done by EpiAfric®-Polling Analytical Databank Strategies

(an NGO based in Abuja) in 2014, were the proportion was almost equal with 51% and 49%

respectively.1 Majority of the respondents were within the age group 18-24 years (50.7%),

and most of the respondents were Muslim (59.9%) and with Hausa accounting for most of the

respondents (52.6%) followed by Igbo tribe (9.2%) and other tribes (21.7%)

Majority of the respondents (46.7%) had secondary education, followed by Tertiary

level of education (36.8%), 8.6% of the respondents had Quranic education, (5.3%) had

Primary education, while four of them (2.7%) had no form of formal education. Half (51.3%)

of the respondents were students; followed by business men/women (22 .4%); petty traders

(10.5%). The lowest represented occupation in the research was farming (2.6%), this is

contrary to that found by the earlier quoted study1 in which a slight majority of the

respondents were self-employed (23%), followed by business men/women (18%), and their

lowest was religious leader/missionary (1%).

Concerning the awareness of EVD, almost everyone has heard of EVD (98%) and

74.5% believe EVD had been in Nigeria. This is similar to that found in a study, among 1,007

United State (U.S) adults by the Pew Research Centre56 where 98% have heard at least a little

about the current outbreak of the virus and nearly half of Americans (49%) were tracking news

49

about Ebola very closely, while in Nigeria, 97% are aware of EVD as found in the study by

EpiAfric. However, a study in Sierra Leone by Catholic Relief Services in conjunction with

UNICEF and FOCUS 1000, found out that everyone (100%) is aware of EVD and 97% of the

respondent surveyed belief EVD exist in Sierra Leone. 44 Majority of the respondent heard of

EVD through Television (38.8%), followed by radio (32.9%), internet (22.4%) then public

announcement (19.7%), and least (7.9%) in religious venues such as mosques and churches.

Similarly, the source of information is similar to that found in Sierra Leone with radio being

by far the primary channel of receiving information on EVD (88%), followed by television

(21%).44

Regarding the cause of EVD, bats, monkey, chimpanzee, and wild animals are mostly

associated with the cause of EVD (79.7%) and (26.3%) of the respondents link the cause of

EVD to a micro-organism. Respondents with no or low level of education 2.8% and 6.3%

respectively were less likely to associate the cause of Ebola virus disease to microorganism

(virus) as compared to those with secondary (14.7%) or higher level of education (tertiary)

18.7% . Less than (3.4%) of the respondents believe that EVD is caused by gods, witchcraft,

evil-doing, or curse. This is less than that found by in a study in the U.S by the Harvard school

of public health in which they found two-third of the respondents (68%) attributed the cause

of EVD to microorganism (virus).45

Misconception that EVD could be transmitted by mosquitoes was found among 10.1%

of the respondents and by air in 15.4% of them as compared to 7% found in the former in the

Nigerian study by EpiAfric. However, a high misconception (30%) that EVD can be caught

through mosquitoes and another 30% by air was found in a study by Oxfam in Guinea 2014.1,55

There is however good knowledge on the transmission of EVD through exchange of body

fluids (79.1%) similar to the study in Nigeria by EpiAfric 2014 in which 83% of the

50

respondents believe EVD spreads through exchange of body fluids while 43% was found in

Sierra Leone by CRS/UNICEF/FOCUS 1000.1, 44

Knowledge of correct incubation period of 2-21 days was found in majority of the

study subjects (64.7%) as well as correct knowledge of the symptoms of EVD where two-third

(60.1%) and a third (45.6%) of the respondent knew fever and gastrointestinal bleeding as a

symptoms of EVD respectively. 12.1% of the respondents believe respiratory symptoms

(cough, breathlessness) could be a presentation of EVD, this is similar to that found in a study

in Washington 2014, out of 1204 respondents, 65% knew the incubation period of EVD and

69% knew fever and gastrointestinal bleeding as a symptoms of EVD.57

Despite half (53.3%) of the respondents drank salt water to prevent themselves from

EVD during the Ebola outbreak in Nigeria 2014, only less than one quarter believe that they

can protect themselves from Ebola by drinking salt water or bathing with it or eating biter

kola; such believe is lower compared to that found in Sierra Leone in which they found 40%

of respondents believe bathing with salt and hot water can prevent EVD and 1 in 5 believe that

spiritual healers can successfully treat the disease.43 Further Chi-square analysis at 5 degree of

freedom and level of significance-p value of 0.05 showed that there is no relationship between

bathing with or drinking salt water and level of education. This is contrary to what was found

in a study44 to assess knowledge, attitude and practice relating to EVD prevention and medical

care in Sera Leone, where they found out that such belief is higher in both the educated in

urban and rural areas.

There is significant change in behaviour and practice towards prevention of EVD in

which 70% wash hands with soap and water upon hearing Ebola outbreak in Nigeria. However,

18% of the respondents have not changed their behaviour. This is lower than that found in the

Sierra Leonean study44 where nearly everyone (95%) reported some behaviour change and

92% in Guinea in the study by Oxfam 2014.4, 56

51

Generally, there are positive perception towards key prevention of Ebola virus disease

such that 88% of the respondents agree that they can prevent Ebola by quarantine of contacts,

91.9% agree that they can prevent the disease by safe burial practices; and 79.9% agree

prevention should include wearing of protective clothing. This is contrary to that found in

Guinea in study by Start Fund Project in 2014, which demonstrated that 67% of 2,050

respondents did not know any method of preventing Ebola and 47% did not even believe Ebola

existed and, 88% said it was a way for the government and non-governmental organisation

(NGOs) to make money.56

Chi-square analysis (x2=28.533 with p value of 0.05 and 1 degree of freedom) of the

relationship between friend’s advice and those who drank or bathed with salt water for the

prevention of EVD showed that there is significant relationship. Similarly, although 2.6% of

those that drank or bathe with salt water were advised by a health worker, there is no

relationship between health worker’s advice and bathing with salt water for the prevention of

EVD as analyzed by chi-square (x=1.345, p value=0.05, df=1).

5.2 CONCLUSION

Although majority of the respondents have a good knowledge and perception of the cause,

means of transmission, symptoms ways of prevention of Ebola virus disease, there is some

misconception of regarding the practice of prevention of EVD. Majority of the respondents

believe EVD had been transmitted in Nigeria. The good knowledge and perception of EVD as

well as the belief that it ever exist in Nigeria could be responsible for the significant change in

behaviour of the respondents towards EVD prevention.

5.3 RECOMMENDATIONS

52

The Kaduna state government in collaboration with the federal ministry of health should create

policies and programmes to:

Address misconception about the disease and clearly spell out mode of transmission in

the local languages

Develop clear messages in local languages on protective practices through health talks

and programmes on mass media.

Should set up strategies towards educating Palladan community to maximally use

television and radio as it is the preferred channel with the widest geographic reach and

effectively use television medium to tell survivor stories and create a hopeful narrative

stories;

Support inter-personal engagement at grassroots level in order to improve community

response and ownership of the social mobilization efforts;

Health workers in collaboration with the ministry of health of Kaduna state to

Ensure that key information on Ebola is communicated directly by health professional.

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.

53

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58

DEPARTMENT OF COMMUNITY MEDICINE

FACULTY OF MEDICINE, AHMADU BELLO UNIVERSITY, ZARIA.

FINAL YEAR MBBS PROJECT,

QUESTIONNAIRE ON KNOWLEDGE, PERCEPTION AND BELIEF OF EBOLA

VIRUS DISEASE AMONG THE RESIDENTS OF PALLADAN

INSTRUCTION

Please kindly answer the following questions by ticking. It is strictly for research purpose and

full confidentiality will be ensured.

SECTION A: SOCIO-DEMOGRAPHIC DATA

1) Age______________

2) Gender 1. M [ ] 2. F [ ]

3) Marital Status 1. Married [ ] 2. Divorced [ ] 3. Widow/widower [ ] 4. Single

[ ]

4) Religion 1. Islam [ ] 2. Christianity [ ] 3. Others (specify) __________

5) Tribe

1. Hausa [ ] 2. Yoruba [ ] 3.Igbo [ ] 4.Others (specify)

_________________

6) Highest level of education

1. Quranic [ ] 2. Primary [ ] 3. Secondary[ ] 4. Tertiary[ ] 5. None[ ] 6.

Others_________

7) Occupation

1. Farming[ ] 2. Petty trader [ ] 3. Artisan[ ] 4. Business[ ] 5. Civil

servant[ ] 6. Student [ ]

59

8) Marital status: 1. Single [ ] 2. Married [ ] 3. Widowed [ ] 4. Separated [ ] 5. Divorced[

]

SECTION B: KNOWLEDGE

1) Have you heard of Ebola virus disease? 1. Yes[ ] 2. No [ ]

2) If yes form which source

1. Television[ ] 2. Radio[ ] 3. Public announcement[ ] 4. Mosque/Church

[ ] 5. Mobile phone[ ] 6. Internet[ ] 7. Newspaper[ ]

3) What causes Ebola virus disease?

1. Poor hygiene [ ] 2.A micro-organism [ ] 3. Contact with body fluid of infected

persons[ ] 4. Eating bush meat[ ] 5. Others[ ]

4) As far as you know, how do you think the Ebola virus is spread?

1. By mosquitoes[ ] 2. By air[ ] 3. By exchange of body fluids[ ] 4. Others (please

specify)…………….

5) Ebola virus disease has a cure 1. Yes [ ] 2. No[ ]

6) Mention the symptoms and signs of Ebola virus Disease that you know (please tick any of

the following if mentioned). 1. Fever [ ] 2.Flu-like symptoms [ ]

3.Haemorrhagic Rashes [ ] 4.Eye manifestation[ ] 5. Respiratory symptoms [ ] 6.

GIT symptoms e.g. bleeding[ ]

7) Ebola virus disease can be prevented by using Personal protective Clothing.

1. Yes [ ] 2. No[ ]

8) Ebola virus disease can be diagnosed through laboratory test.

1. Yes[ ] 2. No[ ]

9) The incubation period for Ebola virus disease is

1. 10days [ ] 2. 2-21days[ ] 3. 10-15days [ ] 4. 5days[ ] 5. None of

the above[ ]

60

SECTION C: PERCEPTION AND BELIEF

1) Do you believe Ebola virus disease ever exist in Nigeria?

1.Yes[ ] 2. No[ ]

2) Ebola virus disease is cause by

1. Evil spirit[ ] 2. God[ ] 3. Witchcraft [ ] 4. Evil

doing/ sin[ ] 5. Curse[ ] 5. Bat/monkey/chimpanzees[ ]

3) Ebola virus disease can be treated by bitter kola. 1. Yes[ ] 2. No[ ]

4) Ebola virus disease can be prevented by drinking salt water or bathing with it.

1. Yes[ ] 2. No[ ]

5) In the event of another outbreak of Ebola virus disease in Nigeria, prevention should

include Safe Burial Practices. 1. Yes [ ] 2. No[ ]

6) In the event of another outbreak of Ebola virus disease in Nigeria, prevention should

quarantine of contacts. 1. Yes[ ] 2. No[ ]

7) In the event of another outbreak of Ebola virus disease in Nigeria, will you be willing

to nurse any infected person without wearing protective clothings?

1. Yes [ ] 2. No[ ]

8) Since Ebola virus disease came into Nigeria which behavioral change have you

adapted? 1. Wash hands with soap and water[ ] 2. Drink traditional herbs[

] 2. Take antibiotics [ ] 3. Wear gloves and protective clothing [ ] 4. None[ ]

9) Did you drink salt water recently to prevent Ebola virus disease scare?

1. Yes [ ] 2. No[ ]

10) If yes, who advised you to do so?

1. Health Worker [ ] 2. A Friend [ ] 3. A Family member[ ] 4. Others[

]

61

11) Through which means did he/she advised you to do so?

1. Phone call[ ] 2. Face to face instruction[ ] 3. Through a

third party[ ] 4. Others[ ]

12) Did you bathe with salt water recently to prevent Ebola virus disease?

1. Yes [ ] 2. No[ ]

13) Did any of your family members drink salt water or bathe with salt water in order to

prevent Ebola virus disease recently? 1. Yes[ ] 2. No[ ]

14) If yes, how many members of your family did so?

(1) 1 [ ] (2) 2 [ ] (3) 3 [ ] (4) more than 3[ ]

Thank you.