The 2014 Ebola Virus Disease Outbreak In Nigeria

Researchjournali’s Journal of Public Health Vol. 2 | No. 8 August | 2016

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The 2014 Ebola Virus Disease Outbreak In Nigeria: A Retrospective Risk Perception Survey

Isoken T. Aighewi Department of Environmental Management and

And Public Health Implications

Toxicology, Faculty of Life Sciences, University of Benin, Ugbowo, Benin City, Nigeria

Isoken H. Igbinosa Department of Environmental Management and Toxicology, Faculty of Life Sciences, University of Benin, Ugbowo, Benin City, Nigeria

www.researchjournali.com


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ABSTRACT Ebola Virus Disease (EVD) is an acute zoonotic disease with no known cures, and thus the necessity for more effective preventive strategies. In 2014, there was EVD outbreak, resulting in 8 reported fatality of the 19 laboratory-confirmed cases in Nigeria due in part to the timely containment. However, the potential for greater spread existed and may still exist as new cases are still being reported in neighboring countries. Because risk perceptions can affect protective behavior, we initiated this survey to evaluate the risk perception of EVD one year after the outbreak. We interviewed 300 subjects in Lagos, Benin City and Abuja Nigeria and found that though initially dreaded, there was a 43% drop in perceived risk one year after the outbreak. The initially heightened risk perception did not significantly affect the consumption of game/bush meat linked to the Ebola virus, but positively affected frequent hand washing to prevent human-to-human spread. A national health education program for EVD and a new Public Toilet policy for Nigeria as well as a regional disease control center for West Africa are recommended. Key Words: Ebola, risk perception, Nigeria, Public health, Epidemic, Health Policy, Zoonosis.

1. INTRODUCTION Ebola Virus Disease (EVD) is an acute zoonotic disease with very high case fatality rate of 50% with a range of 25-90%. The disease is caused by a group of genetically distinct filoviradae virus family that causes haemorrhagic fever in its final stage of infection. EVD first appeared in 1976 in Sudan and Democratic Republic of Congo and recently re-emerged in West Africa in 2014. Currently, there are no approved antiviral drugs or vaccines against filoviruses, thus making the prevention and containment of any outbreak much more challenging. The recent outbreak is historic as it has affected several countries-Guinea, Senegal, Sierra Leon, Liberia, Mali and Nigeria, as well as a few isolated cases in some western nations such as Italy, Spain, United Kingdom and the United States (WHO 2014a). However, preventing the spread of present and future outbreak of this virulent communicable disease requires improving our understanding of its epidemiology, especially the role of wildlife in the transmission of the Ebola virus to humans and from humans to humans through body fluids. The recent EVD epidemic in Nigeria, the most populous African nation, was the first of its kind and was introduced by a single source, a Liberian visitor to Lagos, Nigeria. The presence of such a deadly and relatively unknown communicable disease was potentially catastrophic and hence created hysteria everywhere in the country as it dominated all local and international press, including the internet social media; more so that the index case occurred in Lagos-one of the most densely populated commercial metropolis in the world with a population of more than 21million people (Demographia 2015).

Although this epidemic was successfully

contained (Asuzu et al, 2015), and Nigeria declared Ebola-free by the World Health Organization in October, 2014 (WHO, 2014b) the epidemic resulted in 8 deaths out of the 19 laboratory-confirmed cases in Nigeria



(CDC, 2015) and a total death toll of 11,299 in all countries affected as of November 30, 2015 (WHO, 2015b). That EVD was successfully contained in Nigeria does not however indicate its complete elimination from the country as the potential risk of outbreak may still exist-particularly as cases of outbreak have continued to be reported in neighbouring countries as at when this study was concluded Vanguard, 2015). The risk is further buttressed by the fact that there is currently little or inadequate public health infrastructure and manpower in Nigeria (Aighewi, 2014a). In fact, the first ever Society of Public health in Nigeria was inaugurated following the EVD outbreak in Nigeria in 2014 (Asuzu et al; 2015) and many developing economies in Sub-Saharan Africa are no better off and thus quite as vulnerable. Therefore efforts aimed at front-ending future occurrences of EVD in Nigeria, West Africa and the world in general cannot be overemphasised at this time! A starting point for laying a solid foundation for preventing future EVD outbreak requires an appraisal of the recent one through the eyes of the masses as well as the professionals in the Public health field. Whereas Asuzu et al; (2015) recently provided a comprehensive account of the Nigeria’s EVD outbreak and how it was successfully contained, there is the need to assess the risk perception of the masses as it is a well-established fact that risk perceptions can affect protective behavior and protective behavior can affect risk perceptions (Brewer et al, 2004). For example, such information could help lay the foundation for sound public health education, health promotion campaigns as well as public health policy formulation for Nigeria and other countries, particularly the developing Sub-Saharan Africa countries. In fact, Goorah and Jokhoo (2013) opined that health risk perception often reflects a society’s particular concerns and appreciation of the prevailing health threats; and evaluating same has both managerial and policy implications (Menon et al, 2007). During the EVD outbreak in Nigeria, it became commonplace to refuse handshake with friends and loved ones for fear of human-to-human transmission; many also abstained from bush meat consumption at home and public bars as some wild animals like Bats, Chimpanzees, Gorilla and Velvet Monkeys have been linked to some strains of the Ebola virus in the past (WHO, 2014a). False rumors also spread like wild fires such as bathing with salt water as a preventive measure (salt therapy) which led to more deaths than the EVD in Nigeria (Alao et al, 2014). McCrary and Baumgaten (2004) and Sandman (1989) have identified behavioral factors that may affect the perceptions that people have about risks, notable among which are controllability, news media, voluntariness, lethality and fairness. Other studies have also shown that feelings of dread were the major determiner of public perception and acceptance of risk for a wide range of hazards. Therefore this study was initiated to evaluate the risk perception of Ebola Virus Disease EVD during and one year after the outbreak in Nigeria with a view to providing future bases for primary prevention through training or health education, as well as policy formulation.


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2. MATERIALS AND METHODS Study Location: The choice of the states and subjects for this study were based on stratified random sampling procedure because of the need to include at least one of the two major cities where the EVD outbreak occurred (i.e., Lagos in Lagos State, and Port Harcourt in Rivers State) and all other southern states in Nigeria where no cases were reported. This was necessary in order to evaluate possible differences in EVD perception by subjects on the basis of location. To this end, Lagos, was randomly picked and Port Harcourt left out; while Abuja, Nigeria’s Federal Capital Territory (FCT) and Benin City, Edo State, were randomly selected from the stage of the randomization procedure among the other 19 states in the southern half of the country. The survey was conducted using a paper-based questionnaire developed (in English language) to include sociodemographic characteristics such as age, sex, education and city of residence. In addition, specific questions about knowledge of the Ebola disease before and after the outbreak, their perception and behavioural practices before, during and after the outbreak such as hand washing and consumption of bush or game meat; access to soap and water in public places, including their opinion about the possibility of future outbreak were targeted questions included in the survey. The questions were drawn according to Green et al (1993) and the questionnaires administered to 20 subjects at the City Centre (Kings Square) in Benin City as a pilot; this was in order to test the effectiveness of the questionnaire and how long it took the average subject to complete and return them. Field observations and feedback from this pilot study formed the basis of the final structured questionnaire administered. A total of 300 adult subjects out of 383 selected at random to participate in this survey successfully completed the questionnaires in Lagos, Lagos State, Benin City, Edo State, and Abuja, the Federal Capital Territory of Nigeria (100 questionnaire each). For all survey location, students who administered the questionnaires approached adults in market places, offices, churches and city centres, ascertained whether or not they were more than 18 years old and kind enough to volunteer their time to complete the survey in a few minutes. Individuals under 18yrs and those not living in the studied cities at the time of the outbreak were not included in the survey and informed consent was obtained from the respondents who were assured of voluntary participation and confidentiality of their responses. Data obtained were collated in Microsoft Excel and analysed using chi-square test of independence, percentages including bar graphs and pie chat where necessary.

3. RESULTS AND DISCUSSION Of the subjects contacted, 78.3% completed and returned the questionnaire. Table 1 shows the result of the demographic data of the study subjects in the three states. Of the 300 respondents, 56.3% were males while 43.7% were females, with age ranging from 18-75 and a minimum of secondary school education.


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Because knowledge about a disease is normally a prerequisite for avoidance of the disease, the respondents were asked about the cause of the EVD and whether they had any knowledge about the disease before the outbreak. Although most (87%) subjects polled had never heard about the EVD before the outbreak, a majority claimed to be aware about the disease one year later. However, more of the subjects in Lagos (94%) where the outbreak first occurred, claimed to know about the disease than in Benin City and Abuja. This result is indicative of a major improvement in awareness and thus the perception of the disease as less risky now than when the outbreak occurred in 2014. Table 1: Socio-demographic characteristics of Respondents in three Nigerian Locations RESPONDENTS CHARACTERISTICS Age: 18-30 31-50 51-70 70+ Sex: Male Female Occupation: Clinicians Civil Servants Business People Students Education: None Primary Education Secondary Education Tertiary Education Post-graduate Education

LAGOS STATE

ABUJA, FCT

EDO STATE

Mean (%)

64 28 9 8 55 45 7 23 51 19 8 23 35 22 12

71 19 2 1 51 49 0 27 10 63 1 1 69 21 8

53 17 8 20 63 37 11 34 21 34 10 19 25 31 15

62.7 21.3 6.3 9.7 56.3 43.7 06 28 27.3 38.7 9.6 14.3 43 24.7 11.7

The result is obviously due to the information from print and electronic media coverage, internet social media and cell phone exchanges during the outbreak, including health advisories by Nigeria’s Federal Ministry of health and time lag. Lack of awareness about health hazard or risk tends to make people perceive risks as riskier than when they are aware of it (sandman, 1989). The outbreak of EVD caused hysteria all over Nigeria due in part to the lack of prior knowledge about the disease. The fear was reinforced by the print and electronic media who were abuzz with the news about this “mysterious Ebola disease” and how deadly it could be; and more importantly the reality that immediate solution to this issue was beyond the scope or training of most Nigerian physicians since it was more of a public health issue in a country without a robust public health infrastructure. In fact, the paucity of knowledge fuelled several false rumors about the disease and remedies. This result is further supported by the fact that when humans first encounter a risk, they are more afraid than after they have lived with the risk for a while (Green et al, 1993). One year after the outbreak, the respondents were asked to rate their level of fright during and after the EVD outbreak; their responses was subjected to a Chi-Square test of independence in order to assess possible changes in the level of fright during and one year after the outbreak. The 2x2 contingency table shown in Table 2 indicate



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that the level of fright during and after the outbreak were not independent as the frequency of respondents who claimed to be very/extremely frightened and those who claimed to be somewhat frightened/not frightened during and post-EVD outbreak were significantly different (P