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KNOWLEDGE, PERCEPTION AND BELIEF OF EBOLA VIRUS DISEASE
(EVD) AMONG THE RESIDENTS OF PALLADAN, ZARIA.
BY
MUSA, IKO
(U07M...
ii
DECLARATION
I hereby declare that this project was written by me and it is the product of my research work.
All sources...
iii
CERTIFICATION
I certify that this research work was carried out by MUSA IKO (U07MD1104) under my direct
supervision.
_...
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 thes...
vi
LIST OF ABBREVIATION AND ACRONYMS
Abbreviation Definition
BEBOV Bundibugyo ebola virus
BSL-4 Biosafety level 4
CDC Cent...
vii
TABLE OF CONTENTS
Title page……………………………………………………………i
Declaration………………………………………………………….ii
Certification ..………………………………...
viii
CHAPTER THREE
Methodology………………………………………………..…………..28
Background of study area……………………………...………………..28
Study design……...
ix
LIST OF TABLES
Table 4.1: socio-demographic characteristics of the respondents ……………..35
Table 4.2: Sex distribution of...
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...
xii
ABSTRACT
BACKGROUND
Ebola virus disease (EVD), previously known as Ebola haemorrhagic fever, is a serious, often
fatal...
xiii
ever exist in Nigeria where majority of the respondent heard of EVD through Television (38.8%),
and by radio (32.9%)....
1
CHAPTER ONE
1.0 INTRODUCTION
1.1 Background
Ebola virus disease (EVD), previously known as Ebola haemorrhagic fever, is ...
2
yellow fever, Lassa and South American arena viral haemorrhagic fevers, Congo-Crimean
haemorrhagic fever, Rift Valley fe...
3
measures that individuals can take is an effective way to reduce human transmission. These
preventive measures include: ...
4
recommendations of its Emergency Committee, declared the current outbreak a Public Health
Emergency of International Con...
5
people refusing to cooperate with medical personnel, helping patients escape isolation wards,
and exhibiting hostile beh...
6
CHAPTER TWO
2.0 LITERATURE REVIEW
2.1 INTRODUCTION
Ebola virus is regarded as the prototype pathogen of viral haemorrhag...
7
2.2 EPIDEMIOLOGY
The 2014 Ebola outbreak in West Africa is the largest and most complicated that the
world has ever seen...
8
2014, a total of 17,145 confirmed, probable, and suspected cases of Ebola virus disease
(EVD) have been reported in five...
9
intense transmission. In Nigeria, there have been 20 cases and eight deaths, while in Senegal,
there has been one case.2...
10
the State through a corpse brought in from Liberia and deposited at Apex Mortuary in
Nkwelle Ezunaka.1
However, subsequ...
11
The reservoir hosts of the various species of Filoviruses have not been identified. The viruses
could be maintained in ...
12
Person-to-person transmission occurs through direct contact of broken skin or
unprotected mucous membranes with virus-c...
13
2.3 PATHOGENESIS
Ebola virus has a nonsegmented negative-stranded RNA genome containing 7
structural and regulatory gen...
14
glycoprotein, is incorporated into the Ebola virion and binds to endothelial cells but not to
neutrophils. Ebola virus ...
15
Phase C. Pseudo-remission (day 7–8): During this phase the patient feels better and seeks
food. The health situation pr...
16
result. Because the disease was poorly known or rare, laboratory investigations were oriented
towards the more common, ...
17
inactivation.19
Similarly, the nucleic acid can be amplified by purification of the virus RNA
from materials treated wi...
18
signs of improvement. In 1999, seven out of eight victims who received serum from survivors
survived.8
Another drug, th...
19
Leone has heard of Ebola and nearly everyone believes that it exists in the country (97%) and
approximately, 77% of res...
20
reinforced by the realization that there is currently no vaccine or treatment for this fatal
illness with case fatality...
21
be useful to the local, national and international teams in the control of rapid epidemics such
as EVD and other viral ...
22
First is to prevent the infection from entering the human population by avoiding
contact with all known vectors of the ...
23
human primates, the gold standard animal model for viral haemorrhagic fever caused by
several pathogens such as Ebola v...
24
Generally, live attenuated viruses are more advantageous than non-replicating
vaccines because of ease of production an...
25
2.9.3 Secondary Prevention
Secondary prevention comes into play after the disease process has been initiated in
the hum...
26
optimizing his functional ability. It involves psychological, vocational and social and
educational intervention.
Compr...
27
1. Patient placement: Patients should be placed in a single room (containing a private
bathroom) with the door closed. ...
28
CHAPTER THREE
3.0 METHODOLOGY
3.1 BACKGROUND OF THE STUDY AREA
Zaria is a major city in Kaduna State in North-Western N...
29
usually experienced due to North-Easterly wind (the Harmatan) which controls the tropical
continental air mass coming i...
30
3.2 STUDY DESIGN
This is a cross sectional descriptive study to assess the knowledge, perception and belief of
Ebola vi...
31
p= proportion of individuals with good knowledge, perception and belief of Ebola
virus disease
q = complementary probab...
32
3.7 SAMPLING TECHNIQUE
A multistage sampling technique was employed.
Stage 1. The Palladan ward was divided into 4 usin...
33
3.9 DATA ANALYSIS
The data collected from the study was checked for errors and then edited accordingly. It was
then ent...
34
2) Some of the respondents did not cooperate to be questioned because according to them,
for the past few years they ha...
35
CHAPTER FOUR
4.0 RESULT
4.1 INTRODUCTION
A total of 152 questionnaires were administered and all questionnaires were fi...
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% ...
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 ...
38
4.3 KNOWLEDGE OF EBOLA VIRUS DISEASE (EVD)
Figure 4.1 Percentage of the awareness of Ebola virus disease. 98 % of the r...
39
Figure 4.3. Source of information
Majority of the respondent (38.8% and 32.9%) heard of EVD through television and radi...
40
Table 4.9 Percentage of knowledge of the cause of EVD
Highest
level of
education
Microorganism Bat/monkey/
chimpanzee
E...
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...
42
Table 4.11: Prevention with Personal Protective Clothing
Prevented using personal
protective clothing
Frequency Percent...
43
Figure 4.7. Perception and belief towards prevention of Ebola virus disease
Most of the respondent (91.9% and 88%) beli...
44
Figure 4.9. Who advised the respondent to drink or bathe with salt water
Majority of the respondent (34.1%) were advise...
45
Table 4.12. Number of family members respondents that drank or bathe with salt water
family members that drank or bathe...
46
Table 4.14: Cross tabulation of health worker’s advice and those who drank or bathe
with salt water
Health worker’s adv...
47
Table 4.16: Cross tabulation of gender and those who drank or bathe with salt water
Gender drank or bathe with salt wat...
48
CHAPTER FIVE
5.1 Discussion
The study was conducted among the residents of Palladan, Zaria. It assessed the
knowledge, ...
49
about Ebola very closely, while in Nigeria, 97% are aware of EVD as found in the study by
EpiAfric. However, a study in...
50
respondents believe EVD spreads through exchange of body fluids while 43% was found in
Sierra Leone by CRS/UNICEF/FOCUS...
51
Generally, there are positive perception towards key prevention of Ebola virus disease
such that 88% of the respondents...
52
The Kaduna state government in collaboration with the federal ministry of health should create
policies and programmes ...
53
REFERENCES
1. The Ebola Virus Disease Poll Report Abuja: Polling Analytics Databank Strategy;
2014 [Accessed 18 Septemb...
54
13. Casillas AM, Nyamathi AM, Sosa A, Wilder CL, Sands H. A current review of Ebola
virus: pathogenesis, clinical prese...
55
25. WHO. Situation reports: Ebola response roadmap Geneva: World Health
Organization; 2014 [Accessed 20 October 2014]. ...
56
37. Bausch DG, Sprecher AG, Jeffs B, Boumandouki P. Treatment of Marburg and Ebola
hemorrhagic fevers: a strategy for t...
Knowledge perception and belief of Ebola virus disease (EVD) among the residents of palladan, Zaria
Knowledge perception and belief of Ebola virus disease (EVD) among the residents of palladan, Zaria
Knowledge perception and belief of Ebola virus disease (EVD) among the residents of palladan, Zaria
Knowledge perception and belief of Ebola virus disease (EVD) among the residents of palladan, Zaria
Knowledge perception and belief of Ebola virus disease (EVD) among the residents of palladan, Zaria
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Knowledge perception and belief of Ebola virus disease (EVD) among the residents of palladan, Zaria

  1. 1. 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.
  2. 2. 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
  3. 3. 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)
  4. 4. iv DEDICATION This piece of work is dedicated to my beloved late father Mr. Musa Wundu
  5. 5. 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.
  6. 6. 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
  7. 7. 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
  8. 8. 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
  9. 9. 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
  10. 10. x Table 4.16: Cross tabulation of gender and those who drank or bathe with salt water ………………………………………………………………………………………..47
  11. 11. 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
  12. 12. 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
  13. 13. 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.
  14. 14. 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,
  15. 15. 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
  16. 16. 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
  17. 17. 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
  18. 18. 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
  19. 19. 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
  20. 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
  21. 21. 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
  22. 22. 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
  23. 23. 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
  24. 24. 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
  25. 25. 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
  26. 26. 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
  27. 27. 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.
  28. 28. 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
  29. 29. 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
  30. 30. 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
  31. 31. 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
  32. 32. 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,
  33. 33. 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
  34. 34. 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.
  35. 35. 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-
  36. 36. 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.
  37. 37. 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.
  38. 38. 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
  39. 39. 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:
  40. 40. 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.
  41. 41. 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
  42. 42. 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
  43. 43. 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= 𝑧2 𝑝𝑞 𝑑2 Where n = minimum sample size d = desired degree of precision = 0.05
  44. 44. 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)
  45. 45. 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.
  46. 46. 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.
  47. 47. 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
  48. 48. 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
  49. 49. 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
  50. 50. 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
  51. 51. 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
  52. 52. 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 Televisio n Radio Public announc ement Mosque/ Church Moblie phone Internet Newspa 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 Percentage Source of information on EVD
  53. 53. 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. 10.1 15.4 79.1 9.5 0 10 20 30 40 50 60 70 80 90 By mosquitoes By air By exchange of body fluids Others percentage
  54. 54. 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-like symptoms Haemorrhagic rash Eye manifestation Respiratory symptoms GIT symptoms e.g. bleeding Percentage
  55. 55. 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 9.4 14.1 2 3.4 4 79.9 0 10 20 30 40 50 60 70 80 90 percentage
  56. 56. 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 2.1 7.3 7.3 18 0 10 20 30 40 50 60 70 80 Wash hands with soap and water Drink traditional herbs Take antibiotics Wear gloves and protective clothing None percentage Behavioural change adapted
  57. 57. 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 percentage Source of advice on salt bathe and water as means of EVD prevention 39.3 9 11.9 2.2 3.8 Phone call Text message Face to face instruction Through a third party Others
  58. 58. 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
  59. 59. 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.
  60. 60. 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.
  61. 61. 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
  62. 62. 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
  63. 63. 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
  64. 64. 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
  65. 65. 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.
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