The case study will be on a communicable disease in a given jurisdiction. Students are expected to address the different scales of disease, from the
... [Show More] microbial, transmission and spatial patterns and examining the importance of cultural, political, physical, environmental and social factors in the population’s epidemiologic profile (multi-level model).
• Through the integration of the main concepts discussed in class and mastering critical and creative thinking, students are expected to debate the societal and political complexities of health and disease.
Assessment 2 | Case-Study
• The case-study will be on a communicable disease in a given
jurisdiction. Students are expected to address the different scales of
disease, from the microbial, transmission and spatial patters and
examining the importance of cultural, political, physical,
environment and social factors in the population’s epidemiologic
profile (multi-level model).
• Through the integration of the main concepts discussed in class and
mastering critical and creative thinking, students are expected to
debate the societal and political complexities of health and disease.
• The class presentation on the selected communicable disease and
jurisdictions will take place on September 16.
EBOLA VIRUS DISEASE: West Africa Case - Research Report
Glen Burton 16547881
Background
The Ebola virus disease or Ebola Haemorrhagic fever first appeared in 1976 breaking out in Sudan
with 284 and 318 cases in the Democratic Republic of Congo. The nature of Ebola with varying
strains and cell mutations means that number of deaths resulting from cases is often relative to each
outbreak (Laupland & Valliquette, 2014). Ebola is mutating communicable, zoonotic viral disease
that is historically prevalent in Central Africa, with rare isolated cases persisting, historically in
neighbouring regions. Researchers have identifies five species of the ebolavirus including Zaire,
Sudan, Taï Forest, Bundibugyo and Reston ebolavirus (Park, 2015). Definite diagnosis of clinically
suspected Ebola remains difficult due to the extreme biohazard risk posed by exposure to the virus.
(Alexander et Al, 2015). This analysis gauges the varying scales of the disease followed by the factors
which encompass and influence its spread. The analysis of the disease in this manner highlights the
conceptual inter-dependant relations between health and geography.
Symptoms/Treatment
Clinical pathology studies of EVD have historically been limited due to lack of medical resources in
regions with Ebola outbreaks in addition to the infrequent number of events associated with the
virus and extreme level of risk embodied by bio-hazardous nature of the virus posed in previous
outbreaks. Pathological data from the initial cases of the virus demonstrate that ebolavirus can
infect varying cell types and tissues. The most common reported symptoms of the illness includes 3
phases, starting with a few days after initial signs of infection in which the host may display
headache, non-specific fever and myalgia. This is followed with a phase of gastrointestinal illness
where commonly reported symptoms include diarrhoea and vomiting, abdominal symptoms and
dehydration. The third phase of the illness can be fatal, including collapse, neurological
manifestations and bleeding (Beeching, 2014). Patients who survive the second week of Ebola will
have approximately 75% chance of surviving. Ebola currently has no specific treatment meaning that
survivors of the illness require a supportive process of managing the patient to full recovery. Rates of
death relevant to specific past cases differ in relation to strain of the virus and country of origin.
Medical, immunotherapy, nucleic acid therapy and other approaches are currently being developed
with greater understanding following the latest outbreak in improving means of recovery in patients
with wider implications for prevention (Laupland & Valliquette, 2014).
Vectors/Pathogens
Fruit bats of West Africa, particularly of the Pteropodidae family, are known to be the natural hosts
of Ebola viruses while humans and other mammals serve as accidental hosts. Laupland & Valliquette
(2014) further note Ebola virus disease as the major cause of decline in African chimpanzee and
gorilla populations in recent years. Though the virus is believed to initially be acquired by exposure
to body fluids or tissue from infected animals though the natural reservoir, direct mode of
transmission to humans has not been confirmed (Beeching, 2014). Laboratory confirmation of
reservoir competence identifies successful transmission between bats and rodents but not plants or
arthropods. Furthermore, Laupland & Valiquette (2014) notes that while exposure to infected bats
may occur as a result of being a food to local inhabitants of Central and West Africa, there are no
documented cases of direct bat-to-human transmission of the disease. The spill over of Ebola virus
disease from the wildlife reservoir to human host populations continues to be a complex process
involving social factors and environmental drivers. Alexander et al (2015) further asserts the modes
of transmission through a number of bat species in which a risk outbreak range has been identified,
particularly in the straw coloured fruit bat which has the ability to migrate distances up to 2500km.
Therefore the movement of Ebola through such vectors as bat colonies from Central Africa have the
potential to transmit the disease to West Africa and into other reservoir-host populations. The
transmission of Ebola to wildlife species is believed to occur with evidence of ingestion of fruit
contaminated with infected bat saliva or faeces. Furthermore organs from laboratory-infected,
nonhuman primates had extremely high infectivity rates. This is supported by Beeching (2014) who
contends that human transmission may occur during hunting and consumption of reservoir bush
meat of infected non-human primates. This is a practice that remains culturally embedded in many
groups across Africa. A case in Côte d'Ivoire following the initial outbreak of disease in the 70s was
centred on hunting activities of chimpanzees’ and noted as the first recorded outbreak resulting
from bush meat consumption.
Transmission
During the time between the first onset of the Ebola virus disease in 1976 and the recent case of
outbreak and subsequent West African epidemic, 24 clusters of Ebola virus disease occurred,
including 2400 cases reported by the WHO, (WHO, 2016).In regard to human to human
transmission, Ebola virus disease is primarily transmitted through close contact with blood and
bodily fluids from exposure to another infected human. This can occur through both direct contact
or indirectly transmitted from a contaminated environment Laupland & Valiquette (2014). Beeching
(2014) further addresses this, noting that the majority of recorded early epidemics, the use of non-
sterile injections from infected patients was held responsible for a range of health care associated
transmissions yet the significant instances of transmission of Ebola come from result of physical
contact or contact with an infected patients body fluids. Ebola has previously been isolated in saliva,
breast milk, stool, tears, sweat, blood, faeces, urine, genital secretions and semen with cases ranging
up to 40 days to displaying signs of the infection after initial exposure. This highlights the risk Ebola
has as a communicable disease, with a highly contagious and slow onset nature, Ebola poses grave
potentials for outbreak occurrence given its ease of transmission coupled with an extensive
incubation period where the disease may be masked for time while simultaneously being spread by
human carriers through delayed sexual transmission. However, much works on the nature of
transmissions of this phenomenon remains under development. So far there is no evidence in
humans to suggest that the disease is capable of airborne transmission. Epidemiological risk factors
have been addressed by the WHO (2016) and designated into high risk cases with contact defined as
someone who has slept in the same household as a patient, had physical contact with an infected
person during the illness or at funeral, touched the persons skin, body fluids, clothes or bed linen, or
been breast fed in the case of infected mothers during the illness.
Spread - West Africa Outbreak
The outbreak and eventual epidemic of Ebola in West Africa is known to have originated from an
epizootic case in Guinea that lead to human-host spread of the disease. Early reports suggest this
was instigated in remote semirural areas of West Africa before introductions into high density urban
areas, in which propelled a rapid rise in occurrence of the disease prevalence into neighbouring
Sierra Leone and Liberia to lead the 2013-16 epidemic (Dahl, 2016). The use of big data can be
disseminated to be used in modelling the spatiotemporal spread of the Ebola virus disease. The 2013
West African Epidemic is a case that allows for the process of disease mapping by following the
movements of individuals, including patients not infected, seeking health facilities, the movements
of individuals taking care of patients infected with Ebola but not admitted to hospitals, the
attendance of individuals to funerals and individuals who travelled across borders. The epidemic,
caused by the Makona variant of Ebola virus disease was the most significant outbreak to date (Kuhn
et al., 2014), estimated to have spread mainly as result of exposure in hospitals followed by
households and funerals. The movements and mixing of the virus in hospitals during the early phases
of the outbreak was the main contributing factor leading to the escalated epidemic across West
Africa (Merler, et al, 2015). Prior to the most recent outbreak, monitoring data suggests there have
been an estimated 20 countries which have been implicated in outbreaks manifested by 2500 cases
in the Democratic Republic of Congo, Sudan, Gabon, Uganda and Côte d’Ivoire before 2013. The
most recent outbreak is novel in that it’s centred in West Africa and forged new geographical
distributions for understanding spread of Ebola virus disease in humans. The movement across
borders forms manifestation of wider theoretical understandings surrounding the significance of
global health in the 21st century, therefore encompassing the assessment of communicable disease
requires analysis at multiscale levels. This is further supported by Laupland & Valiquette (2014) who
contend that research of the virus and its involvement with humans and animals needs to be stated
on a greater scale. With the propelling mechanisms of globalisation and ease of mobility, the need
for research and surveillance remains a vigilant practice with the enduring risk of the disease and its
potential for spread across borders. The outbreak led to a Public Health Emergency of International
Concern being designated by the World Health organisation on August 8, 2014, which was recently
lifted on 29th March 2016. As of this date, the epidemic has reached 28 616 specific cases, reported
across borders in Guinea, Liberia and Sierra Leone, with a total of 11 310 subsequent deaths (WHO,
2016). Disease surveillance remains a high priority for Sierra Leone officials while Guinea and Liberia
have declared an end to most recent outbreaks and transmission. Performance indicators suggest
these nations still have much improvement to make in public health capacities in order to sustain
preventative, detection and responsive measures. Some positive signs from the outbreak persists
with over 10 000 individuals surviving the disease during the outbreak. First declared on March
2014, the outbreak remains significant due to its prevalence of isolated cases scattered around the
globe, disease clusters among populations in West Africa where the disease was centred, has never
in history been transmitted among humans for such a sustained amount of time (Baize et al., 2014).
The significance of factors relative to the burden of disease characterised by Ebola therefore
requires analysis of the events at global scale.
Globalisation/Global Health
The term globalisation is increasingly used as a summary for explaining the emerging interplays of
technology and communication and the contemporary nexus on global markets, economies and
culture which has largely been integrated through means of interconnected nodes and networks of
multilateral cooperation, development and exchange (McCracken and Phillips, 2012). The
asymmetric impact of globalisation affects developing nations more than wealth ones due to
presence of social structures in resisting to market fluctuation, the presence of these structures
convergently impact on health economies of poorer nations. Therefore the requirement for
addressing Global Health on part of the trans-border risk of this virus typified by the recent 2013
Ebola outbreak, at the scale of global governance must be considered. Global health for many
scholars, relates to the shifts in health status and reported shifts in health experiences across the
globe, more specifically it can be used to adequately describe the nature of response to some
diseases. The relation of global health and it’s mechanisms for governance is significant in that it
forms strategic objectives aimed at the reduction, prevention and elimination of infectious disease
to support the reduction of incidence and prevalence that encompass burden of disease in different
regions. It forms a conceptual framework for cooperation and provision, while accounting for broad
data sets aimed at disease monitoring, mapping and surveillance, research, preventative and
response efforts. These factors remains vital parts of global governance that impact on the burden
of Ebola in West Africa. Global Health encompasses concepts of causation models, noting the link of
global geographies with epidemiology and medicine with the intent of reducing risk factors.
McCracken and Phillips (2012) extend the interplay of global health and disease by introducing the
epidemiological triad as a framework for understanding how disease develops, spreads and
controlled. This particularly relates to the interaction of the host who acquires or incubates disease,
agents that cause the disease and the environmental sphere. The interplay of these factors form
relational experiences inherent in the concept of the epidemiological triad. Framing the Ebola virus
disease in this manner is incredibly valuable when addressing the variety of health conditions
involved with the disease and well as the varying frameworks of society, environment and the
significance of global, national and subnational forces that must be considered in accordance with
the transnational risk associated with Ebola virus disease.
Responses
The role of global governance is largely attributable to the relative country and specific international
agency and partners working with governments under a collective effort. The majority of CDC and
WHO workers were primarily engaged in offering expertise on the core principles of control,
including the provision and expansion of surveillance across the region and ensuring prompt and
efficient contact tracing practices. In addition to control and mapping, health workers supported
overall technical guidance in relation to training, support and communication in infection control
practices (Dahl, 2016). Collective partners operate under the absolute objective of eradicating the
status of epidemic in West Africa and the collective operational presence is noted as a key part of
the global frameworks effectiveness in attaining control. Supporters of global health practices argue
that operational presence on the part of the CDC, WHO and UN in the early stages of the outbreak
may have led to a considerable more effective response. The CDC has since established offices in
West Africa in accordance with future outbreak measures. The sentiment of growing capacity for
international response is echoed by the UN Development Group (2015) who note the nature of
Ebola in the recent outbreak means not one country can manage the crisis on its own. The West
Africa outbreak represents an unprecedented situation in which handling, requires impeccable
regional solidarity, collaboration and communicative dialogue to save lives and rekindle health and
prosperity amongst the population and region. These actions ensure a template of international aid
response which serves as a foundation to which developing priority actions and preventative
measures in each respective nation may be attained. This includes improving health resources and
systems of the nations of West Africa, to ensure at an national-individual scale there remains
universal access to basic health services in remote regions, clear education focused on infectious
disease in order to dispel myths negligible practices and to also improve conditions at the systemic
level to ensure provisions of vulnerability mitigation are met in order to build resilience in future
incidence of Ebola virus. In addition, the UN (2015) outlines requirements for improved early
warning mechanisms in non-affected states. The health institutions in West Africa are similar in
standard to the majority of African nations, in this respect the UN has previously called for the
African Union to institutionalise highly preventive mechanisms across the continent as a whole on
part of efforts for wider systemic containment in the future. In order for the structural forces of
global health to remain viable, the international community must consistently act efficient in dealing
with outbreaks for the perception amongst national stake holders on how the global community acts
in crisis is an integral factor in managing the burden of Ebola on a global scale.
Impacts/Challenges
Institutions of global governance are also significant in measuring the impacts of the disease across
the affected regions, as well as gaining insight into social factors that propagate health inequities
which indirectly contribute national-level burden of disease. Taking note of these factors is an
integral part in addressing more appropriate means of mitigation and prevention to deal with future
outbreaks. The UNDP (2014) notes extensive impacts on education characterised by the closure of
schools, reduction in attendance rates and loss of teaching staff. This is on trend with wider analysis
of inter-communal relationships which appeared to have been severely weaken by the onset of
Ebola virus disease. According to big data analysis collected, fear of disease in society remains
prevalent, impacting frequency of visits to relatives and linkages between different villages and
ethnic groups. Traditional ceremonies where relatives touch the bodies of deceased individuals is no
longer carried out due to transmission concerns. Feelings of distrust among different localities as
well as the negative perceptions of aid workers is still significant. Mistrust is an often understated
factor involved in the interplay of long standing and deep seated inequities, thwarted with
inaccurate information and inadequate resources to deal with the onset of Ebola, social division
driven by mistrust, fear and panic during the outbreak was an incredibly negative factor in the global
response (Agyepong, 2014). This is supported by Frieden et al (2014) who notes the fear of being
quarantined in the perceptions of local communities and subsequent concerns of transmission in
hospitals which drove trends against testing and treatment. Prior to the outbreak, health resources
were deemed inadequate to deal with the containment of Ebola due to unfamiliarity with the re-
emergence of the disease and prevalence of other diseases endemic to the region that masked it’s
diagnosis with similar symptoms. This was made worse due to the inherent biohazard nature of
Ebola virus disease. In addition to the virus itself and the involvement of global governance in
preventing, responding to and contain the outbreak, many scholars note the extensive societal
factors such as poor infrastructure, healthcare, poverty, urban density and population movements
as more extensive drivers of disease burden rather than Ebola’s unique biological characterisation
examined in the latest strain (Osterholm et al, 2015).
National Health & Structural Factors
Furthermore, individuals are not at risk in West Africa only because of the given proximity to
centres of outbreak or the highly infectious, fatal nature of the virus alone, rather the contextual
conditions inherent to the nations of West Africa that contribute to the burden of disease
escalation and complexities in regards to containment, education and control. Primarily, national
health systems in the region are inadequately prepared to handle Ebola at the outset, due to
structural implications of lack of primary and tertiary healthcare, funding and objectives coupled
with inefficiencies in medicines, ambulances, facilities and trained professionals with appropriate
medicinal equipment. These factors led to an inequitable distribution on infection whereby rural
regions were significantly limited in receiving adequate provisions of health during early stages.
The outbreak has worsened national health resources in Liberia Sierra Leone and Guinea, typified
by the UNDP (2014) noting a sharp reduction of health service access, access to birth control
services and skilled health workers. The mistrust among health practices stemming from such
facilities as the source of infection has created a paradoxical issue for Ebola propagation in
endemic regions. The case also showed instances where health workers deaths due to
inadequate infection controls could have been prevented with 90 out of 153 deaths from cases in
Guinea, these instances also serve social fears on part of health workers with some clinics being
forced to shut down temporarily during the epidemic (UNDP, 2014). The nature of conflict and
political instability rising from social divisions and inequities placed with mistrust, an inadequate
national health systems, fear and ignorance all remain congruent societal factors inherent to the
rapid spread of Ebola virus disease in 2013. Greater national measures are required in part of
wider efforts with global agencies to support long term investment, health and access systems
and resources, education measures, surveillance systems and outbreak preparedness. Marchal,
(2009) further asserts that funding for health systems needs to be well sustained and balanced
between the two main goals of health systems (prevention and treatment). Without this focus,
investment in promoting tertiary services alone, will not be adequate. Finally, robust strategies
with tested empirical methods need to be promoted in accordance with current interventions
and urgently put into field practice to ensure against re-occurrence of outbreak.
Politics/Conflict/Economy – Social Factors
There is growing sentiment amongst scholars in health geographies in developing states that
many components of effective change are bound in domestic politics and power relationships.
The case of unhealthy power relationships and ineffective governmental structure is well
characterised in the case of West African nations and historical dependence on structural
adjustment programs (World Bank, 2010). Liberia’s government was in shambles following 14
years of civil war. So too is the case with Sierra Leone suffering from factional and militant civil
war from 1991 to 2002 leaving over 50 000 dead (UN, 2015). Since 2011, Guinea has too been
recovering from systemic political, economic and social crisis where poor management of
resources and lack of confident in the population led to the folding of democratic institutions in
the regions and poor social fabric. Road systems, transportation services, and
telecommunications are weak in all three countries with a graver implication for inhabitants of
the rural setting. The presence of political mismanagement of power, corruption and conflict
severely undermines the ability for structural components at a state level to manage health
services effectively. Furthermore this has a structural impact on poverty, thereby indirectly
contributing to health disparities and further promoting burden of disease.
Poverty/Discrimination
The enduring years of continued systemic factors contributing to inequity has had adverse
implications on poverty, not to mention the cyclical impacts of the most recent outbreak on poverty
and individual access to health. Sierra Leone, Liberia and Guinea have some of the lowest Gross
National Incomes per capita in the sub region of West Africa and some of the lowest in the world.
The economic situation has deteriorated through much of the epidemic with contingency plans
coming into effect this year. Under a minimalist economic modelling Ebola scenario, the estimated
loss in GDP for the whole 15 states in the region is US$1.8 billion in 2014, which is expected to rise to
US$4.7 billion in 2017. The socio-economic impacts of poverty in relation to health inequality and
prevalence of Ebola is far reaching, states must engage with neighbours and global institutions
encompassing a multi-scale focus aimed at embracing epidemiological transition toward wider
efforts for investment and resources inherent to economic and social development, cultural
education programs, technology, urbanisation, age structure and fertility. Such efforts support the
obligation of the implementation of Abuja Declaration thereby increasing financial resource
appropriation to health sectors across all Africa. Poverty has negative social bearings as it reinforces
untoward exploitative practices such as prostitution interplayed with poor education and illiteracy
indicators suggesting the empowerment of women and the varied implication on social factors
remains a congruent factor in determining health inequalities (Tuwor & Sossou, 2008).
Environmental Factors
Environmental and physical factors have a keen influence on prevalence and burden of disease in
causing epidemics. Climate may impact on drought and flooding, leading to overflow and
contamination issues, this supports the transmissibility of Ebola through such pathogens from the
biosphere (WHO, 2016). Poor sanitation in West Africa is a keen contributor to the propagation of
disease spread. Improving sanitation resources at the source remains a key focus (Cairncross, 2003).
Seasonality can also cause mobility of populations across borders, particularly in the case of West
Africa where mobility in these nations is seven times higher than elsewhere in the world. The
interplay of unsafe drinking water and food security coupled with inadequate sanitation facilities,
poor hygiene and unfit food sources all have the ability to cause disease and thereby indirectly
contribute to the geographic prevalence of disease risk and burden of disease in the scope of West
Africa.
Conclusion
Ebola virus disease in its most recent emergence exemplifies the inextricable nature of variables
between health and geography. The burden of communicable disease with conceptions of causation
forms one element along with the congruent and inherent implications of place with far reaching
environmental and social manifestations contributing to its prevalence. The applicability of a
multiscale analysis in assessing a transnational disease such as Ebola allows for multifaceted all-
inclusive understanding required in volatile regions with high risk of disease and complex social
structures. This remains more significant than ever, in the era of globalisation to promote efforts of
epidemiological transition and relative health profiles for different geographies and communities
across the globe.
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