In the last years of the 1970s, there was global concern over the discovery of a deadly virus that resulted in outbreaks of a hemorrhagic fever in West Africa (Peters & LeDuc, 1999). The high rate of death and the contagious nature of the disease was a cause of concern to the international medical community and researchers combined efforts to discover the cause, etiology, effective therapies, and methods of control of what would come to be known as the Ebola virus. Although there have been few cases reported outside West Africa, the potential for the spread of the disease prompts planning on how to handle a virus with the potential to create a worldwide pandemic. For this reason, governments have formulated strategies on dealing with patients who, while at this point remained relatively contained to one part of the world, have high percentages of fatalities and are extremely contagious.
There are five species of the Ebola virus, but one has only been found to exist in animals (WHO.int, 2014). Humans and other animals are believed to become hosts accidentally with natural hosts being fruit bats (Leroy et al., 2005). The virus is transmitted to humans through contact with body fluids and blood from infected animals and other humans; contact may be direct or within an environment with contamination. The Ebola virus, also called Ebola hemorrhagic fever, appeared initially in 1976 with two outbreaks with 602 reported cases resulting in 431 deaths (Bull World Health Organization, 1978). Outbreaks in 2013 numbered about 20 with almost 2500 reported cases (WHO.int, 2014). For the time being, most cases are reported in West Africa which is not surprising given the numbers of fruit bats in the area. However, there have been no documented cases of transmission of the Ebola virus directly to humans from bats. Although the disease is rare, the elements of Ebola that are disturbing are the high rates of fatalities and chances of human-to-human infection possibly during hospitalization (Gulland, 2014; Kinsman, 2012).
It is not the purpose of this paper to go into detail on the etiology of the Ebola virus disease. Rather, information presented will concern the challenges and key players associated with the diagnosis, treatment, and control of the outbreaks, the possible responses and their impact on stakeholders, and the presentation of a conclusion concerning the responses and their effects.
Challenges Associated with Ebola Outbreaks
One of the primary issues with the Ebola virus is the high rate of fatalities. The rate of deaths per reported cases is approximately 66 percent (WHO, 2014). The outbreak in the last and present years promotes the importance of controlling and preventing the infection. It is believed that the first reported death from Ebola was probably caused by a contaminated needle used in the treatment of a patient with malaria and a significant proportion of the subsequent infections are within health care staff members (Bull World Health Organization, 1978). During the 2014 outbreak, Guinea health care workers accounted for 54 percent of the reported fatalities from the infection.
Another severe challenge in the outbreaks has been the infrastructure of the medical care. In the face of stigmatism and public fear, hospitals were closed; 30 percent of the doctors treating patients and 10 percent of the nurses contracted the disease in Kikwit (Peters & LeDuc, 1999). The number of people in the city was greater than 250,000 and there was a severe lack of methods to disseminate public information, few vehicles, and unreliable electricity. The negative response of the population to the patients with the disease prompted families to keep them in the home, caring for them in secret and increasing the spread of the virus. The end of transmission of the disease to health care providers was also assisted by introducing adequate training in barrier techniques and the availability of supplies for patient isolation (Khan et al., 1999; Tomori et al., 1999). It has become clear that the weak link in the medical infrastructure concerning the epidemics is hospitals. At the end of the outbreaks, workers reverted to previous ineffective techniques within three months due to inadequate methods of organizational change and dwindling lack of supplies (Peters & LeDuc, 1999).
An additional problem realized is the inability to recognize sporadic infections or the initial cases of an outbreak. It is possible to detect the presence of the Ebola virus without symptoms in humans or animals by testing for antigens in the skin ((Lloyd et al., 1999; Zaki et al., 1999). The technique creates the ability for authorities to put special precautions in place for the shipment of potentially infectious material and the testing of suspected carriers of the disease. Barriers to the use of the test involve the manufacture, distribution, training, and shelf-life of the paper strips (Peters & LeDuc, 1999). The speed of testing provides rapid definitive diagnosis, leading to containment of the virus.
Key players in the Diagnosis, Treatment, and Control of Ebola Outbreaks
Differences in the fatality rates in Ebola infection over the last decades probably are a reflection of advances in diagnostic accuracy, proficiency in acute care stages, and identification of infection sources (Laupland & Valiquette, 2014).
Diagnosis. When the details associated with the symptoms of Ebola hemorrhagic fever became available to the public, the image was horrifying. Initial complaints are of an elevated temperature, diarrhea, headache, and nausea and vomiting. The patient’s condition fails rapidly, advancing to decreased liver and kidney function, rashes, lethargy, a face void of expression, deep-set eyes, and often bleeding internally and externally (WHO, 2008). If the patient expires, it is generally within two weeks of the onset of symptoms (Simpson, 1978). When a case presents that is suspected of being the Ebola virus, definitive diagnosis is through laboratory tests (Laupland & Valiquette, 2014). It is necessary for the testing to take place in a biosafety level 4 laboratory due to the high degree of biohazard risk. Reverse transcriptase-polymerase chain reaction identification or antigen- or antibody-based assays are used.
Treatment. Case management is focused on supportive care because there are no specific treatments currently recommended; however, research is exploring nucleic acid treatment and immunotherapy (Falzarano & Feldmann, 2014; Kuehn, 2013; Warren et al., 2014).
Control. When it was realized that hospitals were a source of contamination, control efforts were directed there. The hospital in Yambuku was closed and considered one of the first measures taken for controlling the Ebola virus during the original outbreak (Bull World Health Org., 1978). During the outbreaks in 196, the patients were forced to remain in their homes and this action effectively ended the spread at that time. For this reason, it is vital that the disease be detected early and protective equipment and decontamination of the environment take place quickly (Ftika & Maltezou, 2013; Shoemaker et al., 2012; WHO, 2014).
After the Ebola virus was identified, the next step was to find as many cases as possible within the general population in order to attempt control of the contamination. Methods used included an evaluation of hospital records over immediate past for symptoms of the disease with fresh insight, visiting the homes of diagnosed patients for signs of Ebola in family members and others who had direct contact, searching the neighborhood for unreported cases, and contacting local government officials for assistance (WHO, 2008).
Key Players. The primary stakeholders in the outbreaks of the Ebola virus are the patients and potential patients from contamination, health care providers, government officials involved in the chain of command, and researchers seeking more information about the disease.A chain of command for departmental responsibilities and government agencies allows for increased efficiency in the detection, treatment, and control of the Ebola virus. An organizational flowchart such as that used in Liberia is helpful (Fig. 1).
It has been demonstrated that healthcare workers are particularly at risk. In the 1995 outbreak in Zaire, fear of contamination resulted in many employees leaving their jobs (Khan et al., 1999). Social stigmatization was seen against the employees who remained at their posts when they became viewed as carriers of the disease; some individuals were chased from their homes and pelted with stones (Guimard et al., 1999). In the United States, as of September 2014, there have been only four cases reported outside the seven cases evacuated to America for medical care or were already infected prior to boarding airlines ; two of these patients
Figure 1. Organizational flowchart for Ebola response Incident Management System, Liberia Ministry of Health and Social Welfare (MOHSW), August 2014. UNMIL, United Nations Mission in Liberia (CDC.gov., 2014a)
Succumbed to the disease (CDC.gov., 2016b). One man had contracted Ebola in Liberia and lied about his exposure prior to entering the United States and later died. Two nurses treating him in Dallas also became infected, but survived. A physician working in an international health program in West Africa also was diagnosed with Ebola and survived. These are the only confirmed cases of the virus in the United States.
Conclusion
The Ebola virus outbreak documented as starting in 2014 in West Africa has to potential to spread outside the boundaries of that nation into other countries and continents. Human and animal are at high risk of contamination secondary to easy access to international travel. For that reason, it is necessary to continue research into the cause, transmission, development of effective treatment, and methods of containment of the disease. The major challenges are involved in biology and wide range of influences on the etiology of the disease; little is known about the virology of the virus. In addition, there is insufficient information regarding clinical treatment of Ebola such as the impact of co-morbidities. Finally, it is vital to establish an effective plan for response in the event of an outbreak that allows teams to be prepared and equipped. It is only by remaining vigilant to the signs and symptoms of the Ebola virus that health care providers can identify, diagnose, and contain this deadly disease.
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