Epidemiology and control of the 2014 ebola virus disease outbreak in western africa: A narrative review of literature

JOURNAL OF MEDICAL RESEARCH

EPIDEMIOLOGY AND CONTROL OF THE 2014 EBOLA VIRUS
DISEASE OUTBREAK IN WESTERN AFRICA:
A NARRATIVE REVIEW OF LITERATURE
1

Ninsawu Nicholas Nakpan, 2Stanley Gordon Fenwick
Le Minh Giang, 4Pham Quang Thai, 5Prosper Mandela Amaltinga
1
Institute of Preventive Medicine and Public Health, Hanoi Medical University, Vietnam
2
Fenwick Tufts University, United States; 3Department of Global Health-Hanoi Medical University, Vietnam;
3

4

National Institute of Hygiene and Epidemiology, Vietnam;
5
Clinical Nursing Department, Nyaho Clinic-Ghana
The 2014 West Africa Ebola outbreak was the largest outbreak of the disease on the continent and the
globe at large, beginning December 2013 in Guinea. The disease rendered wide spread devastation in the
Sub Region causing the death of several thousands of infected cases before it was subsequently brought
under control, draining significant resources. This study reviewed existing literature using the PRISMA statement for reporting systematic review as a guide. It sorts to describe the epidemiological and socio-economic
factors that affected the Ebola Virus Disease (EVD) outbreak and to highlight the control measures
implemented during the period. Human interaction with the vegetation created exposure to the EVD and males
had an overall incidence slightly higher than females whilst being a child was a significant risk of dying from the
infection. A weak health system and inadequate infrastructure in affected countries contributed largely to early
spread. International organizations’ collaborating with local partners formed an immense component to controlling the outbreak. Effective collaboration is required at international and national levels of the world to remain
prepared for future outbreaks. It calls for a ‘One Health’ approach to tackling future events.
Keywords: Epidemiology, socio-economic factors, control, containment, implementation, West Africa

I. INTRODUCTION

outbreak started in December 2013 in Guinea,

The world has been confronted in recent

followed by its spread in subsequent months

years with a host of infectious diseases that

to neighboring Liberia and Sierra Leone. The

are either emerging or reemerging. They have

infection was later reported in Senegal, Mali,

included the zika virus infection, Mers-Cov,

Nigeria and outside the African Region to

SARS, Avian influenza and lastly, Ebola Virus

Europe (Spain, Italy and England) and the

Disease (EVD) which gave the world a scare

USA [2; 3].

during its outbreak in West Africa. The former

Ebola virus disease (EVD) is a rare and

Director General of the World Health Organi-

fatal disease [4] of zoonotic origin believed to

zation (WHO) described the 2014 Ebola virus

have originated in a reservoir of fruit bats of

disease

as

the family Pteropodidae. So far there is no

“unquestionably the most severe acute public

specific treatment for this deadly infection.

health emergency in modern times” [1]. The

First observed in humans in 1976, EVD has

outbreak

in

West

Africa

caused around 25 outbreaks to date [5; 6];
Corresponding author: Ninsawu
IPMPH, Hanoi Medical University
Email:
Received: 12/7/2018
Accepted: 18/11/2018

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Nicholas

Nakpan,

however, a yet to be licensed vaccine (rVSVZEBOV) is being administered to prevent
transmission as is in the case of the ongoing
outbreak in Democratic Republic of Congo

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(DRC) declared on May 8, 2018 [7]. Epidemics

as was in the case of Senegal and DRC in

have also occurred in Sudan, Gabon and

2017 [14].

Uganda. A non-human type of the virus known

This

article

aims

to

describe

the

as Ebola Reston Virus has also been found

epidemiological

present in the Philippines, affecting other

changes that affected the 2014 Ebola virus

primates rather than humans [8]. The Ebola

outbreak and highlight the control measures

virus is transmitted to humans through contact

implemented during the West Africa Ebola

with infected living or dead animals, and its

outbreak from a review of existing literature.

and

socio-economical

propagation in the human population occurs
through human-to-human transmission of the

II. METHODS

virus. The most recent outbreak to have

This study conducted a narrative review

caused significant devastation occurred in

using the PRISMA statement for reporting sys-

West Africa with deaths totaling 11,300 as of
early September 2015 [6; 9; 10]. EVD is associated with a case fatality rate of 30% to 90%,
depending on the virus species [8]. The index
case of the West Africa EVD outbreak was
identified to have originated in an under 2 year
old boy in Meliandou, Guinea [4; 5].
Prompt international response provided by

the World Health Organization, Médecins
Sans Frontières (MSF) and the Center for Disease Control during the early part of 2014
seemed to have helped in controlling the outbreak. It, however, circulated rapidly across
borders due to ineffective tracking [11]. The
recent outbreak in DRC starting in Bikoro has
recorded a total of 55 cases as of June 28,
2018. It includes 38 confirmed cases, 15 probable cases and 2 suspected cases, while 29
have died [12].

tematic reviews as a guide [15]. To develop
this study, 52 published articles were reviewed, published from 2013 to 2017. Articles
selected for retrieval were assessed for methodological validity prior to inclusion in the review using standardized critical appraisal instruments from the Joanna Briggs Institute
(JBI) Assessment and Review Instrument for
an observational, qualitative and quantitative
study.
The review focused on full-text articles
published in English and French with an option
to translate into English. It also examined the
reports of conferences and meetings of organizations and stakeholders. The articles
extracted were biased to those that have been
published during the past 5 years to enable it
to capture the most recent development in the
field. When the titles of the retrieved articles

During the West Africa Ebola outbreak,

were insufficient to determine eligibility, the

about $2.2 billion was lost in GDP in the three

abstracts were read to determine if they could

worst affected countries, according to the

be included. A thorough search was extended

World Bank. The disease resulted in lower

to the websites of major international agencies

investment and a substantial loss in private

such as the World Health Organization, the

sector growth, with declining agricultural pro-

US Centers for Disease Control (CDC), the

duction among other negative consequences

Pan African Medical Journal (PAMJ) and bibli-

[13]. An effective preparedness plan has been

ographies of indexed papers. Search terms

the hallmark of rapid containment and controls

comprised

102

epidemiology,

EVD,

socio-

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economic factors, and containment and con-

Out of a total of 872 articles identified, 490

trol efforts. A specific search for appropriate

articles were duplicated and 382 non-duplicate

articles began with a few of the keywords

articles were screened further for inclusion.

above to include a large collection of articles.

216 articles were further excluded after title

It then narrowed the search using the following

and abstract screening was done. These did

key

syno-

not meet the inclusion criteria because they

nyms: Epidemiological factors AND socio-

covered information of the Ebola virus out-

economic factors AND control measures OR

break that occurred in other places outside of

containment AND Implemented AND Ebola

West Africa. Sixty articles were excluded after

Virus Outbreak OR Ebola hemorrhagic fever

full text screening because the information did

AND West Africa. Information obtained from

not relate specifically to the epidemiology and

the search databases and other sources were

control of the EVD outbreak in 2014. Thirty-

saved using the Zotero software.

two (32) were excluded because they focused

search

terms

and

their

775 articles were identified from the data-

only on describing the clinical features of the

base search which related to the topic in addi-

disease; 14 articles focused only on Socio-

tion to 97 articles from bibliographies, agency

economic aspect of the Ebola outbreaks that

websites and grey literature (Figure 1). The

occurred in other parts of Africa rather West

inclusion criteria included articles with informa-

Africa; 8 articles were non-specific in describ-

tion on Ebola epidemiology or its control in

ing control programs implemented during the

West Africa. The exclusion criteria included all

outbreak in 2014 in West Africa. Fifty-two (52)

articles with information other than the Ebola

studies were finally included in this review due

outbreak in West Africa, its epidemiology and

to it having relevant information on the epide-

control measures implemented during 2014.

miology and control of EVD outbreak in 2014.

The prisma flow chart

Figure 1. PRISMA Flow diagram for systematic review [15]
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III. RESULTS

ing and consuming fruit bats is suspected as
the likely way humans were exposed to the

1. Epidemiological factors affecting the
2014 West African EVD outbreak

infection in Guinea [16]. In a study in 2014,
[10], the authors agreed that biological and

investigations

ecological factors may drive emergence of the

have been conducted in affected countries to

virus from the forest, but suggested that socio-

provide a better understanding of the disease

political landscape dictated where the virus

and to institute mechanisms to contain or con-

went next.

Several

epidemiological

trol the disease. The basis of such investigations has often been demonstrated to be nec-

1.2. The distribution of Ebola virus disease

essary in making available information for
In Conakry, Guinea and surrounding pre-

clinical and preventive decisions.

fectures, a descriptive study analyzed data
1.1. The vegetation

involving 1355 cases reported. During the

There are a number of studies that have

study period, the overall number of EVD cases

argued the role of ecological forces in sparking

per 100,000 persons was 33.2 in Conakry,

outbreaks of Ebola [9 - 10]. The environment

89.3 in Coyah, 37.5 in Dubreka, 136.9 in Fore-

provides a special space for interaction be-

cariah, and 24.6 in Kindia [17] (See Table 2).

tween

animals.

Cumulative incidence was slightly higher

Gue´cke´dou in Guinea’s remote southeast-

among males (46.8 cases/100.000 persons)

ern forest region is thought to be the epicenter

than females (45.3 cases/100.000 persons).

of the Ebola virus infection that spans into

Furthermore, incidence varied by sex in pre-

various regions of Guinea as well as to

fectures; incidence was higher among female

neighboring Liberia and Sierra Leone [10].

residents in Coyah, Forecariah and Kindia

Ebola virus required two transmission proc-

(Table 2).

human

population

and

esses for outbreaks to emerge. It required an

A descriptive retrospective study in Sierra

initial spillover event referring to a zoonotic

Leone, amongst other findings confirmed a

transmission from either the primary Sylvan

high infectivity among males than was ob-

reservoir or from a secondary host for whom

served in the opposite sex group [13].

the virus is pathogenic. It is then accompanied

A descriptive study using 4.955 probable

by a second process which is a person-to-

and confirmed cases in the same country how-

person spread from the index case occurring

ever, showed a slightly contrasting finding [14;

from the spillover infection [8]. Human popula-

18]. It showed that the ratio of male to female

tion density and their interaction with sylvan

EVD cases, irrespective of the district of origin,

habitat creating pressure in the landscape

was 1:1. This means there was an equal inci-

may have opened a channel for EVD spillover

dence between males and females. It however

into human communities. The human popula-

maintained that EVD affected all age groups

tion’s interaction with the vegetation paved the

with the most affected age groups being be-

way for a zoonotic otic transmission [8]. Hunt-

tween 26-45 years old (Table 3).

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Table 2. Ebola virus disease cases by prefecture and sex in Conakry and surrounding
prefectures in Guinea, January 1, 2014 – March 29, 2015 [17]

Table 3. Aggregated age-specific case fatality in Western Area Region, Sierra Leone,
June 2014 – November 2015 [14]
Age group (years) Totals cases (N)

%missing records
N

%

Dead (N)

Age-specific
fatality (%)

<1

172

2

1.15

126

73.26

1-5

422

5

1.17

184

43.60

6 - 14

530

7

1.30

133

25.09

15 - 29

1,493

14

0.93

376

25.18

30 - 49

1,446

15

1.03

537

37.14

50 - 64

396

6

1.49

203

51.26

65 +

291

0

0.00

203

69.76

Age not indicated

144

11

7.10

54

37.50

Total

4.954

60

1.21

1.816

36.66

1.3. Risk of mortality from EVD

significantly associated with death. The case

Most EVD patients were likely to die of the

fatality rate was highest in infants, at approxi-

infection as opposed to surviving due to the

mately 70% [19]. Progression to death accord-

high case fatality [18]. Being a child was a risk

ing the authors was swift and the overall death

factor of dying from an Ebola infection [19]. In

rate was high. Diarrhea at presentation would

Sierra Leone, this study found that younger

worsen the infection and doubled the risk for

age of life and diarrhea at presentation was

death in children [19].

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A similar age-specific fatality rate was iden-

link between healthcare workers dedicated to

tified in WA in Sierra Leone from June 2014-

EVD settings and contracting the disease [13].

November 2015 [14]. The age-specific fatality

Burial ceremonies serve as a vehicle of

rate was highest for children below the first

spread when mourners or relatives come into

year of age (73%). In the Moyamba district in

direct contact with the body of the deceased.

Sierra Leone, a different picture was noted in

A study in the three most affected countries in

relation to the risk of dying from EVD. Here,

Africa found out that 25% of cases of EVD

among the 88 patients admitted to the

who reported any exposure in the outbreak

Moyamba Ebola Treatment Center, 31 pa-

reported exposures at funerals. About 65% of

tients tested positive for Ebola virus. The age

these cases reported having touched the

range of patients was from 3 months to 85

corpse. It was greatest in Guinea (71%) and

years. An overall case fatality of 58% was

least for Liberia (61%) [23]. Non-funeral con-

reported and the study found no significant

tacts such as direct physical contact and bod-

correlation between age and fatal outcome

ily fluids contributed in driving the EVD trans-

[20]. It related fatal outcomes to the clinical

mission [24]. In Nigeria, frequent exposure

features of patients who died 83% compared

among health workers was through physical

to 46% in survivals.

contact, accounting for 73% of infections

1.4. Risk of exposure and transmission
of EVD
Contact with bodily fluids and secretions as
well as organs of infected animals, either
hunted or found dead, can lead to introduction
of EVD into the human population [19; 21]. It

among health care workers [25].
2. Socio- economic factors affecting the
2014 Ebola outbreak
2.1. Family interaction and social practices

usually starts from a single animal transmis-

Notable drivers of the Ebola outbreak

sion to humans. Amplification then takes place

transmission were the role family played,

via human-to-human spread [2; 18].

practices such as marriage and funerals and

Person-to-person transmission of Ebola

other social events such as migrations and

virus involves close personal contact with in-

markets. Rural people are heavily dependent

fected person through skin ulcers or mucous

on and trust their immediate family in times of

membrane and has been a source of trans-

crisis [26; 27]. Marriage and funerals met a

mission in the West Africa outbreak [4; 8].

need to understand Ebola risks from the per-

Body fluids contacted from infected persons

spective of family and its notions of unavoid-

such as semen, oral secretions, urine, feces

able social obligations. During an outbreak like

and handling human corpses during burial

EVD, such social activities become a driver for

activities poses a risk. This review found that

transmission [3; 27]. A funeral of the wife of a

healthcare workers particularly are thought to

chief in a chiefdom in Guinea border is be-

be at higher risk when they work in unhygienic

lieved to have generated an Ebola outbreak in

and unprotected conditions [21; 22].

Daru which spread to the neighboring Sierra

A key

finding of a study dissociated the belief of a

106

Leone town Fogbo [27].

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2.2. Inadequate and weakened health
system and lack of trust in services

is found to be a primary source of the spillover of EBV wildlife reservoirs to humans [33;

Several included studies identified an in-

35]. Bush meat in Liberia is a critical source of

adequate, weakened health system and the

protein, estimated to account for three-

lack of trust in these where they existed as the

quarters of the country’s meat use [36]. A sur-

fulcrum of the EVD spread during the outbreak

vey of 277 households in 73 locations in Libe-

[28 - 33]. The three most affected countries

ria indicated that consumption of bush meat in

(Guinea, Sierra Leone, Liberia), had been re-

households had decreased. Perceived risk of

ported to have less functional or weak health

bush meat consumption had a significant in-

systems contributing to delayed effective diag-

fluence on this outcome [38].

nosis, laboratory confirmation of cases and an
overall unpreparedness [34; 35]. Risk of dying
was higher in intense transmission countries
with scarce or overstretched health facilities
[31]. In places where basic facilities existed,
the facilities were often closed because they
lacked well-trained personnel, particularly in
Guinea, or essential medication among others
[32; 33]. The absence of effective surveillance

3. Control measures implemented during the EVD outbreak in West Africa
Early response is a vital component to controlling an outbreak such as Ebola Virus disease. The containment of the West Africa
Ebola outbreak placed a significant strain on
both international and national resource capacity.

systems and other public health infrastructure

3.1. Logistic provision and management

impeded the ability of affected countries to

Logistic

availability

both

as

response

effectively detect and respond to the rapid and

experts and material logistics were very vital to

lethal outbreak [4].

the control of the 2014 Ebola outbreak in West

There was little trust in the government and

Africa. Essentially, logistics

came in as

most health care facilities during the early pe-

finances, erection of Ebola treatment units,

riod of the West Africa outbreak of Ebola.

and the provision of isolation wards, personal

Communities did not trust interventions com-

protective equipment (PPE), laboratory equip-

ing from central government and the most pre-

ment and medical supplies [11].

ferred treatment were traditional cures. For

The World Health Organization collabo-

example, in the Ugandan outbreak, people

rated with the United Nations in 2014 to coor-

feared that once they went to hospital they

dinate a system-wide response across agen-

would never see their families again [36].

cies. It used the STEPP strategic framework

Stigma arising from isolation and quarantine in

which sought to stop the outbreak, treat the

health institution further fueled the fears and

infected, ensure essential services, preserve

trust of suspected cases [37].

stability and prevent further outbreaks [22].

2.3. Bush meat consumption

The International Medical Corps (IMC) in

Bush meat is both an economic benefit and

cooperation with local health ministries oper-

a source of protein to most people in West

ated 5 ETUs in Sierra Leone and Liberia be-

Africa. The consumption and use of bush meat

tween September 15, 2014, and December

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31, 2015. It assumed management of the

vital assistance to control measures by identi-

ETUs and provided a laboratory, clinic and an

fying Ebola survivors who tested positive to

effective data collection [39]. The IMC col-

Ebola in their semen and improving behavior

lected clinical and epidemiological data in the

change in the community [44].

most difficult circumstance where infection
control was regarded paramount.
Provision of beds to Ebola Holding Centers
(EHCs) and Community Care Centers (CCCs)
averted an estimated 56.000 cases in Sierra
Leone between June 2014 and February 2015
[40]. Emergency Management Centers (EMC)
with increased bed capacity and improvements in detection and treatment were opened
in the Kailahun district in Sierra Leone. This
resulted in an increase in the proportion of
patients admitted to EMC from 35% to 83%

3.3.Travel restrictions
The constant and massive movement of
people and goods across the world makes
national boundaries meaningless, at least in
terms of disease transmission. Many countries
resorted to border closures, heightening entry
and exit airport screening, restricting flights to
affected countries and banning passengers
from affected countries, seen as quite a controversial decision [42; 45].

IV. DISCUSSION

[41].
The search for articles on EVD outbreak
3.2. State-related interventions

generated several results due to the large

In late July 2014, the Liberia ministry of

amount of literature published after the out-

Health and social welfare (MOHSW) imple-

break in West Africa, however, few articles

mented an Incident Management System

related to the specific objectives of this study

(IMS) with support from the CDC, WHO and

with the entry of specific keyword terms.

other partners. Upon cooperation with interna-

Spillover events could have occurred from

tional partners, they provided technical activi-

the resultant interaction between human popu-

ties such as case management, contact trac-

lation density and vegetation in affected re-

ing, safe burials, surveillance, and laboratory

gions [5; 10]. The increasing activities of hu-

and social mobilization [42]. The Liberian gov-

mans in response to settlement or develop-

ernment enforced a quarantine for asympto-

mental needs have created a platform for the

matic individuals suspected to have come in

exposure of humans to zoonotic diseases.

contact with EVD positive cases and crema-

These activities have altered population densi-

tion of bodies of deceased cases [43]. The

ties around vegetation which could be serving

paper observed responses managed by state-

as home to the reservoir of the Ebola virus. It

related actors created an atmosphere of fear

is worthy to note that not all cases of animal

and mistrust.

spillovers led to outbreaks in humans [46].

In July 2015, the Men’s Health Screening

Conflicts, need of land for human settlement

Programme (MHSP) was implemented in Libe-

and economic activities including harvesting of

ria by the Ministry of Health in collaboration

wood for charcoal burning and hunting has

with other partners. The screening provided

over the years created a complex web of rela-

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tionships which could have contributed to the

Mortality from EVD was highest in children

spread of the Ebola virus [8; 10]. Humans can

[14; 19] and even more severe before the first

be infected from close contact with the secre-

year of life [8; 19]. Children progressed swiftly

tions, organs, blood or other bodily fluids of

towards death with a median time of three

infected animals. These animals have been

days. For example in Moyamba district of Si-

either hunted or found ill or dead in the rainfor-

erra Leone, in an Ebola Treatment Center, 31

est [21; 23]. Amplification of the virus has

patients tested positive for Ebola virus. Diar-

come from human-human spread of the virus

rhea was significantly more common in those

through close contact with the body fluid or

who died (83%) as compared to those that

secretions of an infected person. Body fluids

survived. Diarrhea raised the risk of death

of infected people or those that have died of

from EVD. The study did not find any correla-

EVD pose significant danger to close contacts

tion between age and fatal outcome [8]. Chil-

or health workers who may be handling these

dren are more vulnerable because they easily

people without appropriate protection.

become dehydrated from diarrhea and this

The overall incidence of EVD in the West
Africa outbreak was slightly higher in males

could account for the increased mortality in
such instances.

than females. This difference, though biased

The 2014 West Africa Ebola Virus outbreak

towards males, was not significant. Different

laid bare an age long problem of the continent

study sites showed different outcomes, even

and most importantly the sub-region. This per-

in the same country. Overall cumulative inci-

haps was a bitter exposure of the sub-region’s

dence in the capital city of Guinea was slightly

inadequacies as a significant number of pre-

higher in men though in three surrounding

cious lives were lost. It was estimated as of

prefectures, incidence of EVD was higher in

August 31, 2014, about 3.685 cases were con-

females (Table 2).

firmed and suspected cases were recorded-

Table 3 shows EVD infectivity to be higher

which rose through 2016 to over 28.000 [48;

in males in the healthcare workers WAR with

49]. Severely affected countries were already

all age groups. This is likely because males in

bedeviled by burden of extreme poverty, re-

healthcare settings may be tasked with the

cent history of civil conflict, and weak health-

transport of patients, handling corpses of the

care systems. Sierra Leone, Liberia, and

dead since women are less culturally involved

Guinea are among the countries with the

in this regard. It can therefore be concluded

world’s lowest levels of public investment in

that the incidence of Ebola among sex groups

health, the fault lines along which the EVD

depended on exposure factors such as do-

outbreak exploded [26 - 28].

mestic, social and economic responsibilities of

Unavailable laboratory facilities to enhance

the individuals. Women’s domestic role in tak-

diagnosis of EVD at the early onset of the out-

ing care of the sick usually places them at risk

break was a significant hindrance to early re-

of contracting EVD [10; 17]. Women in Africa

sponse [30]. Lack of approved diagnostic tools

usually are involved in trade and sometimes

adapted to such a large-scale outbreak, staff

travel distances for this, heightening their risk

shortage and limited biosafety knowledge and

of exposure to EVD during the outbreak.

weak national laboratory systems[50] were

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driving factors of transmission. Improving the

ance of these social functions such as mar-

overall laboratory systems will capacitate

riage and funeral ceremonies provided an ave-

countries’ preparedness against future out-

nue for interaction between family and com-

breaks.

munity members. Marriage and responsibilities

Healthcare workers may have incurred

of individual spouses and families were a con-

considerable risk in either the hospital or their

tributing factor to the spread of the Ebola out-

community, especially given the difficulty in

break as this study identified. As a matter of

making a clinical diagnosis of EVD at the on-

domestic responsibility, women took care of ill

set [33]. It was easy to misdiagnose EVD in

spouses and in some cases relatives to pro-

the early onset of the outbreak since it was

vide feeding, cleaning of clothes and environ-

clinically similar to febrile conditions common

ment where such patients lived. Handling of

to these countries such as malaria and ty-

corpses and burial activities was a significant

phoid. Healthcare workers therefore may have

source of exposure and spread of the Ebola

had significant exposure in the formal or infor-

virus disease in West Africa.

mal practice of their profession. Implementa-

This study also purposed to review the

tion of a triage system in Kenama, for in-

measures that were implemented to control

stance, led to a significant decline in the num-

the EVD outbreak in 2014. Much international

ber of EVD cases in healthcare workers [51].

support has included the shipment of large

Much was reported of affected communities refusing healthcare assistance due to lack
of trust in the healthcare system [36; 50; 51].
The African society is built strongly around
close family ties. In the African context, most
people, especially those in rural areas, relied
heavily on immediate and extended family for
support in times of material needs or health
challenges. This may have accounted for the

quantities of personal protective equipment,
diagnostic laboratory apparatus and vehicles.
Medical and logistic advisors from MSF, the
US Center for Disease Control & Prevention,
and WHO aided in the disease control [53].
Early response came in the form of expertise
and provision of essential material or financial
logistics. Aside the CDCs early response role
acknowledged in the introduction of this
review, other organizations deployed huge

observation of some included studies that

number of its response work force to the

found trust to be highest among households

affected

[52]. This could explain why the outbreak

overwhelmed by the outbreak [43].

spread easily during its onset. It is however
difficult to delineate this trust in family from
possible factors such as the economic status,

areas

and

sometimes

were

All articles included in this study for the
purpose of reviewing the control measures
echoed the significant impact of the interna-

availability and distance to healthcare institu-

tional organizations had on containing and

tions as likely factors influencing family trust.

controlling the spread of the Ebola outbreak.

Available evidence from articles reviewed

Some important ones captured by this study

in this study also underscored the influence of

referred to the role the WHO played in coordi-

social obligations and cultural practices on the

nation with several international or local agen-

potential driving of EVD [3; 52]. The perform-

cies [38].

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The Ministry of Health of affected countries
collaborated with international and local partners to achieve successful implementation of
control measures. The IMC operated five
ETUs in Sierra Leone [37]. They

provided

services ranging from case management, contact tracing, surveillance and data collection
activities and social mobilization [39; 54; 55].
Similarly, the WHO and UN collaboration using STEPP strategic framework proposed intervention packages that resulted in significant
gains [56]. Semen screening was a valuable
control measure in Liberia as 63% of participants’ semen tested positive for Ebola virus

RNA up to 12 months or longer after surviving
Ebola [44]. The WHO encourages the testing
every three months from the onset of symptoms and a periodic testing to curb transmission of the virus [57]. The challenges with this
program could be the low participation by
Ebola survivors who for fear of stigmatization
may not enroll in the program.
Porous borders with little vigilance meant
easy transportation of disease from one state
to another as was the case in West Africa [58].

V. CONCLUSION
The outbreak in 2014 inflicted untold social
and economic crisis for the affected countries.
The outbreak exposed existing cracks in the
health system and the overall unpreparedness
of countries to handle outbreaks of such magnitude. The lack of healthcare infrastructure
with diagnostic capabilities and poor infection
control at such facilities ensured an unimpeded transmission of the outbreak. Familial
and cultural demands in marriage and funerals
were a vehicle fueling early community transmission. The major drivers of the Ebola outbreak in West Africa included human population interaction with the vegetation, humanhuman interaction with little concern to infection control, little trust from community in government implemented control measures and
available health facilities. The WHO and other
international agencies were instrumental in the
containment and subsequent control of the
outbreak. Cooperating with the governments
of affected countries, several measures ranging from deployment of experts, logistic provi-

Many countries had heightened security at the

sion and strategic programs were imple-

borders and instituted screening at their airports

mented which contributed significantly to the

and other points of entry. Some countries posed

control of the 2014 outbreak. The keys to a

travel sanctions to travelers from affected re-

successful control of the outbreak was the

gions or countries [45]. Under the leadership of

collaborative approach from international, na-

president Obama, the United States announced

tional and community efforts in implementing

a travel restriction for people traveling from af-

and supporting control measures in 2014.

fected countries in West Africa. Travelers were

However, weaknesses in health infrastructure

required to fly through airports with screening

are an important issue to tackle if future out-

procedures [45]. Canada and Australia were the

breaks are to be averted. Focus should be

two other countries during the outbreak of the

placed on strengthening countries’ healthcare

Ebola in West Africa to pose travel restrictions

systems. This should be combined with mobi-

to passengers from West Africa. This was ar-

lizing both financial and human resources to

gued to be in conflict with the International

enhance preparedness for future events.

Health Regulations [59; 60].

Countries should strengthen their public health

JMR 116 E3 (7) - 2018

111

JOURNAL OF MEDICAL RESEARCH
surveillance systems to enhance early detec-

Pacific.

WHO.

[Online].

Available:

http://

tion, tracing of contacts and improving on the

www.who.int/dg/speeches/2014/regional-

overall provision of prompt and effective re-

committee-western-pacific/en/. [Accessed: 07-

sponses. Developed countries therefore must

Jul-2018].

be willing to collaborate with poorly resourced

2. N. R. Ngatu (2017). Epidemiology of

countries to ensure collaboration and collec-

ebolavirus disease (EVD) and occupational

tive efforts in fighting infectious diseases. A

EVD in health care workers in Sub-Saharan

“One Health Approach” to tackling a future

Africa: Need for strengthened public health

Ebola outbreak will be worth contemplating in

preparedness. J. Epidemiol, 27(10), 455 - 461.

the sub region. Human and animal health au-

3. T. E. West and A. von Saint André-von

thorities, environmental officers and social

Arnim, “Clinical presentation and management

groups can work together to educate commu-

of severe Ebola virus disease. Ann. Am. Tho-

nities and provide new socio-economic orien-

rac. Soc, 11(9), 1341 - 1350, Nov. 2014.

tations to reduce risk of exposures.

4. B. P. Bell (2016). Overview, Control

The study was faced by some limitations

Strategies, and Lessons Learned in the CDC

that impacts on its overall findings. Articles

Response to the 2014-2016 Ebola Epidemic.

that required payment before ac-cessing such

MMWR Suppl, 65(3), 4 - 11.

articles could not be included in the study due

5. J. Kaner and S (2016). Schaack, Under-

to financial constraints. Addition-ally, the Eng-

standing Ebola: the 2014 epidemic. Glob.

lish versions of some articles pub-lished in

Health, 12(53).

other languages were unavailable, reducing
the richness of articles included in the review.

ACKNOWLEDGMENTS
This paper is extracted from my final thesis
submitted

to

the

Institute

of

Preventive

Medicine and Public Health, Hanoi Medical
School. I would like to acknowledge Professor
Le Minh Giang and Professor Stanley Fenwick
who have been of tremendous support in
guiding me through to this stage. I would also
like to acknowledge Dr. Pham Quang Thai and
all the staff of Hanoi Medical University at the
Institute of Preventive Medicine and Public
Health who in one way or another offered me
advice and encouragement in writing my thesis.

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