Our country has been overtaken by the encircling and ever threatening advance of the Ebola virus disease. The sense of foreboding of an impending and its accompanying gloom is compounded by our current situation of erratic and epileptic energy supply, the depreciation of the cedi and worsening living conditions due to our over import dependent economy, engulfing filth leading to dehydrating and life threatening diarrhoea fro cholera and now the mother of all monsters; EBOLA. The name sounds eerily like a deity or some principality with an extremely malevolent disposition.

The scare of Ebola has affected almost every aspect of our lives, from religion, social, emotional, economic, and even our perspectives of our self-worth. We cannot shake hands of our friends and acquaintances even at church. Our social lives and activities have been placed on hold. It would be a pity if attendance at church has taken a dip because this would really hit some of our churches unfavourably from the loss of revenue that they may need to hopefully prosecute the Lord’s work on this earth. We can no longer hug our long lost but found friends and loved ones.

Patronage of our food and hospitality industries has also not been spared the scourge of this monster. The airline industry is still reeling under this Ebola scourge. I am very sure most businesses in the country would appreciate the effect of Ebola if they conducted a quick business audit. The threat from this clear and present danger of this bloody death lurking just beyond our borders is sure to lead to the some level of uncertainty, anxiety and a feeling of powerlessness and stress build-up.

This together with the background stress of going through the daily grind of life could potentially tip a decent proportion of our populace into depression. I am sure our political leaders are aware that the threat of this disease hanging around us does not make us attractive to potential investors. We might lose a lot of foreign direct investments if we do not act expeditiously to dispel this thing which is hanging around us like an evil shadow. Ghanaians should not be surprised if we make it to the notorious list of countries whose nationals must be screened at every international airport because of our proximity to the epicentre of this epidemic. Our national pride and integrity is under threat and I would not hesitate to classify Ebola as a national security threat if I were ever asked. The way we conduct ourselves to either overcome this threat or succumb to it would in a large measure influence the perception the outside world would have of us and our own evaluation of our self worth.

Unfortunately the mainstream old media and social media are awash with a lot of scare mongering and sensationalism leading to a contagious hysteria of fear, panic and irrational behaviours. We are trying to fight an enemy whose reputation precedes him. We are told this monster is so fearful, merciless and kills just for sport. We are told to run away from it since it takes no prisoners. Our medical personnel are not giving us adequate assurance of protection because they do not have the weapons necessary to protect themselves and a plan to manage those who might catch this dreadful disease. Some have even hinted they might equally flee if Ebola comes calling. We are petrified and have prostrated ourselves before this monster asking for the mercy that we know would not be granted. We grit our teeth, close our eyes and wait in trepidation for the fatal blow to be struck. What at all is this Ebola? What really makes Ebola that fearful and ruthless? Does it have any weaknesses we can exploit? What do we need and what do we have available? What would be the most effective way to defeat this monster and how do we use what we have to defeat this monster since we know it shall not show mercy? We do not have the luxury of choice; we either confront it or die.

In this write up I would like to share the scanty knowledge I have of Ebola, reminding readers that most of the information was gathered from Wikipedia and might not have been peer reviewed but then again Wikipedia is a reputable on-line information source.

So it is said that if you know your enemies and know yourself, you can win a hundred battles without a single loss. If you only know yourself, but not your opponent, you may win or may lose. If you know neither yourself nor your enemy, you will always endanger yourself.

The Art of War by Sun Tzu

It is important that we know as much about Ebola as possible to enable us design strategies to enable us effectively defeat it. This would then inform the strategies that we need to put in place to achieve our objective. I would now like to introduce Ebola. Please this information was picked from the internet from Wikipedia, the worldwide open encyclopaedia and is duly acknowledged.

Ebola virus disease (EVD) or Ebola hemorrhagic fever (EHF) is a disease of humans and monkeys caused by the Ebola virus.  

History

Ebola virus was first isolated in 1976 during outbreaks of hemorrhagic fever in the Democratic Republic of the Congo (then Zaire) and Sudan. The name of the disease originates from the first recorded outbreak in 1976 in Yambuku, Democratic Republic of the Congo, which lies on the Ebola River.  The strain of Ebola that broke out in the Democratic Republic of the Congo had one of the highest case fatality rates for any human virus at that time, 88%.; 318 cases and 280 deaths occurred in that outbreak. This has been followed by a series of outbreaks which hardly last more than a year.

In March 2014, the World Health Organization (WHO) reported a major Ebola outbreak in Guinea.

As of 10 April 2014, WHO reported 157 suspected and confirmed cases in Guinea, 22 suspected cases in Liberia, and 8 suspected cases in Sierra Leone. By mid-August 2014, 2,127 suspected cases including 1,145 deaths had been reported including some cases in Nigeria,

 Signs and Symptoms

Signs and symptoms of Ebola usually begin suddenly with catarrh-like stage characterized by fatigue, fever, headaches, joint, and muscle and stomach pain. Vomiting, diarrhoea and loss of appetite are also common. Less common symptoms include sore throat, chest pain, hiccups, shortness of breath and trouble swallowing. The average time between contracting the infection and the start of symptoms (incubation period) is 8 to 10 days, but it can vary between 2 and 21 days. Skin manifestations may include a raised rash in about 50% of cases. Early symptoms of EVD may be similar to those of malaria, typhoid fever and other tropical fevers before the bleeding stage starts. The bleeding stage starts with bleeding from needle sites, mouth, gums, nose, vagina, the anus and then skin both internally and externally leading to reddening of the eyes, bloody vomit, bloody stools, bloody cough and bleeding under the skin. If the infected person does not recover, death occurs usually between 8 and 9 days after first symptoms.

Transmission

Bats are suspected to be the most likely natural reservoir of the Ebola virus.  Transmission between natural reservoir and humans are not very common even though fruit bats are eaten by people in parts of the continent where they are smoked, grilled or made into a spicy soup and could be potential sources of infection. Bats drop partially eaten fruits and pulp, then land mammals such as gorillas and other bush animals feed on these fallen fruits. This chain of events forms a possible indirect means of transmission from the natural host to animal populations and subsequently to humans through the consumption of bush animals in the form of bushmeat.

 Outbreaks are usually traceable to a single case where an individual has handled the carcass of gorilla, chimpanzee or other forms of bushmeat. EVD is believed to occur after an Ebola virus is transmitted to an initial human by contact with an infected animal's body fluids. Human-to-human transmission can occur via direct contact with blood or bodily fluids from an infected person (including embalming of an infected dead person) or by contact with contaminated medical equipment, particularly needles and syringes. The potential for widespread EVD infections is considered low as the disease is only spread by direct contact with the secretions from someone who is showing signs of infection. The quick onset of symptoms makes it easier to identify sick individuals and limits a person's ability to spread the disease by traveling. Because dead bodies are still infectious local traditional burial rituals may spread the disease. Semen may be infectious in survivors for up to 50 days. Medical workers who do not wear appropriate protective clothing may also contract the disease and spread it. In effect its means of transmission is quite close to that of the HIV virus except it kills more quickly if not properly managed.

EVD is contagious, with prevention predominantly involving behaviour changes, proper full-body personal protective equipment, and disinfection. Techniques to avoid infection involve not contacting infected blood or secretions, including from those who are dead. This involves suspecting and diagnosing the disease early and using standard precautions for all patients in the healthcare setting.  Recommended measures when caring for those who are infected include isolating them, sterilizing equipment, and wearing protective clothing including masks, gloves, gowns, and goggles. Hand washing is important but can be difficult in areas where there is not even enough water for drinking. The Ebola virus can be physically inactivated by heating for 30 to 60 minutes at 60ºC, boiling for 5 minutes, and gamma irradiation. It is susceptible to sodium hypochlorite (bleach), lipid solvents such as detergents, phenolic disinfectants, peracetic acid, methyl alcohol, ether, sodium deoxycholate, 2% glutaraldehyde, 0.25% Triton X-100, β-propiolactone, 3% acetic acid (pH 2.5), formaldehyde and paraformaldehyde.

Treatment

No Ebola virus-specific treatment exists. Treatment is primarily supportive in nature and includes minimizing invasive procedures, balancing fluids and electrolytes to counter dehydration, administration of anticoagulants early in infection to prevent or control disseminated intravascular coagulation, administration of procoagulants late in infection to control bleeding, maintaining oxygen levels, pain management, and the use of medications to treat bacterial or fungal secondary infections. Early treatment may increase the chance of survival. A number of experimental treatments are being studied. The FDA has allowed two drugs, ZMapp and TKM-Ebola, to be used in people infected with Ebola under these programs during the 2014 outbreak.  Other drugs that have proved useful in studies with mice include Favipiravir, Amiodarone clomiphene and toremifene. Given their oral availability and history of human use, these drugs would be candidates for treating Ebola virus infection in our case where we have no other option, either on their own or together with other antiviral drugs.

Summary

The Ebola virus is a deadly disease with the ability to kill within two weeks of onset of symptoms. The virus is suspected to live in bats in which it causes no sickness but can get transmitted to humans and monkeys in which it causes disease. It has a history of sporadic outbreaks which do not last for long because it gets spent out because of how it rapidly kills its victims. Infected persons usually transmit the infection after the symptoms start. The virus is relatively week and can be inactivated by most of the common disinfectants. The virus needs to get into contact directly through the blood, cuts on the skin or through the mucus membranes, that is the inner coverings of our body cavities. There is no known cure for it but experiments which has been done animals and in laboratories have shown some drugs which are meant for other medical conditions are able to control the virus. Ebola in humans can be eliminated but can still persist in bats and other animals in the bush.

The way forward

Our strategy should be aimed at avoiding infection in Ghana and helping our West African neighbours who have been afflicted to eradicate this disease. I would leave the formulation of the grand strategy to people who have more expertise in that area than I do. The good news is that the disease has a relatively short incubation period, does not start transmission before symptoms show and kills its victims quickly. This means we can defeat it by prevention of infection, early detection and isolation of infected persons and managing them accordingly.

 I would however like to suggest my three pronged strategy

1. Prevention through proactive screening and active public involvement.

 Unfortunately there is no available rapid test kit for diagnosing Ebola, unlike that for HIV.  On the other hand we know that the transmission starts when the infected person starts showing symptoms. And the earliest symptom is fever or increased body temperature. There are however a lot of diseases that also present with fever. The screening can be refined further by enquiries about recent travels or contact with someone from the affected countries. Any contact with bush animals or recent consumption of bushmeat would also help refine it further. Those with the “suspicious fevers” can then be monitored more closely. This would be relatively cheap and can be carried out with the help of the general public.

Our most important arsenal in fighting this disease is the public. It is obvious we cannot adequately police our borders with the available immigration personnel that we have. That is why we must empower the public. The foot soldiers of the main political parties become especially relevant. They are spread across every nook and cranny of the country and since it is currently political off season, we can engage their services using the various party structures. It would be a pleasure to see them work for the national good for once instead of their usual partisan squabbles. It would be in the interest of the parties to encourage them to help with the education since they would need the people alive to vote for them during the 2016 election.

The various communities along the borders should be sensitised to be vigilant and trained on basic screening methods. Since the virus usually gets transmitted in when symptoms start, monitoring persons with fever would be good start. The public should be taught how to measure temperature using preferably the digital thermometer which is less than 10 Ghana cedis. The government should be able to subsidize it and make it available to all households after they have been trained on how to use it. Any body found with a temperature above 38 Celsius should be advised or asked to visits a health facility for evaluation and treatment. As school re-opens where we are going to have inevitably large gathering of students, this basic screening daily for those with fever would assist in the early detection and quarantine of suspected cases. Employees with fevers at the various workplaces should be encouraged to visit the nearest hospital. People with fever should be educated to appreciate the importance of not going near public gatherings including church services unless they had been seen by a health personnel.

It is of utmost importance that we make it clear that having a fever does not mean one has the virus but that it is important the fever is treated after the patient has been evaluated. Things to look out for should be history of recent travel to affected countries, contact with wild animals and consumption of bush meat. A good history taken by the medical personnel would clear most people and those with a high possibility of contact with the infection can then be monitored closely. With an effective education and temperature screening, our people along the borders would automatically be involved and positively engaged in the fight against the virus. This is particularly so in our case since most of the people across the borders are usually relatives and they would be the best people to monitor them.

2. Public education with emphasis on empowerment of our people.

 There should be intensified positive public education about this disease and with emphasis on its prevention instead of painting a gloomy and helpless situation. Yes it is a deadly disease but with courage and fortitude, it can be defeated. Basic infection prevention measures in our health facilities by the appropriate use and change of gloves by health personnel would help a long way. There should be adequate decontamination of all materials, proper disposal of syringes and needles and the practice of the universal infection prevention guidelines that health personnel are aware of. In addition adequate educational materials for the various categories of health personnel especially the laboratory personnel should be prepared and distributed by the health authorities. The education on the avoidance of contact and consumption of bushmeat should be intensified. The FDA should as a matter of urgency assess the various sanitizers on the market and recommend some effective brands to the public for use since it is now known that not all  of them have the right ingredients and the right concentrations to deactivate the virus. This is particularly so because of the erratic and sometimes absence of running water in most communities.

3. De-stigmatization of potential victims and the encouragement of self compliance.

It is important we start de-stigmatizing Ebola before we record any case at all officially. This is because the stigma may prevent infected persons or their relatives from seeking early medical care and this would definitely make the management of the situation very difficult. The campaign to remove the stigma from Ebola victims should start now so that patients can come freely forward for treatment or their relatives or neighbours would encourage them to do so.

Other matters

There might need to be some legal review of our current patients’ charter. This is because if the health personnel suspect someone with a fever has a high possibility of carrying the virus but the individual in question refuses treatment or monitoring, what does the doctor do? We might need to have a look at the possibility of surrendering some aspects of our civil liberties in the interest of the collective good. 

The national health insurance authority might have to consider suspending the current biometric registration exercise and allow the old cards which have expired to be renewed for use to reduce the cost barrier to the access to early healthcare. We must consider ways of universally removing cost as a barrier to access to healthcare since this would go a long way to aid early detecting and management should we get hit. If we can afford, it I would suggest the government offers free treatment for feverish conditions should it become necessary.

There should be a call to arms by our health personnel. The great Nelson Mandela said”I learned that courage is not the absence of fear, but the triumph over it. The brave man is not he who does not feel, afraid but he who conquers that fear”. I am aware this disease is scary, but like the soldier who is called upon to fight in times of war or the policeman who is called upon to confront dangerous armed robbers; this is our call to duty. I am not unaware of the shameful and shabby condition of our health personnel but I also believe in the innate goodness of our health personnel and their willingness to contribute their quota if given their due. I therefore agree partly with the call from our religious leaders for a special package to be made available for doctors who handle Ebola cases. I however think the conditions of our health personnel should be addressed holistically to ensure we can always count on them in such situations as we find ourselves. Running away is not an option since we cannot guarantee our own safety, that of our loved ones and the poor people of this country. Some of our political leaders would flee immediately with their families if it happens but our people would be counting on us. We dare not fail them.

In conclusion, we are in difficult times and we must all contribute our bit to help avert this Ebola threat. I feel guilty going to church and not be able to shake my neighbours hand because of Ebola. These are my thoughts that I want to share and I look forward to criticisms, recommendations and input from readers to enable us move forward.

Dr Wisdom Amegbletor.

MB ChB(UG) MBA(UG)

New Crystal Health Services

 Ashiaman

Email: wisamegbet@yahoo.com