Gender dimensions to the Ebola outbreak in Nigeria.

BACKGROUND: An outbreak of Ebola disease was declared in Lagos, South West Nigeria, on 23rd July 2014. Later, the outbreak spread to the south south and south eastern part of the country. The last cases occurred on August 31, 2014 and the country was certified to be Ebola free on 20th October, 2014. This paper describes the experiences and implications of the Ebola outbreak for Nigerian women. SUBJECTS AND METHODS: Identification and listing of cases and contacts was done in Lagos, Port Harcourt and Enugu. Socio demographic information was collected.
RESULTS: Women made up 55% of Ebola cases and 56.6% of contacts traced. Of the 8 deaths reported 50.0% (4) were women, of which 75.0% (3) were health care providers. The sex specific case attack and fatality rates for males and females were 2.2% versus 2.3% and 45.5% versus 33.3% respectively. The women restricted their movement in order to avoid the infection. The outbreak affected their utilisation of health care services and livelihood.
CONCLUSION: Women were exposed occupationally and domestically due to their care giving roles. In health facilities, they were directly involved in the care or encountered persons who had been in contact with persons with Ebola. In the homes, they were at the forefront of nursing the sick. There is the need to ensure women have access to information, services and personal protective equipment to enable them protect themselves from infection. Education and engagement of women is crucial to protect women from infection and for prompt outbreak containment.

Introduction

Ebola virus disease (EVD) has a high fatality rate and currently lacks a treatment or vaccine with proven safety and efficacy. It is endemic in some parts of Africa and may emerge as sporadic outbreaks.[1] On July 20, 2014, an acutely ill traveler from Liberia arrived in Lagos, Nigeria and was confirmed to have EVD (Ebola) after being admitted to a private hospital. On July 23, the Federal Ministry of Health, with the Lagos State Government and International partners, activated an Ebola Incident Management Center as a precursor to the Emergency Operations Center (EOC) to rapidly respond to the outbreak. There were 20 laboratory-confirmed Ebola cases and one probable case, with 899 contacts identified and followed during the response. No new cases had occurred since August 31; the country was certified to be Ebola free on October 20, 2014.[2] This was a feat that received commendation from national governments and international agencies. However, the number of cases and deaths occurring from this public health emergency generated concern from some organizations on its effect on women.[3]

This outbreak was characterized by fever and hemorrhagic manifestations. It affected both healthcare providers and community members.[245] The response to contain the outbreak was intensive, rapid, and co-ordinated. An epidemiology and surveillance team traced contacts, managed alerts and rumors, and implemented community surveillance while a social mobilization team went house-to-house within a specific radius of the homes of Ebola contacts. The Port health services sent out outbreak notifications and screened for symptomatic persons at ports of entry. Case management and infection control committees treated cases and carried out decontaminations.[45] Despite the rapid response and certification as being Ebola free, the infection left its impact on household and families with women being mostly affected. This paper is a review of the Nigerian outbreak; the cases, contacts, and case fatality rate from a gender perspective are described. Furthermore, women’s involvement, such as their vulnerability to the infection, how they can be useful to prevent and respond into future outbreaks are discussed.

Subjects and Methods

The outbreak

Outbreak sites

The outbreak investigation was carried out in the three cities namely Lagos, Port-Harcourt, and Enugu cities in South-West, South-South, and South-East regions of the country. Lagos is a mega city and the most populous city in Nigeria. It is the economic center of the country, the second fastest-growing city in Africa and the seventh in the world.[6] The population of Lagos according to the Lagos State Government as at 2013 was 17.5 million.[7] Port-Harcourt, the capital city of rivers state, is the second major economic city in Nigeria. Port-Harcourt is a major industrial city with a large number of multinational firms, particularly petro-chemical industries. It has an estimated population of 3.3 million inhabitants.[7] Enugu is the largest city in the South-Eastern region of Nigeria. It has an estimated population of 723,000 inhabitants.[7] In the past, it was a popular coal miming city. All three cities are state capitals.

Epidemiological investigations

Contact tracing

Contact identification and listing was done in all the three cities. The focus was to identify and follow-up all persons who might have had contact with a suspected or confirmed case of Ebola. A contact was defined as any person without any signs and symptoms of the disease but who had physical contact with either living or dead case of Ebola or contact with the body fluids of such a case within the last 3 weeks. Physical contact included sharing the same room or bed, caring for a patient, touching body fluids or closely participating in a burial of a suspected case. The contact tracing team was composed of Nigeria Field Epidemiology and Laboratory Training Program (NFELTP) staff, graduates, and residents, World Health Organization (WHO) staff, National Postgraduate Medical College Residents, State Ministry of Health, Red Cross Volunteers, Nigeria Army Personnel, and Independent volunteers who are healthcare workers. 21, 28, and one team each comprising of two to four members were constituted in Lagos, Port-Harcourt, and Enugu, respectively to collect sociodemographic and clinical information on contacts.

The contact tracing and follow-up measures undertaken were adapted from the WHO Guidelines.[5] Contact tracers were trained on EVD, procedures and tools including on safety precautions before embarking on their activities.

Data collection methods

Data were collected using case/contact listing and follow-up forms. Contacts were placed on 21 days follow-up, and temperature monitoring was done daily under the supervision of the contact tracers. Contacts that completed 21 days follow-up without developing any signs and symptoms were discharged with a letter indicating their EVD status. Due to the stigma experienced by many contacts, a psychosocial team was available to help cases/contacts deal with the stigma.

Identification of cases

A suspected case was defined as any person with acute onset of fever, malaise, myalgia, headache, followed by pharyngitis, vomiting, diarrhea, maculopapular rash, which may or may not be accompanied by any of the following signs: Bloody diarrhea, bleeding from the gums, bleeding under the skin (purpura), bleeding into the eyes (conjunctiva hemorrhage), blood in the urine (hematuria), no known predisposing hemorrhagic condition with history of contact with a case. A probable case was defined as a case or death with symptoms compatible with clinical illness and a history within the 3 weeks before onset of fever of the following: Traveled to an area of the country where an outbreak of viral hemorrhagic fever (VHF) has recently occurred or direct contact with blood or other body fluid secretions or excretions of a person or animal with a confirmed or probable case of VHF or work in a laboratory or animal facility that handles hemorrhagic fever viruses. A confirmed case was defined as a case with clinical illness and laboratory confirmation of infection or a probable case with laboratory confirmation of infection.[89]

Data management

Microsoft Excel and Epi-Info software (Version 5)[10] were used for data entry and analysis. Frequencies, graphs, and charts were generated. Confidentiality was maintained on collected data, and data were available only to EOC members.

Results

Twenty confirmed cases were reported nationwide over the duration of the outbreak, eleven of which were females [Table 1]. Of the eleven female cases, nine were healthcare providers, (eight of whom were linked with the index case) while the remaining two were close family members (wife and sister) of cases. Of the 899 contacts traced, 56.6% were females. Eight deaths were reported of which four (50.0%) were females, all of whom (100.0%) were healthcare providers. The sex-specific case fatality was higher in women (45.5% vs. 33.3%).

Table 1

Sex distribution of Ebola cases, deaths, and contacts in Nigeria

Sex	n (%)
EVD cases (n=20)
Males	9 (45.0)
Females	11 (55.0)
EVD deaths (n=8)
Males	3 (37.5)
Females	5 (62.5)
Case fatality rate
Males	33.3
Females	45.5
Contacts traced (n=899)
Males	390 (43.4)
Females	509 (56.6)

EVD=Ebola virus disease

Table 2 shows the sex-disaggregated distribution of the contacts. In Port-Harcourt and Enugu most (61.6% and 57.1%, respectively) of the contacts were females, while in Lagos they were almost of equal proportion (49.2% and 50.8% for females and males, respectively). The attack rate was the same for both sexes (2.2% and 2.3% in males and females, respectively).

Table 2

Sex distribution of Ebola contacts by place of occurrence in Nigeria

Sex	n (%)
Lagos contacts (n=356)
Males	181 (50.8)
Females	175 (49.2)
Port-Harcourt contacts (n=536)
Males	206 (38.4)
Females	330 (61.6)
Enugu contacts (n=7)
Males	3 (42.9)
Females	4 (57.1)

Table 3 shows the age distribution and source of infection of the EVD cases. Most (63.4%) of the cases were between 30 and 39 years of age. Compared to the males, more female’s cases were health facility (43.8% vs. 56.2%) and household contacts (33.3% vs. 66.7%).

Table 3

Age and source of infection of cases of EVD by sex

Characteristic	Total	Male	Female
Cases	n=20	n=9	n=11
Age (years)
20-29	4	1 (25.0)	3 (75.0)
30-39	8	4 (50.0)	4 (50.0)
40-49	3	3 (100.0)	0
50-59	3	0 (0)	3 (100.0)
60-69	2	1 (50.0)	1 (50.0)
Source of infection/type of contact
Health facility	16*	7 (43.8)	9 (56.2)
Household	3	1 (33.3)	2 (66.7)

*The index case a male was excluded since he was not a contact. EVD=Ebola virus disease

Table 4 shows the age distribution and source of infection of the EVD contacts. More females were health facility (60.0% vs. 40.0%) and household contacts (53.4% vs. 46.6%) than males.

Table 4

Age and source of infection of contacts by sex

Contacts (n=899)	Total (n=813)	Male (n=347)	Female (n=446)
Age (years)
0-9	54	30 (55.6)	24 (44.4)
10-19	43	21 (48.8)	22 (51.2)
20-29	230	75 (32.6)	155 (67.4)
30-39	219	91 (41.5)	128 (58.5)
40-49	149	74 (49.7)	75 (50.3)
50-59	78	36 (46.2)	42 (53.8)
60-69	32	17 (53.1)	15 (46.9)
70-79	7	3 (42.9)	4 (56.1)
≥80	1	0 (0)	1 (100)
Type of contact/source
Health facility	300	120 (40.0)	180 (60.0)
Household	599	279 (46.6)	329 (53.4)

Discussion

Women's vulnerability

Women made up the majority of the contacts, cases, and fatalities of the outbreak. This highlights their increased vulnerability to the infection. Researchers have found no biological difference to increase women’s risk, rather differences in exposure between males and females have been shown to be the important factor in the transmission of Ebola.[1] Transmission of the virus has been related to direct contact with blood and other bodily fluids of people who are acutely ill.[1] In most communities, the social burden of caregiving often falls solely to the lot of women. Thus, women are more likely to be exposed to vomit or feces of an infected family member, hence their increased vulnerability.[11]

African women are culturally revered and almost glamorized for their caregiving roles. These caregiving roles have resulted in feminization of many epidemics due to the social customs. For example, more Nigerian women have been affected by the HIV/AIDS epidemic than men. Currently, women account for about 60% of the 3.5 million Nigerians living with the virus.[12] Women and girls carry the bulk of the burden in caring for people living with HIV/AIDS, accounting for two-thirds to 90% of caregivers for people living with HIV in Africa.[12] Similarly, women were disproportionately affected during previous Ebola outbreaks. A 2007 study on the 2003 Ebola outbreak in the Congo and Gabon found that men deliberately made use of the social custom that women care for the sick in order to avoid contact with patients.[1314]

Women are often on the front line as caregivers both in the households and as healthcare workers. These caregiving roles naturally extend to the hospitals where women predominantly serve as nurses and cleaners. Unfortunately, even at these institutions, women are not often provided with sufficient protective gear compared with the protection given to male doctors and other high-ranking hospital personnel. As health workers, they make up the majority of nurses, traditional birth attendants, cleaners and laundry workers in health facilities.[14] In the current outbreak, women constituted part of the medical team who managed the index case in a private hospital.[2] Some of such women actually became cases, and this included a medical practitioner who eventually died from the disease.

Women were also household contacts. Household members who fall ill and convalescent persons are often left to women for care.[15] Traditionally, women take care of the men, however, men hardly take care of the women because it is culturally unacceptable. Furthermore, women are closely involved with funeral and burial preparations for female relatives where they may contract the infection.[16] Even when Ebola patients die, women perform the traditional rites of preparing the corpses for burial – a high-risk activity that is mostly conducted with bare hands. Women are also traditional birth attendants, putting them at a greater risk of contracting the deadly virus.[17]

The traditional notion of female caregivers is not an exclusively African phenomenon. Around the world, there are more female caregivers than male ones. For example, more women than men provide caregiving in the United States (U.S.). More than 90% of registered nurses in the U.S. are women, according to the U.S. Department of Labor. Ebola’s effect on female caregivers is not limited by culture or geography either. Female nurses in the United States and Spain have also contracted the deadly virus after treating Ebola patients.[1819]

Effects of the outbreak

The Ebola outbreak placed a stigma on both public and private health facilities, as the populace protected themselves from the infection by avoiding healthcare facilities. Women avoided utilizing health facilities for care. Furthermore, women from other towns who might have sought maternity care avoided utilizing health facilities in the affected cities. Some pregnant women opted for home deliveries by traditional birth attendants. The maternal mortality rate in Nigeria is among the highest in the world and is estimated to be about 576 deaths/100,000 births.[2021] Hence, this outbreak may have increased the already high rates and resulted in serious obstetrics complications for some women.[2021]

Apart from the effect on maternal care services, a visit to health facilities for preventive, medical, and surgical services was avoided. Instead, women may have patronized other sources of care such as traditional healers, pharmacies or used self-medication.[21] The withdrawal and low patronization of health facilities was further compounded by the national industrial action embarked upon by the National Medical Association (association of medical doctors in the country) and the sacking of members of the National Association of Resident Doctors during the period of the outbreak.

The outbreak may also have impacted women’s livelihoods. In the Southern part of the country, many women work in the informal sector. Women constitute the majority of small-scale traders, farmers, and represent a sizeable percent of iterant traders.[19] They trade at local markets and across borders. Many women limited travel to big markets across states to trade. However, some women deliberately avoided contacts and self-quarantined themselves to avoid infection. Stigmatization of people coming from infected states and self-restrictions on movement to neighboring cities and towns may have resulted in economic loss to women in business thereby affecting their ability to support their families adequately. Furthermore, some women may also have had to stay back at home to nurse the sick. They had to perform household duties such as cooking, feeding, bathing, cleaning open wounds, and washing soiled clothes and linens of the sick, all while not wearing any form of protective clothing. The caregiving roles reduced their opportunity to work and make money for their upkeep. It also increased their chance of acquiring the infection.[1622] The outbreak was also attributed to the consumption of wild animals, therefore most people avoided consuming bushmeat (a delicacy). Thus women who relied on the sales of this meat as their source of livelihood recorded very poor sales. Furthermore, persons who depended on the animals for their source of protein may also have had their nutrition affected.

Women's responses

It is worthy to note that women’s relationship to Ebola was not primarily one of vulnerability. Women were in the front line of response to the disease, as caregivers and health workers in hospitals, families, and communities. Women were part of the national response at federal, state, and local government levels; they also constituted part of the implementing partners and global experts who provided technical support to the government.[3] At the community level, they were part of the social mobilizers and contact tracers. Women were able to use their connections to facilitate dialogue between global health experts and local caregivers, including religious leaders and opinion leaders, with their unique status. Thus, infected countries need to leverage women’s contribution effectively for response to be successful. At the household level, social mobilization activities aimed at preventing the infection were targeted at women to ensure they understood why and when it was important to wash hands. Most of the prevention messages/strategies involved measures that required the cooperation and involvement of women. This included the provision of soap and water for hand washing, the creation of places to do the hand wash and procurement of sanitizers among others.[89] Even the management of the rumor that the Ebola can be cured by consuming bitter kola nuts and prevented by drinking and bathing with salt water were been dispersed primarily by addressing mothers. Furthermore, information and education of women to promoted timely and honest reporting of contacts and symptomatic persons were directed at women.

Gender sensitive solutions

It is important that caregiving responses to Ebola are gender sensitive and recognize the value of women’s lives. Unfortunately, despite their major role in response to the epidemics, women are rarely considered in the development of solutions to the outbreak. Understanding possible roles women play in transmission and prevention can have immediate effects on outbreak containment.[11] Sensitization programs are urgently needed to improve women’s knowledge and enable them protect themselves from the infection. These enlightenment programs should consider the cultural norms and practices on the care of the sick and dead. Education programs should be targeted at different groups including mothers, pregnant women, men, fathers, male and female adolescents, and schoolchildren. These sessions should emphasize the importance of early recognition of EVD, and should encourage more equitable household decision-making and sharing of caregiving activities. This should be supported by the provision of protective devices.

Women can improve communication between experts and local caregivers. Different modes of communication, such as the use of community dialogue, radio, television including the social media can be employed to raise women’s awareness about the disease and share risk mitigation measures. Social mobilization teams should engage caregivers in discussions on infection prevention and disease containment. Federal, state, and local governments should provide guidelines to caregivers, on how to care for the sick at the same time protect oneself against the virus. Caregivers should be given appropriate community-based support when performing their tasks. Finally, it is crucial to determine in advance of outbreaks, how understanding gender roles might help in the development of a containment or prevention strategies. Women should be involved when designing responses outbreak responses. Quantitative studies to assess women’s knowledge on EVD, their attitude toward the infection and how they can assist in preventing cases in this environment are also recommended.

Conclusion

Women were at greater risk of EVD both in the community and health facility. The outbreak resulted in more cases, contacts and fatalities in women because of their caregiving roles. It restricted movement, which affected their ability to earn their livelihood and to care for their families. It resulted in increased morbidity and mortality as women avoided utilizing the health facilities for care. Women’s increased risk of exposure should be countered with a response that ensures women’s access to information and personal protective equipment particularly, for female healthcare providers. Future outbreak response needs to recognize these gender dimensions to protect deliberately women, and also should capitalize on their unique role during outbreak containment.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.