The post-Ebola virus disease scourge in Nigeria: Individual levels of preparedness among physicians in the Federal Capital Territory Abuja.

BACKGROUND: Ebola virus disease (EVD) is a viral hemorrhagic illness with great propensity for spread across international borders. The latest outbreak in the West African region, which involved Nigeria, was the worst among previously documented 25 outbreaks since discovery in 1976. The Nigerian response toward attaining Ebola free status was phenomenal and a case study for most nations. However, the persistence of EVD in West Africa is still a risk to recurrence, hence, the need to assess the level of consciousness of Nigerian physicians towards this.
METHODOLOGY: A cross-sectional study utilizing the instrument of a pretested semi-structured questionnaire was conducted among physicians practicing within the federal capital city of Nigeria. General knowledge, treatment, prevention, and reporting of EVD were assessed and appropriate statistical analyses done using SPSS 20.
RESULTS: Of the 101 respondents, 45% and 87% showed excellent level (>80% score) of "general knowledge" and "reporting" on EVD, respectively. However, only 51% respondents had good (60-80%) knowledge on EVD treatment. Three percent correctly identified the "EVD helpline" phone-numbers for reporting suspected cases. Furthermore, 43.6% admitted the availability of personal protective equipment (PPE) in their hospitals while 35.6% had witnessed a demonstration of the use. The distribution of the PPEs appeared skewed - 74.4% (teaching-hospitals), 16% (private-hospitals), and the primary health care centers (9.6%).
CONCLUSION: A majority of the physicians showed good level of preparedness as it relates to general knowledge on EVD, knowledge on good clinical practice, use of protocols and standard precautions and PPE. The identification of deficits in knowledge on treatment of EVD and flow path for the notification of suspected cases requires urgent redress given the risk of re-occurrence in the country.

Introduction

Ebola virus disease (EVD) is a viral hemorrhagic disease caused by a Filoviridae spp. family of viruses. Five species of the virus (Zaire, Bundibugyo, Sudan, Reston and Tai Forest) have been identified. The first three are largely associated with outbreaks of the disease in Africa.[1] The Zaire species is the most virulent and leading cause of highly contagious and lethal form of this human hemorrhagic viral infection. About 25 disease outbreaks[2] leading to human illnesses and variable levels of morbidity and mortality have been recorded particularly but not restricted to West African coasts since the discovery of the virus in 1976 near Ebola river basin of the Democratic Republic of Congo.

In 2014, Nigeria was among the West Africa countries affected by Ebola virus outbreak for the 1st time. This was the worst outbreak in history, according to the Centre for Disease Control and Prevention. A total of 24,701 people were infected while 10,194 deaths were recorded;[3] giving a fatality rate of about 41.3%. Prior to this period, most cases of EVD have been witnessed in East Africa where recurrent outbreaks are continually being documented. The reason for this recurrence has been attributed to the vast reservoir of tropical rain forests which constitute a common ecosystem for Ebola virus emergence and a rich animal biodiversity.[4] The disease is also observed to be seasonal with most outbreaks occurring during the rainy seasons. Most countries in Africa have recorded multiple Ebola virus outbreaks (Democratic Republic of Congo have seven; Uganda has five; Gabon four). Experts believe that the epidemic will return in West Africa except an effective vaccine becomes widely available.

The Nigerian response to the Ebola outbreak was exceptionally swift and serves as a role model to how future Ebola outbreaks should be approached, despite this being the country’s first documented human outbreak. The health care sector, as well as the government-related agencies, contributed to this success.[2] However, according to the hypothesis proposed by Muyembe-Tamfum et al.,[4] hospital-based outbreaks of EVD have higher transmission cycles and mortalities than community-based outbreaks, and it is possible for isolated cases to occur frequently in the community. This is supported by the fact that most hospital settings in Africa are not equipped with adequate resources to encourage barrier nursing techniques and universal hygiene measures. In addition, it is quite improbable to recognize an index case of an EVD outbreak on clinical grounds alone when outside the epidemic context, since the clinical signs are generally nonspecific. EVD is usually suspected during the aggravation phase which may occur from day 9 of disease onset.[24]

It is a known fact that myths, misconception, and misinformation exist in communities concerning EVD and these have put a strain on measures to fight the disease, especially during an outbreak. In view of the understanding which has been corroborated by a study in Sierra Leone[5] that health workers are the most trusted sources of information on EVD, there is need for regular assessment of the knowledge base of the physicians who form the pivot of these medical professionals. Furthermore, a continuous education of the populace and assessment of adequate preparedness by the health workers both in non-Ebola infested and Ebola certified free West African countries is imperative.

To this end, the study is designed to measure the level of preparedness an average physician practicing in the Federal Capital Territory, Abuja, has of EVD; 6 months post the Nigerian disease scourge. We wish to assess their knowledge level, daily preventive level of preparedness (availability and use of personal protective equipment (PPE) – how to wear and dispose, standard precautions in taking and transporting samples) and management of EVD. This is important for a nation with a newly acquired management experience of an emerging but deadly disease. This could be used to determine how effective our health care system will respond to a possible new outbreak.

Methodology

This was a cross-sectional based study involving medical doctors only. The physicians were recruited during 2015 first quarter continuing medical education (CME) program organized by the Federal Capital Territory branch of Nigerian Medical Association in collaboration with the medical and dental council of Nigeria. These CME sessions which are regular and compulsory, being prerequisites for renewal of annual practicing licenses, attract doctors from different areas of specialization (medicine, surgery, pediatrics, general practice, obstetrics, and gynecology); different places of practice (private hospital, primary health care center, district hospital, and tertiary hospital) and different years of work experience. Each of these programs has an average attendance of 130 physicians.

Appling Fishers formula:[6]

where; nf = the desired sample size when populations is <10,000.

n = The desired sample size when the population is more than 10,000.

N = The estimate of the population size.

However to get n, the following formula is utilized;

where:

n = The desired sample size (when population is >10,000).

z = The standard deviate, usually set at 1.96 which corresponds to the 95% confidence level.

p = The proportion in the target population estimated to have a particular characteristic; since there is no reasonable estimate, 50% was used (i.e., 0.50).

q = 1.0 – p

d = Degree of accuracy desired, usually set at 0.05.

Since n is <10,000

Sample size

While a minimum sample size of 97 was calculated, we distributed a total of 124 questionnaires to physicians who consented to participate in the study.

Following institutional approval by the ethical review board of the University of Abuja Teaching Hospital, the commencement of the study was preceded with a pretest of the questionnaire among twenty respondents (about 20% of the sample size) who were physicians working in the University of Abuja Teaching Hospital. Those who participated in the pilot pretesting were not included in the final sample, and the few modifications suggested by the responses from the pilot subjects were adopted in the eventual study questionnaire. This prevalidated semi-structured questionnaire comprised 25 questions and the identity cum anonymity of the participants’ responses was assured.

The questions were related to the most common knowledge on EVD (nature of virus, mode of transmission, incubation period, signs, and symptoms), preventive measure against Ebola as well as questions to assess the knowledge on the protocol and precautionary measures in place in the Federal Capital Territory should there be a possible recurrent outbreak. We also assessed their possible response to a confirmed or suspected EVD patient. To assess the level of knowledge, answers to the first ten questions of the questionnaire were added up and expressed as a percentage and subsequently cross-tabulated with place and year of practice. The level of suspicion and action to be taken was assessed using the following questions: Response if a patient presents with high-grade fever, vomiting, and blood-stained stool, knowledge of any EVD helpline phone number, knowledge, and the presence of PPE in their hospitals/institutions and signs of possible EVD. These were also summed up, and levels of assessment were expressed based on performance as follows: >80% - excellent, 60–80% - good, 50–59% - fair, and <50% - poor.

Statistical analysis was done using SPSS version 20 (IBM, Armonk, NY, United States of America). Data were expressed as frequency and analyzed by Chi-square with level of significance set at P ≤ 0.05.

Results

A total of 124 questionnaires were distributed, 110 of which were returned and 101 were completely filled and included in the study. Among the 101 questionnaires evaluated, 63.4% of the physicians were males while 36.6% were females. 40.6% of these respondents had been in practice for <5 years while 21.8% had been in practice for ≥15 years [Table 1].

Table 1

The years of medical practice/experience of the respondents

Years of practice	Frequency	Percentage	Cumulative percentage
<5	41	40.6	40.6
5-9	22	21.8	62.4
10-14	16	15.8	78.2
15-19	10	9.9	88.1
>20	12	11.9	100
Total	101	100.0

The bulk of the respondents were practitioners in general medical practice (31.7%). Others included internal medicine (26.7%), surgery (22.9%), obstetrics and gynecology (11.9%), and pediatrics (6.9%). About eighty-percent (80.2%) of the physicians who participated in our study were from the government-owned health system while 19.8% were into private practice. These government-owned health institutions spanned the three tiers of the healthcare system viz., tertiary (63.4%), secondary (10.9%), and primary (5.9%) healthcare levels, respectively [Table 2].

Table 2

Distribution of respondents according to places of work

Place of practice	Frequency	Percent
Private hospital	20	19.8
Primary health center	6	5.9
General/District hospital	11	10.9
Teaching hospital/Federal Medical Centers	64	63.4
Total	101	100.0

Majority of the respondents were from the Public Health system (approximately 80%) and the rest private

Findings from our study showed that 45.5% of the practitioners had excellent (>80% score), 47.6% had good (60–80% score) while 5.9% had fair (50–59%) general knowledge of EVD. There was no significant difference between years and place of practice and the respondents’ level of knowledge (P = 0.93 and 0.71, respectively) [Tables 3 and 4]. On knowledge of reportage of EVD, the participants showed an excellent level of knowledge (86.1%) [Figure 1] which however contrasted with the findings on evaluation of their knowledge on treatment of the disease. In the latter, only 52% of the respondents had good knowledge of EVD treatment [Figure 2].

Table 3

Impact of years of practice on general knowledge about Ebola Virus Disease

Knowledge	Years of experience					Total
	<5	5-9	10-14	15-19	>20
40%	1	0	0	0	0	1
50%	4	1	0	0	1	6
60%	4	2	2	0	1	9
70%	8	1	2	1	3	15
80%	10	5	3	3	3	24
90%	9	7	6	5	3	30
100%	5	6	3	1	1	16
Total	41	22	16	10	12	101
Chi-Square tests
			Value	df	Asymp. Sig. (2-sided)
Pearson Chi-Square			14.495a	24	935
Likelihood ratio			17.139	24	843
Linear-by-linear association			.940	1	332
Number of valid cases			101

The years of practice had no significant(P=0.935) influence on the respondents knowledge about EVD, probably because it is a novelle disease in Nigeria

Table 4

The statistical impact of place of practice on knowledge about Ebola Virus Disease

Knowledge	Place of practice				Total
	Private hospital	Primary health center	General/District hospital	Teaching hospital/Federal Medical Centers
40%	0	0	0	1	1
50%	1	0	1	4	6
60%	2	1	2	4	9
70%	1	0	4	10	15
80%	4	2	1	17	24
90%	6	2	2	20	30
100%	6	1	1	8	16
Total	20	6	11	64	101
Chi-Square tests
			Value	df	Asymp. Sig. (2-sided)
Pearson Chi-Square			14.240a	18	0.713
Likelihood ratio			14.907	18	0.668
Linear-by-linear association			1.434	1	0.231
Number of valid cases			101

a22 cells (78.6%) have expected count less than 5. The minimum expected count is 0.06

Figure 1

The pie chart illustrates the knowledge base of the physicians across all specialties on the reportage of suspected cases of Ebola virus disease

Figure 2

The chart showed the distribution of the level of knowledge on treatment of Ebola virus disease among the physicians. Satisfactory knowledge on modality for treatment was recorded in 68%

It is worthy of note that just 3% of the physicians who participated in the study correctly identified any of the Ebola virus “disease helpline” phone-numbers. The respondents who had the PPE in their hospitals constituted 43.6% whereas those who had seen the demonstration of its use were 35.6%. Further analysis revealed that most of these equipment are available in teaching hospitals (74.4%) compared to private hospitals (16%). The district hospitals and primary health care centers which are usually the first point of presentation and closest to the communities could hardly boast of having any PPEs (9.6%).

Discussion

The level of preparedness amongst physicians practicing in the federal capital of Nigeria as regards general knowledge of EBV, index of suspicion and knowledge of both preventive measures and means/form of reporting suspected cases was fairly good and commendable (≥80% score). This knowledge cut across the board and showed no significant difference in the areas of specialization and places of practice. This is higher than what was observed in a recent Indian study.[7]

Though Ebola is a relatively uncommon infectious disease, it is good to note that medical doctors across all specialties and in different levels of care (primary health care, district hospital, and tertiary hospitals) can easily identify the symptoms and signs of EVD whenever it presents. Similarly, most of them had good knowledge on preventive measures against EVD. The reason for this high-level of knowledge could be due to the recent nature of this outbreak, the level of awareness created following the first index case in Nigeria and the circumstances surrounding the case whose impact can be noted as historic both in magnitude and distribution. In addition, the swift, coordinated response of the Nigerian government in information dissemination, training of health personnel, and other measures also contributed.[8]

Although our study did not evaluate the sources of the knowledge espoused by the respondents, it can be postulated that the extraordinary and all-inclusive method of information dissemination in Nigeria throughout the 93 days of EVD outbreak in the country was key. The national response anchored by the Federal Ministry of Health had a consistent flow of information on EVD through a centralized “command-chain” structure accessible across the board.[8] The Nigerian Medical Association was actively involved in the sensitization, education and training of her members on all that was needed to combat EVD.

Despite the fact that a majority of the respondents claimed good knowledge on when to report a suspected case(s) of EVD, only half of them knew how to treat an actual case. This may not be unconnected with the fact the protocol in the FCT made the treatment of EVD a specialized process at clearly designated locations and by specifically trained staff. Presumably, the feeling among the physicians might be that only adequate knowledge, enough to identify suspected cases and refer same to the designated centers is all that is required of them. However, the knowledge on how to prevent a new outbreak alone is not sufficient. It has to be combined with knowledge on the management of confirmed or suspected Ebola case(s). This combination will enhance prevention of spread at hospital and communal levels and promote special barrier precautionary measures such as isolation of patients and post contact decontamination of health workers.[9] Knowledge and practice of these measures have prevented outbreaks in developed countries.[10] Therefore, the area of treatment should be emphasized to the physicians in our index location of study.

Furthermore, it was disappointing to note that less than a quarter of the respondents knew the designated institution, where the EVD patients can be isolated in the Federal Capital Territory, Nigeria. Again, very few respondents (3%) were abreast of the EVD helpline phone-numbers for contacting relevant authorities. This may undermine individual, institutional and state's efforts at containment of outbreaks in the country. Less than half of the respondents have access to PPEs in their health institutions, and only about a third had witnessed the procedures of donning the PPEs. This is similar to the situation in East Africa with documented multiple Ebola outbreaks, where transmission of this deadly disease is largely nosocomial and have been attributed to poor implementation of high-level barrier precautions by some health institutions.[11]

Finally, eternal vigilance is needed in Nigeria since the declaration of Nigeria “Ebola free” does not confer immunity from the chains of transmission of the disease from within the West African sub-region.

Recommendation

A holistic knowledge on EVD has helped early detection and prompt containment of the disease by health care workers in Sudan[12] and this was proposed as vital in preventing future mortalities in the postoutbreak assessment of the year 2000 Uganda outbreak.[9] However, since EVD symptoms and signs in the early stages is no different from common infectious diseases such as malaria and typhoid, making early detection difficult even for a skilled physician, there is need to institute strict EVD management protocols with availability of necessary facilities. The EVD helpline phone-numbers should be well displayed/known, and every institution should have PPE. This is because there is a good possibility that EVD will reoccur in West Africa, and we need to be ready so as to avoid a repeat of the 2014 Ebola epidemic.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.