HEALTH PLAQUE AND POLICY

RISK COMMUNICATION

FOR GLOBAL OUTBREAK MANAGEMENT: EBOLA CASE STUDY.

By

MORITA SARI

DrPH program

College of Public Health, University of Kentucky.

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INTRODUCTION

Disease outbreak has always been a threat for every nation. It is fast, unpredictable

and devastating. In a human history disease outbreak had happen from time to time. The

diseases are morbid and have rapid movement from non-contagious to very contagious. Up to

know scientist still amaze with the development of new outbreak.

Outbreak and natural disaster has similarity in the sense of unpredictable event, we

cannot predict outbreak or natural disaster. First of all we need to know what is outbreak.

According to the CDC, an “outbreak” is the occurrence of more cases of disease than

normally expected within a specific place or group of people over a given period of time. In

the midst of panic and fear, public health authority should not ignore their role to make

people feel safe, but often time even public health does not know what to do or how to do

because there is no integrated protocol to overcome outbreak. The lack of transparency

increases the possibility of rumors and misinformation, result in distress of the disease

control. Failure to demonstrate transparency can lead to serious negative public health,

economic and political consequences. In this discussion we are going to take Ebola Outbreak

as our case study.

EBOLA OUTBREAK

Ebola Virus Disease (EVD) was first described in 1976 after two nearly simultaneous

outbreaks in the nations now known as South Sudan and the Democratic Republic of the

Congo (DRC; formally known as Zaire) (Toner, 2014). The dispersion of the virus is

incredibly involving human mobility, bodies of infected and animal as the vector. EVD was

never being a mediocrity case during the human health history because it’s quite deadly and

highly contagious. Given the extensive mobility and air travel in West Africa, EVD could

reach other countries in the region and beyond (Frieden et al, 2014). Since December 2013,

an outbreak of Ebola virus disease in the West Africa nation of Guinea has rapidly evolved

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into humanitarian crisis of unforeseen proportions, overwhelming vulnerable communities in

Liberia, Sierra Leone, Nigeria and Senegal. In addition, more than 600 new cases of Ebola

were reported in three countries most affected which are Sierra Leone, Liberia and Guinea

(www.nytimes.com).

To date more than 1000 people, including numerous health care workers have been

killed by EVD in 2014, and the number of cases in the current outbreak now exceeds the

number from all previous outbreaks combined (Friedman et al, 2014). Latest figure provided

by the World Health Organization (WHO) confirmed the epidemic as the worst outbreak of

the particular strain of hemorrhagic fever in history, with 4,555 dead out of 9,216 registered

cases a death rate of about 50% (www.abc.net). Misinformation and a limited understanding

of West Africa societies worsen the impacts of stigmatization and could prevent policy

makers from formulating effective strategies to contain the current Ebola outbreak and

prevent future epidemic (Ravi &Gouldin, 2014). Societies have an obligation to help people

affected Ebola when the cost or imposition of doing so is minimal (Rid & Emanuel, 2014).

West Africa will see much more suffering and many more deaths during childbirth and from

Malaria, TBC, HIV-AIDS, enteric and respiratory illness, diabetes, cancer, cardiovascular

disease, and mental health during and after Ebola epidemic (Farrar &Piot, 2014).

EBOLA MANAGEMENT.

Earlier this year, the US joined partner governments the WHO and other multilateral

organization and non-governmental actors to launch the Global Health Security Agenda

(Frieden et al, 2014). The current outbreak of Ebola virus in West Africa has been declared

public health emergency of international concern by the WHO and is the most severe such

outbreak of Ebola to date (www.kff.org). WHO 1 December target date for achieving

important progress benchmark which is 70% isolation of patient and 70% of burials

performed safety (www.denverpost.com). The management of Ebola cases are extremely

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related with sociocultural dimensions one of them is the funeral procedure. Corpses of Ebola

patients are extremely infectious and are an acute source of contagious. To give information

for the family for reduce the contact from the deceased body is hard. Misconceptions

surrounding Ebola, its transmission, and the people who contact it have complicated efforts to

implement outbreak control strategies and formulate effective disease control. These

misconceptions could inhibit efforts to control the Ebola Outbreak in 2 important ways. First,

those from Ebola affected communities might suspect the motives of foreign soldiers and

health workers and refuse to cooperate with them (Ravi and Gauldin, 2014). Second,

inaccurate portrayals of Ebola and its causes could make both West Africans and African

migrants in other parts of the world the target of xenophobic attitudes

(www.washingtonpost.com).Misinformation and a limited understanding of West African

societies worsen the impacts of stigmatization and could prevent policymakers from

formulating prevent future epidemics. To avoid this, health authority elsewhere might

consider developing coordinated public health messaging strategies to ensure that

policymakers, the public, and the medical responders have access to timely, accurate, and

reliable information about Ebola prevention and transmission. (Ravi and Gauldin, 2014).

While the outbreak continue to rise in West Africa the fear has reach other part of the

world. People start to speculate where will be the next Ebola epidemic. Despite of the vast

scale of the current outbreak, the clinical manifestations of Ebola virus disease, the duration

of illness, the case fatality rate, and the degree of transmissibility are similar to those in

earlier epidemic (Farrar and Piot, 2014, Toner, 2014). However the devastating course of the

disease seems more severe than previous outbreak and it is unlikely be attributed to biologic

of virus solely. The imperfect of the health care systems in the affected countries is already

having a deep impact on the populations’ health beyond Ebola, as clinics close or become

overwhelmed or nonfunctional. Perhaps Farrar and Piot (2004) statement that Ebola has

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reached the point where it could establish itself as an endemic infection because of a highly

inadequate and late global response will soon be true.

The mitigation of Ebola Outbreak could not be done in the classic “outbreak control”

anymore because is no longer sufficient for an epidemic of this size. The resurgence cases

have been noted in the border of Sierra Leone, Guinea and Liberia. Sierra Leone is the focus

of Ebola transmission for West Africa and the leading focus of Ebola activity at this moment

(WHO REPORT, 2014). According to CDC Morbidity and Mortality Weekly Report

(MMWR) cases in Liberia are doubling every 15-20 days, and those in Sierra Leone are

doubling every 30-40 days. In addition still base on CDC MMWR by September 30, 2014

without additional interventions and using the described likelihood of going to an Ebola

Treatment Unit (ETU), approximately 670 daily beds in use will be needed in Liberia and

Sierra Leone (CDC Ebola MMWR, 2014).

EBOLA RISK COMMUNICATION

CDC state that Ebola response mainly tracks patients through the following states of

Ebola –related infection and disease: susceptible to disease, infected, incubating, infectious

and recovered. The infectious state also includes persons who die but whose burial provides

risk for onward transmission. The risk associated with unsafe burial is part of the total daily

risk for transmission for the patients at home without effective isolation.

WHO identified risk communication components which had direct relevance to

outbreaks. The result of this extensive review, filtered through a broad practical assessment,

is a shortlist of outbreak communication best practices that contain trust, announcing early,

transparency, the public and planning. (WHO Outbreak communication guideline, 2014).

The important goal for outbreak communication is to communicate with public in

ways that build, maintain or restore trust while keep the effort to reduce the dispersion. It

happens that trust passes the boundaries of cultures, political systems, and level of country

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development. Consequently, building trust internally between communicators and policy-

makers is critical. Policy makers rely heavily on the data as the combination of fact and

numbers while in outbreaks often time reality is uncontrollable. The source of information

should be reliable and agreed by different health authority. For Ebola outbreaks WHO and

CDC right now is the two main health authority that hold the key information for others

health workforce. Trust is also essential between communicators and technical outbreak

response staff who may not see the need of communicating with the public especially if it

means diverting them from other tasks. Ebola cases at Guinea give evidence about lacking of

trust between communicators when they fail to gain trust from people live at the mountain.

The villagers resist to report about their deceased family who infected by the virus. They

have fear if the health officer will confiscate the body of the loving ones. This ongoing

behavior causes resurgence in the outbreaks as we all aware that the infected corpse is highly

contagious. However, because of the undeniably mortality ratefinally the villagers willing to

cooperate after their community leader bridging the misunderstanding

(www.nytimes.com).Definitely, mechanism of accountability, involvement and transparency

are important to establish and maintain trust.

The parameters of trust are established in the outbreak’s first official announcement.

In today’s globalized, wired world, information about outbreaks is almost impossible to keep

hidden from the public. This message’s timing, information and comprehensiveness may

make it most important outbreak communications. However rapid announcements may

surprise important partners who might disagree with the initial assessment. For example, the

media in Liberia have helped raise public awareness of the disease but have also been a

conduit for misinformation (Ravi and Gauldin, 2014). This can be minimized by having well-

established communication pathways in place among key and predictable stakeholders. A

good example for this will be the European Union Health Security Committee

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Teleconference on 4 December at Luxemburg where they set standard service for the

outbreak and risk communication (HSC report, 2014).

Maintaining the public’s trust throughout an outbreak also requires transparency.

Transparency characterized the relationship between the outbreak managers and the public.

Total fairness should be the operational goal consistent with generally accepted individual

rights, such patient safety. The key is to balance the rights of the individual against

information directly pertinent to the public good and the public’s need and desire for reliable

information. But if limits to transparency become excuses for unnecessary secretiveness, the

likely result will be a loss of public trust. Pride embarrassment, and fear of being blamed can

also lead to lack of fairness. However in general, greater transparency results in greater trust.

Looking back at the Ebola Outbreak response program, CDC’s work so far is satisfying in

updating information about Ebola, however public fear still appear when there is US citizen

positive infected with Ebola after travelling from West Africa. However, CDC is working

intensively with partners to help stop outbreak at its source in Africa. CDC also assisting the

four affected countries to improve their exit-screening protocols to help protect the rest of the

world (Frieden et al, 2014).

Understanding the public is critical to effective communication. It is usually difficult

to change pre-existing beliefs unless those belief are explicitly addressed. It is nearly

impossible to design successful messages that bridge the gap between the expert and the

public without knowing what the public thinks. The public’s concerns must be appreciated

even if they seem unfounded. The perfect example for this is the social cultural that we often

ignore. Often time the health worker fail to navigate effective communication like what

happen in Liberia where misconception and fear hamper the dissemination of correct

information. It is crucial that medical interventions be executed in a culturally competent

manner to ensure their effectiveness (Ravi and Gauldin, 2014). When a publicly held a view

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is mistaken, it should still be acknowledged publicly and corrected, not ignored, patronized or

ridiculed. Communication about personal preventive measures is particularly useful as it

empowers the public to take some responsibility for their own health. Therefore, risk

communication is most effective when it is integrated with risk analysis and risk

management. Risk communication should be incorporated into preparedness planning for

major events and in all aspects of an outbreak response. Outbreak communication planning

must be a part of outbreak management planning from the start. To be effective, outbreak

communication cannot be a last minute adds on feature to announce decisions (WHO

Outbreak communication guideline, 2014).

It is importance to recognize that if certain conditions are met like dysfunctional and

under resourced health systems, national and international indifference, lack of effective

timely response, high population mobility, local customs that can exacerbate morbidity and

mortality, spread in densely populated urban centers, and lack of trust in authorities, then we

might have uncontrollable outbreak (Farrar and Piot, 2014). If implemented effectively, the

guideline for outbreak communication will result in greater public resilience and guide

appropriate public participation to support the rapid containment of an outbreak, thus limiting

morbidity and mortality. In addition, effective outbreak communication will minimize the

damage to a nation’s international standing, its economy and its public health infrastructure.

CONCLUSION

The current Ebola Outbreak is not only the problem of the endemic countries in West

Africa, indeed this outbreak resonate deeply with humanity. Unfortunately, the endemic

countries suffer not only the mortality but also the degradation of integrated health system.

However, assistance from other countries will contribute to ease the burden immensely.

Despite on the outbreaks global alert that has been develop ever since the Ebola Virus start to

emerge in West Africa, the risk communication of the outbreak fell short both in local and

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international level. The resurgence case of Ebola in different part of West Africa mainly due

to sociocultural dimension which being overlooked by health workers. On the other hand the

fear and panic also spread widely in the international level. Transparency and trust are no

longer discourse but have to be truly imbedded in every mitigation step. The longer we let

misinformation and misconception about Ebola the more devastating the impact will be.

REFERENCES

CDC. (2014). Morbidity and Mortality Weekly Report: Estimating the Future Number of Cases in Ebola
Epidemic-Liberia and Sierra Leone, 2014-2015. Atlanta: U.S Department of Health and
Human Service.

Frieden, Thomas R., Damon, Inger., Bell, Beth., Kenyon, Thomas, Nicol, Stuart. (2014). Ebola 2014-
New Challenges, New Global Response. The New England Journal of Medicine, 1117-1545.

HSC REPORT, 2014

Ravi, Sanjana., Gauldin, Eric M. (2014). Sociocultural Dimension of The Ebola Virus Disease Outbreak
in Liberia. Biosecurity and Bioterrorism: Biodefense Strategy, Practice, and Science, 1-5.

Rid, Annette., Emanuel, Ezekiel. (2014). Why Should High-Income Countries Help Combat Ebola?
JAMA, 1297.

Toner, Eric ., Adalja, Amesh., Inglesty, Thomas. (2014). A Primer on Ebola for Clinicians. Disater
Medicine and Public Health Preparadness, 1.

WHO. (2014). WHO outbreak communciation guidlines. WHO.

www.nytimes.com

www.denverport.com

www.abc.net

www.washingtonport.com

www.kff.org.