The landscape configuration of zoonotic transmission of Ebola virus disease in West and Central Africa: interaction between population density and vegetation cover

Impact of a free care policy on routine health service volumes during a protracted Ebola virus disease outbreak in the Democratic Republic of Congo

BACKGROUND

In response to the DRC's 10th Ebola Virus Disease (EVD) outbreak, the government subsidized routine health services in select health zones with the goal of maintaining routine service volumes. We assess the impact of the initial and revised Free Care Policies (FCP) on total clinic visits, uncomplicated malaria, simple pneumonia, fourth antenatal care clinic visits, and measles vaccinations, testing the hypothesis that routine services would not significantly decrease during the FCP.

METHODS AND FINDINGS

We used data from the DRC's national health information system spanning January 2017 to November 2020. Intervention facilities were those that were initially and secondarily enrolled in the FCP, which occurred in August 2018 and November 2018, respectively. Comparison facilities were limited to the North Kivu Province and were from health zones that recorded at least one case of Ebola. A controlled interrupted time series analysis was conducted. The FCP appeared to have a positive effect in increasing overall clinic attendance rates, uncomplicated malaria case rates, and simple pneumonia case rates in those health zones where the policy was enacted relative to comparison sites. The longer-term effects of the FCP were mostly non-significant or, if significant, relatively modest in nature. Rates for measles vaccinations and fourth ANC clinic visits appeared to be unaffected or minimally affected, respectively, by the implementation of the FCP and relative to comparison sites. We did not observe the decrease in measles vaccinations that has been observed elsewhere. The study is limited in that we were unable to account for health facility bypassing and service volumes at private health facilities.

CONCLUSIONS

Our findings provide evidence that FCPs can be used to maintain routine service provision during outbreaks. Additionally, the study design demonstrates that routinely reported health information from the DRC are sensitive enough to detect changes in health policy.

Drivers of African Filovirus (Ebola and Marburg) Outbreaks

Outbreaks of African filoviruses often have high mortality, including more than 11,000 deaths among 28,562 cases during the West Africa Ebola outbreak of 2014-2016. Numerous studies have investigated the factors that contributed to individual filovirus outbreaks, but there has been little quantitative synthesis of this work. In addition, the ways in which the typical causes of filovirus outbreaks differ from other zoonoses remain poorly described. In this study, we quantify factors associated with 45 outbreaks of African filoviruses (ebolaviruses and Marburg virus) using a rubric of 48 candidate causal drivers. For filovirus outbreaks, we reviewed >700 peer-reviewed and gray literature sources and developed a list of the factors reported to contribute to each outbreak (i.e., a "driver profile" for each outbreak). We compare and contrast the profiles of filovirus outbreaks to 200 background outbreaks, randomly selected from a global database of 4463 outbreaks of bacterial and viral zoonotic diseases. We also test whether the quantitative patterns that we observed were robust to the influences of six covariates, country-level factors such as gross domestic product, population density, and latitude that have been shown to bias global outbreak data. We find that, regardless of whether covariates are included or excluded from models, the driver profile of filovirus outbreaks differs from that of background outbreaks. Socioeconomic factors such as trade and travel, wild game consumption, failures of medical procedures, and deficiencies in human health infrastructure were more frequently reported in filovirus outbreaks than in the comparison group. Based on our results, we also present a review of drivers reported in at least 10% of filovirus outbreaks, with examples of each provided.

Henipaviruses-A constant threat to livestock and humans

In this review, we highlight the risk to livestock and humans from infections with henipaviruses, which belong to the virus family Paramyxoviridae. We provide a comprehensive overview of documented outbreaks of Nipah and Hendra virus infections affecting livestock and humans and assess the burden on the economy and health systems. In an increasingly globalized and interconnected world, attention must be paid to emerging viruses and infectious diseases, as transmission routes can be rapid and worldwide.

Genome-centric metagenomics reveals insights into the evolution and metabolism of a new free-living group in Rhizobiales

Background

The Rhizobiales (Proteobacteria) order is an abundant and diverse group of microorganisms, being extensively studied for its lifestyle based on the association with plants, animals, and humans. New studies have demonstrated that the last common ancestor (LCA) of Rhizobiales had a free-living lifestyle, but the phylogenetic and metabolism characterization of basal lineages remains unclear. Here, we used a high-resolution phylogenomic approach to test the monophyly of the Aestuariivirgaceae family, a new taxonomic group of Rhizobiales. Furthermore, a deep metabolic investigation provided an overview of the main functional traits that can be associated with its lifestyle. We hypothesized that the presence of pathways (e.g., Glycolysis/Gluconeogenesis) and the absence of pathogenic genes would be associated with a free-living lifestyle in Aestuariivirgaceae.

Results

Using high-resolution phylogenomics approaches, our results revealed a clear separation of Aestuariivirgaceae into a distinct clade of other Rhizobiales family, suggesting a basal split early group and corroborate the monophyly of this group. A deep functional annotation indicated a metabolic versatility, which includes putative genes related to sugar degradation and aerobic respiration. Furthermore, many of these traits could reflect a basal metabolism and adaptations of Rhizobiales, as such the presence of Glycolysis/Gluconeogenesis pathway and the absence of pathogenicity genes, suggesting a free-living lifestyle in the Aestuariivirgaceae members.

Conclusions

Aestuariivirgaceae (Rhizobiales) family is a monophyletic taxon of the Rhizobiales with a free-living lifestyle and a versatile metabolism that allows these microorganisms to survive in the most diverse microbiomes, demonstrating their adaptability to living in systems with different conditions, such as extremely cold environments to tropical rivers.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12866-021-02354-4.

Mapping of Ebola virus spillover: Suitability and seasonal variability at the landscape scale

The unexpected Ebola virus outbreak in West Africa in 2014 involving the Zaire ebolavirus made clear that other regions outside Central Africa, its previously documented niche, were at risk of future epidemics. The complex transmission cycle and a lack of epidemiological data make mapping areas at risk of the disease challenging. We used a Geographic Information System-based multicriteria evaluation (GIS-MCE), a knowledge-based approach, to identify areas suitable for Ebola virus spillover to humans in regions of Guinea, Congo and Gabon where Ebola viruses already emerged. We identified environmental, climatic and anthropogenic risk factors and potential hosts from a literature review. Geographical data layers, representing risk factors, were combined to produce suitability maps of Ebola virus spillover at the landscape scale. Our maps show high spatial and temporal variability in the suitability for Ebola virus spillover at a fine regional scale. Reported spillover events fell in areas of intermediate to high suitability in our maps, and a sensitivity analysis showed that the maps produced were robust. There are still important gaps in our knowledge about what factors are associated with the risk of Ebola virus spillover. As more information becomes available, maps produced using the GIS-MCE approach can be easily updated to improve surveillance and the prevention of future outbreaks.

Ebola virus disease is a highly pathogenic disease transmitted from wildlife to humans. It was first described in 1976 and its distribution remained restricted to Central Africa until 2014, when an outbreak in West Africa, causing more than 28,000 cases and more than 11,000 deaths, took place. Anthropogenic factors, such as bushmeat hunting, trade and consumption, and environmental and climatic factors, may promote the contact between humans and infected animals, such as bats, primates and duikers, increasing the risk of virus transmission to the human population. In this study, we used the spatial multicriteria evaluation framework to gather all available information on risk factors and animal species susceptible to infection, and produce maps of areas suitable for Ebola virus spillover in regions in Guinea, Congo and Gabon. The resulting maps highlighted high spatial and temporal variability in the suitability for Ebola virus spillover. Data from reported cases of Ebola virus transmission from wild animals to humans were used to validate the maps. The approach developed is capable of integrating a wide diversity of risk factors, and provides a flexible and simple tool for surveillance, which can be updated as more data and knowledge on risk factors become available.

Ecology of Ebolaviruses

Africa is becoming known for the emergence and re-emergence of Ebola virus. The virus, which was initially restricted to East and Central Africa, is now emerging in West Africa. Ecological aspects of Ebola virus diseases are poorly understood. It is suspected that the virus is circulating in the forests of Africa, mostly hosted by migratory bats, which spread the virus to other wildlife particularly great apes and duikers. Spillovers occur when humans have contacts with wildlife. Transmission of the virus within human systems occurs through contacts with body fluids of an infected person. Several factors seem to be responsible for the emergence and re-emergence of the virus in Africa including circulation of the virus in forest ecosystems, persistence of the virus in body fluids (during sickness, upon death, and in survivors), transmission through diverse routes (direct contacts, fomites, oral), presence of infected migratory bats and other wildlife species, forest encroachment, and climatic and seasonal changes. Recent studies show that fresh outbreaks can emerge not only from wildlife but also from survivors of previous outbreaks. It is therefore important to understand the ecology of the virus in order to mitigate future emergence.

Disease Outbreak, Health Scare, and Distance Decay: Evidence from HPAI Shocks in Chinese Meat Sector

Background: During zoonotic disease shocks (ZDSs), zoonotic disease outbreaks (ZDOs) can induce public health scares (PHSs), causing meat price risks (MPRs). Nevertheless, spatial spillovers of zoonotic disease shocks in meat markets remain unclear. We explore how zoonotic disease outbreaks and public health scares locally and spatially spill over to meat price risks, and whether spatial spillovers of public health scares decay with distance. Methods: (i) We construct a long panel covering 30 provinces and 121 months, using highly pathogenic avian influenza (HPAI) epidemics as exogenous shocks in Chinese meat sector. (ii) We decompose zoonotic disease shocks into zoonotic disease outbreaks (objective incident) and public health scares (subjective information) and examine their spillovers to meat price risks. (iii) We identify distance-decaying spatial spillovers of public health scares, by running our dynamic SAR models 147 times, from 80 km to 3000 km with 20 km as incremental value, in a setting with risk-level heterogeneity. Results: (i) Zoonotic disease outbreaks themselves only cause local and neighboring meat price risks for high-risk meat, not for low-risk or substitute meat. (ii) Public health scares exacerbate local and neighboring meat price risks for high-risk and low-risk meat, and local meat price risks for substitute meat. (iii) Spatial spillovers of public health scares are distance-decaying and U-shaped, with four spatial attenuation boundaries, and distance turning point is shorter for high-risk meat (500 km) than for low-risk meat (800 km). Conclusions: We complement the literature by arguing that health scares induced by disease outbreaks negatively spill over to meat prices, with U-shaped distance-decaying spatial effects. This suggests low interregional spatial market integration in meat products, due to distance decay of nonstandardized information and local government control effects, across provincial boundaries. To the best of our knowledge, we are the first to document nonmonotonic distance decay of health scare effects on food prices, previously not found by the literature.

The Emerging Threat of Ebola

Ebola is one of the deadliest infectious disease of the modern era. Over 50% of those infected die. Prior to 1976, the disease was unknown. No one knows exactly where it came from, but it is postulated that a mutation in an animal virus allowed it to jump species and infect humans. In 1976 simultaneous outbreaks of Ebola occurred in what is now South Sudan and the Democratic Republic of the Congo (DRC). For 20 years, only sporadic cases were seen, but in 1995 a new outbreak occurred killing hundreds in the DRC. Since that time the frequency of these outbreaks has been increasing. It is uncertain why this is occurring, but many associate it with increasing human encroachment into forested areas bringing people and animals into more intimate contact and increased mobility of previously remote population. This chapter will navigate Ebola in the context of global health and security.

There are multiple objectives of this chapter. First is to provide a basic understanding of Ebola disease processes and outbreak patterns. Second, is to explore the interplay between social determinants of health and Ebola. The role of technology in spreading Ebola outbreaks will be explained as will Ebola’s potential as a bioweapon. Readers will gain understanding of the link between environmental degradation and Ebola outbreaks.

This chapter will be divided into five main sections. These are (1) a case study; (2) Ebola Disease process; (3) Social determinants of health and Ebola; (4) Ebola in the modern era, and (5) the link between Ebola and environmental degradation.

Exploratory investigation of region level risk factors of Ebola Virus Disease in West Africa

Background

Ebola Virus Disease (EVD) is a highly infectious disease that has produced over 25,000 cases in the past 50 years. While many past outbreaks resulted in relatively few cases, the 2014 outbreak in West Africa was the most deadly occurrence of EVD to date, producing over 15,000 confirmed cases.

Objective

In this study, we investigated population level predictors of EVD risk at the regional level in Sierra Leone, Liberia, and Guinea.

Methods

Spatial and descriptive analyses were conducted to assess distribution of EVD cases. Choropleth maps showing the spatial distribution of EVD risk across the study area were generated in ArcGIS. Poisson and negative binomial models were then used to investigate population and regional predictors of EVD risk.

Results

Results indicated that the risk of EVD was significantly lower in areas with higher proportions of: (a) the population living in urban areas, (b) households with a low quality or no toilets, and (c) married men working in blue collar jobs. However, risk of EVD was significantly higher in areas with high mean years of education.

Conclusions

The identified significant predictors of high risk were associated with areas with higher levels of urbanization. This may be due to higher population densities in the more urban centers and hence higher potential of infectious contact. However, there is need to better understand the role of urbanization and individual contact structure in an Ebola outbreak. We discuss shortcomings in available data and emphasize the need to consider spatial scale in future data collection and epidemiological studies.

Pathogeography: leveraging the biogeography of human infectious diseases for global health management

Biogeography is an implicit and fundamental component of almost every dimension of modern biology, from natural selection and speciation to invasive species and biodiversity management. However, biogeography has rarely been integrated into human or veterinary medicine nor routinely leveraged for global health management. Here we review the theory and application of biogeography to the research and management of human infectious diseases, an integration we refer to as 'pathogeography'. Pathogeography represents a promising framework for understanding and decomposing the spatial distributions, diversity patterns and emergence risks of human infectious diseases into interpretable components of dynamic socio-ecological systems. Analytical tools from biogeography are already helping to improve our understanding of individual infectious disease distributions and the processes that shape them in space and time. At higher levels of organization, biogeographical studies of diseases are rarer but increasing, improving our ability to describe and explain patterns that emerge at the level of disease communities (e.g. co-occurrence, diversity patterns, biogeographic regionalisation). Even in a highly globalized world most human infectious diseases remain constrained in their geographic distributions by ecological barriers to the dispersal or establishment of their causal pathogens, reservoir hosts and/or vectors. These same processes underpin the spatial arrangement of other taxa, such as mammalian biodiversity, providing a strong empirical 'prior' with which to assess the potential distributions of infectious diseases when data on their occurrence is unavailable or limited. In the absence of quality data, generalized biogeographic patterns could provide the earliest (and in some cases the only) insights into the potential distributions of many poorly known or emerging, or as-yet-unknown, infectious disease risks. Encouraging more community ecologists and biogeographers to collaborate with health professionals (and vice versa) has the potential to improve our understanding of infectious disease systems and identify novel management strategies to improve local, global and planetary health.

Mapping Disease Transmission Risk of Nipah Virus in South and Southeast Asia

Since 1998, Nipah virus (NiV) (genus: Henipavirus; family: Paramyxoviridae), an often-fatal and highly virulent zoonotic pathogen, has caused sporadic outbreak events. Fruit bats from the genus Pteropus are the wildlife reservoirs and have a broad distribution throughout South and Southeast Asia, and East Africa. Understanding the disease biogeography of NiV is critical to comprehending the potential geographic distribution of this dangerous zoonosis. This study implemented the R packages ENMeval and BIOMOD2 as a means of modeling regional disease transmission risk and additionally measured niche similarity between the reservoir Pteropus and the ecological characteristics of outbreak localities with the Schoener's D index and I statistic. Results indicate a relatively high degree of niche overlap between models in geographic and environmental space (D statistic, 0.64; and I statistic, 0.89), and a potential geographic distribution encompassing 19% (2,963,178 km²) of South and Southeast Asia. This study should contribute to current and future efforts to understand the critical ecological contributors and geography of NiV. Furthermore, this study can be used as a geospatial guide to identify areas of high disease transmission risk and to inform national public health surveillance programs.

Climate Change and the Neglected Tropical Diseases

Climate change is expected to impact across every domain of society, including health. The majority of the world's population is susceptible to pathological, infectious disease whose life cycles are sensitive to environmental factors across different physical phases including air, water and soil. Nearly all so-called neglected tropical diseases (NTDs) fall into this category, meaning that future geographic patterns of transmission of dozens of infections are likely to be affected by climate change over the short (seasonal), medium (annual) and long (decadal) term. This review offers an introduction into the terms and processes deployed in modelling climate change and reviews the state of the art in terms of research into how climate change may affect future transmission of NTDs. The 34 infections included in this chapter are drawn from the WHO NTD list and the WHO blueprint list of priority diseases. For the majority of infections, some evidence is available of which environmental factors contribute to the population biology of parasites, vectors and zoonotic hosts. There is a general paucity of published research on the potential effects of decadal climate change, with some exceptions, mainly in vector-borne diseases.

Modeling the Ebola zoonotic dynamics: Interplay between enviroclimatic factors and bat ecology

Understanding Ebola necessarily requires the characterization of the ecology of its main enzootic reservoir, i.e. bats, and its interplay with seasonal and enviroclimatic factors. Here we present a SIR compartmental model where we implement a bidirectional coupling between the available resources and the dynamics of the bat population in order to understand their migration patterns. Our compartmental modeling approach and simulations include transport terms to account for bats mobility and spatiotemporal climate variability. We hypothesize that environmental pressure is the main driving force for bats' migration and our results reveal the appearance of sustained migratory waves of Ebola virus infected bats coupled to resources availability. Ultimately, our study can be relevant to predict hot spots of Ebola outbreaks in space and time and suggest conservation policies to mitigate the risk of spillovers.

Health workers perceptions and attitude about Ghana's preparedness towards preventing, containing, and managing Ebola Virus Disease

BACKGROUND

Ebola virus is highly infectious and the disease can be very fatal. The World Health Organization has declared the 2014-2015 Ebola Virus Disease outbreak a Public Health Emergency of International Concern. In response to this, preparations were made in various health facilities and entry points across Ghana. This study explored health workers perceptions, and attitude about Ghana's preparedness towards preventing and containing Ebola Virus Disease.

METHODS

We conducted a qualitative study in five (5) of the ten (10) regions in Ghana. Five focus group discussions (N = 44) were conducted among nurses; one in each region. In addition, ten (10) health workers (2 in each region) who are members of regional Ebola Virus Disease task force were recruited and interviewed. In the Greater Accra, Volta and Western regions that have ports, six (6) port health officials: two in each of these regions were also interviewed. The interviews were recorded digitally and transcribed verbatim. Thematic content analysis was used to analyze the transcripts with the aid of NVivo 10 software.

RESULTS

The results of this study showed that Ghanaian health workers perceived the screening at various ports as important and ongoing but felt that the screenings at in-land ports were being undermined by the use of unapproved routes. Training of health workers was also being carried out in all the regions, however, there was a general perception among 33 out of 44 nurses that majority of health workers have not received training on Ebola Virus Disease prevention and management. Logistical challenges were also reported as some health facilities did not have adequate Personal Protective Equipment. In facilities where equipment was available, they were stored in places which are not easily accessible to health workers at all times of the day. Human resource preparation was also perceived to be a challenge as health workers (38/44 of nurses) generally expressed fear and unwillingness to work in Ebola treatment centres in the event of an outbreak in Ghana.

CONCLUSIONS

Our study concludes that preparatory work for Ebola Virus Disease prevention and containment in Ghana is perceived as inadequate by health workers. Ghana needs to strengthen preparation in the area of training of health workers, provision and accessibility of Personal Protective Equipment and incentives for health workers to better position her to contain and manage any Ebola Virus Disease outbreak.

Spatial Determinants of Ebola Virus Disease Risk for the West African Epidemic

INTRODUCTION

Although many studies have investigated the probability of Ebola virus disease (EVD) outbreaks while other studies have simulated the size and speed of EVD outbreaks, few have investigated the environmental and population-level predictors of Ebola transmission once an outbreak is underway. Identifying strong predictors of transmission could help guide and target limited public health resources during an EVD outbreak. We examined several environmental and population-level demographic predictors of EVD risk from the West African epidemic.

METHODS

We obtained district-level estimates from the World Health Organization EVD case data, demographic indicators obtained from the Demographic and Health surveys, and satellite-derived temperature, rainfall, and land cover estimates. A Bayesian hierarchical Poisson model was used to estimate EVD risk and to evaluate the spatial variability explained by the selected predictors.

RESULTS

 We found that districts had greater risk of EVD with increasing proportion of households not possessing a radio (RR 2.79, 0.90-8.78; RR 4.23, 1.16-15.93), increasing rainfall (RR 2.18; 0.66-7.20; 5.34, 1.20-23.90), and urban land cover (RR 4.87, 1.56-15.40; RR 5.74, 1.68-19.67).

DISCUSSION

 The finding of radio ownership and reduced EVD transmission risk suggests that the use of radio messaging for control and prevention purposes may have been crucial in reducing the EVD transmission risk in certain districts, although this association requires further study. Future research should examine the etiologic relationships between the identified risk factors and human-to-human transmission of EVD with a focus on factors related to population mobility and healthcare accessibility, which are critical features of epidemic propagation and control.

The nexus between forest fragmentation in Africa and Ebola virus disease outbreaks

Tropical forests are undergoing land use change in many regions of the world, including the African continent. Human populations living close to forest margins fragmented and disturbed by deforestation may be particularly exposed to zoonotic infections because of the higher likelihood for humans to be in contact with disease reservoirs. Quantitative analysis of the nexus between deforestation and the emergence of Ebola virus disease (EVD), however, is still missing. Here we use land cover change data in conjunction with EVD outbreak records to investigate the association between recent (2004–2014) outbreaks in West and Central Africa, and patterns of land use change in the region. We show how in these EVD outbreaks the index cases in humans (i.e. spillover from wildlife reservoirs) occurred mostly in hotspots of forest fragmentation.

Preparing towards Preventing and Containing an Ebola Virus Disease Outbreak: What Socio-cultural Practices May Affect Containment Efforts in Ghana?

Background

Ebola Virus Disease (EVD) is a condition with high fatality. Though the disease is deadly, taking precautions to reduce contact with infected people and their secretions can prevent cross- infection. In the 2014 EVD outbreak, socio-cultural factors were identified to be responsible for the spread of the disease in the three most affected countries in West Africa. In this light, we undertook this study to identify socio-cultural factors that may influence the prevention and containment of EVD in Ghana and ways to address such practices.

Methods

We conducted a descriptive qualitative study in five regions in Ghana. Twenty-five focus group discussions (5 in each region) with community members (4 in each region) and nurses (1 in each region) were conducted. In addition, forty (40) in-depth interviews were conducted with various stakeholders and opinion leaders; eight in each region. All interviews were recorded using a digital voice recorder and transcribed. With the aid of Nvivo 10 for windows, we analyzed the data using framework analysis.

Results

We found that socio-cultural practices, such as care of the body of dead and burial practices, widowhood rites and anointing children with water used to rinse the dead, were common. These practices require individuals coming into direct contact with either the dead or items used to take care of the dead. Social norms also require frequent handshakes in all social gatherings such as funeral, and religious congregations. We also found that self-medication (using herbs and orthodox medications) was a common practice. People use both biomedical and non-orthodox health outlets either simultaneously or in sequence in times of ill-health.

Conclusion

The study concludes that high risk socio-cultural practices were common among Ghanaians and generally perceived as indispensable. These high risk practices may hinder containment efforts in the event of an outbreak. Community leaders should be engaged in any social mobilization to modify these practices as part of preparation efforts.

The 2014 Ebola Virus Disease outbreak emerged as the most devastating outbreaks in recent history. This outbreak spread across continents with West Africa remaining the epicenter. Although, the three most affected countries have been declared Ebola free, the recent re-emergence of cases in Sierra Leone require that countries in West Africa do not relent in their EVD containment efforts. Burial and funeral practices are high-risk practices that can facilitate the spread of ebola and hinder containment efforts. These practices vary across countries and regions. In this study, we found that despite the social and contextual difference across regions in Ghana, common high-risk practices exist and perceived to be indispensable. We also found that little attention were given to these practices in risk communication and community engagements. These practices required either touching the dead or items used in taking care of the dead. Widowhood rites require a widow drinking water used to bath the deceased husband to show her innocence in the husband’s death. Findings of this study attest to the need for improved dialogue with community leaders to provide alternatives to these high-risk socio-cultural practices to be able to contain an Ebola outbreak. Countries with similar socio-cultural practices could also use the findings of this study to guide behavioural change communication strategies.

Beyond Knowledge and Awareness: Addressing Misconceptions in Ghana's Preparation towards an Outbreak of Ebola Virus Disease

Background

Ebola Virus Disease (EVD) is not new to the world. However, the West African EVD epidemic which started in 2014 evolved into the largest, most severe and most complex outbreak in the history of the disease. The three most-affected countries faced enormous challenges in stopping the transmission and providing care for all patients. Although Ghana had not recorded any confirmed Ebola case, social factors have been reported to hinder efforts to control the outbreak in the three most affected countries. This qualitative study was designed to explore community knowledge and attitudes about Ebola and its transmission.

Methods

This study was carried out in five of the ten regions in Ghana. Twenty-five focus group discussions (N = 235) and 40 in-depth interviews were conducted across the five regions with community members, stakeholders and opinion leaders. The interviews were recorded digitally and transcribed verbatim. Framework analysis was adopted in the analysis of the data using Nvivo 10.

Results

The results showed a high level of awareness and knowledge about Ebola. The study further showed that knowledge on how to identify suspected cases of Ebola was also high among respondents. However, there was a firm belief that Ebola was a spiritual condition and could also be transmitted through air, mosquito bites and houseflies. These misconceptions resulted in perceptions of stigma and discrimination towards people who may get Ebola or work with Ebola patients.

Conclusion

We conclude that although knowledge and awareness about Ebola is high among Ghanaians who participated in the study, there are still misconceptions about the disease. The study recommends that health education on Ebola disease should move beyond creating awareness to targeting the identified misconceptions to improve future containment efforts.

Testing New Hypotheses Regarding Ebolavirus Reservoirs

Despite a relatively long search for the origin of ebolaviruses, their reservoirs remain elusive. Researchers might have to consider testing alternative hypotheses about how these viruses persist and emerge to advance ebolavirus research. This article aims to encourage researchers to bring forward such hypotheses, to discuss them scientifically and to open alternative research avenues regarding the origin and ecology of ebolaviruses.