Introduction

Urbanization, advancements in technology and efficient modes of transport across the globe describe modern society. Advances in technology and interconnectivity have eliminated geographical barriers, thus spurring economic growth and unity across the world. While globalization is promoting international growth, an outbreak of an infectious disease that is not detected and contained in time at its source can result in expensive health and economic turmoil. The adverse effects of globalization are of particular concern in the developing world, where managing an outbreak that involves pathogens with pandemic potential is a challenge in the surging number of megacities and population. Previous outbreaks underscored the threat of a virus spreading across the globe before the health system responding or even identifying the causative agent. In this sense, the international health agencies establishing secure multispectral systems to detect and respond to local or imported communicable ailments. In this regard, this article analyses the Ebola scourge in West Africa and its spread across the region and importation into the United States.

1. Ebola international outbreak

In early 2000s Guinea trended in international media for most of the adversities against humanity. In 2013, the country was recovering from internal political conflicts that had left the country on its knees when a mysterious disease struck a remote village. The mysterious ailment claimed the life of an eighteen-month-old boy whom villagers believed had gotten the infection from bats (U.S. Department of Health & Human Services, 2019). After a while, the disease reappeared as an extremely virulent strain claiming the lives of five in the village triggering the medical officials to issue a report on January 24, 2014, before the virus proliferated to Conakry. On 13^th March, 2014, Guinea’s health ministry declared an outbreak of a mysterious illness before France’s Pasteur Institute inveterated the disease to be EVD brought about by Zaire ebolavirus. On 23^rd March, 2014, the world health organization (WHO) made an official declaration of the EVD outbreak after 49 confirmed cases and 29 mortalities (U.S. Department of Health & Human Services, 2019).

As the situation deteriorated in West Africa, on 8^th August 2014, WHO triggered the Public Health Emergency of International Concern (PHEIC) protocol designed for hazardous incidents that demand an internationally harmonized response (U.S. Department of Health & Human Services, 2019). After the PHEIC declaration, secondary infections were reported in Nigeria, Mali, the United States and Italy. Between 2014 and 2016, eleven people received Ebola treatments in the United States. The United States verified the first travel-associated EVD case on 30^th September 2014 after a man travelling from West Africa to Dallas was diagnosed with Ebola. The index cased died on 8^th October 2014 after infecting two physicians who later recovered (U.S. Department of Health & Human Services, 2019).

B1. Epidemiological Determinants and Risk Factors

According to the World Health Organization (2019), health officers in Guinea and their international associates took almost three months to recognize the Ebola virus as the causal agent. At the end of the three months, the virus had entrenched firmly and spread across the country. Factors underwriting to the quick spread of the infection are the weak public health infrastructure, high population movement across permeable borders, a severe insufficiency of health care workers, ethnic beliefs and behavioral practices, and spread by intercontinental air travel.

The state of the healthcare system is a notable epidemiological factor because containing and controlling the virus in guinea was hampered by its poor healthcare infrastructure. A poor healthcare structure results in delayed dispensation of services, diagnosis and identification of the causative agent (Fallah, Skrip, Gertler, Yamin, & Galvani, 2015). Also, uncontrolled population movement and porous international borders is a significant impediment to regulating, monitoring and tracing of the virus’ range. The threat of population movement is exacerbated by the shortage of health workers in weak economies, or unstructured systems are vulnerable to the adversities of the virus (Karan & Pogge, 2015). Consequences of inadequate healthcare services are movement of people to regions that can offer services, thus reigniting the menace in the areas that were under control. Also, the importation of Ebola virus in the United States showed that the virus could enter a new country through air travelers. The Dallas event practically indicated that all cities across the globe are susceptible to Ebola infection, given the fundamentally amplified interconnectedness and interdependence that defines this era.

Ebola is spread through direct human contact especially when the skin tissue is torn facilitating exchange of blood or other body fluids of a sick or person that died from the disease, objects contaminated with biological matter from an individual infected with the virus or the body of an individual who died from Ebola (Agua-Agum et al., 2016). Since the transmission of Ebola is through close contact, healthcare workers are frequently affected while attending to confirmed or suspected EVD. Other persons at risk are those attending funeral ceremonies involving direct contact with the body of the deceased.

Epidemiologists associate EVD with various risk factors. A notable risk factor is living in unvaccinated status. World Health Organization (WHO) has partnered with governments in the affected regions to vaccinate high-risk populations against Ebola virus disease. Occupational risks are serving as healthcare workers in areas suspected or confirmed to have an Ebola outbreak. Vulnerable professionals include doctors, nurses, and morticians. Other risk factors entail travelling to Africa and carrying out animal research because animals such as the fruit bats are innate Ebola virus hosts. Fruit bats can infect chimpanzees, gorillas, monkeys and other wild animals that researchers can come in contact with their bodily fluids.

B2. Route of Transmission

Airborne/aerosol

Aerosol virus transmission transpires when miniature, virus-loaded drops evaporate before perching on surfaces, allowing infective droplet nuclei to cover more distance. The tiny dewdrops forming the nuclei are known as aerosols which are the liquefied or solid particles floating in the air (Judson, Prescott & Munster, 2015). Although there are EBOV particles found in human alveoli, there is no empirical evidence confirming whether Ebola virus disease can form droplet containing the virus within the human respiratory system. Consequently, epidemiologists concur that Ebola’s transmission is not airborne, besides, previous incidents show that all patients were infected through direct contact.

Droplet

Droplet conduction or large droplet transmission is the interaction with infectious precipitations that cannot evaporate after being airborne for extended periods (Osterholm et al., 2015). While these droplets are airborne, they do not form nuclei like the evaporating aerosols form nuclei as they travel through the air. Although some pathogens are unstable as droplet nuclei, they can infect people exposed to them because the infections remain stable inside droplets. Pragmatic data indicates that droplet conduction is possible within a meter from the virus carrier or host, although this is subject to droplet mass, environment and stability of the pathogen (Lawrence, Danet, Reynard, Volchkova & Volchkov, 2017). Many biological fluids such as blood, saliva, vomit and stool are EBOV carrying droplets whose transmission range is not yet confirmed. However, previous incidents indicate that droplet transmission is possible because some patients testified not having direct interaction with infested patients but still got infected because they were in close contiguity with infected people.

Fomites and environmental constancy

A fomite is a surface that supports the thriving of a pathogen, and fomite conveyance occurs when a person interacts with a contaminated surface. Ebola virus disease (EVD) transmission route is possible when an individual touches items such as beddings or stretcher that Ebola patients used or other surfaces spoiled with EVD-containing droplets (Weber, Fischer, Wohl & Rutala, 2015). In current literature, there is no data on EVD’s stability on surfaces. Available evidence indicates that Ebola viral load declines significantly on glass surfaces in dark and relatively humid conditions. Also, Ebola can be recovered in surfaces exposed to the virus, such as areas where individuals who died from the infection are buried. In this sense, Ebola virus can still be spread through fomites, and it is stable on all environmental conditions, and as such, it is essential to sustain routine cleaning of hospital surfaces because the virus is unstable in clean areas.

Contact with bodily fluids

Direct interaction with corporeal fluids is the most effective route of Ebola virus transmission between people as compared to all possible ways of communication. Empirical data from previous epidemics, epidemiological records and trials reveal that interaction with Ebola-infected solutions through the mucous sheath, injections, or open wounds can result in infection (Vetter et al., 2016). Also use of contaminated needles is associated with the spread of Ebola in hospitals during the first spate of Ebola, there has been accidental exposure to the Ebola virus through needle-stick injuries among researchers. Most of the infections among caregivers are attributable to direct contact with patients or bodily fluids.

B3. Impact in My Community at a Systems Level

After reviewing the impact of Ebola in West African countries that reported the first incidents of Ebola outbreak, it is apparent that an outbreak of the virus could have a significant effect on the community in Tacoma. In the worst-case scenario, the illness will impact the economy, operations healthcare system, education system and transport system. When Ebola breaks out, the priority is always to contain the virus and prevent it from spreading across borders or in the population. From personal knowledge, an outbreak of Ebola will have a substantial impact on the economy in numerous ways. For instance, the epidemic will result in trade and transport restrictions, reduce tourism activities and other economic activities hinged on the movement of people. Another impact is the cost of response in attempts to mitigate the virus. In the previous outbreaks, the United Kingdom, the United States and Germany donated billions in the fight against Ebola.

Healthcare systems are fundamental to the wellbeing of the community. An outbreak of Ebola will adversely affect the healthcare sector of Tacoma and Washington as a whole. The virus affects the community as a whole, and the healthcare workers are not an exception as previous outbreaks have claimed lives of doctors, nurses and other healthcare providers. As such, the infestation will impair the delivery of healthcare services and result in impediments in the management and control of other serious ailments. Additional impacts will include the need to train more practitioners to assist in the management of the virus and stabilize the healthcare system. Besides straining resources in the healthcare sector, a viral outbreak will increase the vulnerability of the community and result to other health concerns such as mental health.

An Ebola outbreak in Tacoma will disrupt the community and result in cyclical patterns of fear, stigma and loss of trust in the healthcare system. A sense of communal grief will prevail due to substantial losses of members of the community. The disruption will impair the execution of routine social activities such as children attending school and other social engagements. After the first Ebola case, local governments will issue health alerts and restrict the movement of people as they attempt to contain the virus and prevent it from spreading. The issued lockdown will affect school program as they will remain inaccessible as people will be urged to stay indoors. The issued curfew will also affect the transport systems as public transport could be a risk factor of people coming in contact with those infected.

In Guinea, factors concomitant to poverty, such as standard health and access to care played an integral role in the spread and outcome of Ebola. Most of the patients only showed up to health facilities after they were very ill, and it was too late because most of them seeking medical services is an economic decision. As such, if a similar pandemic hits Tacoma, similar socioeconomic patterns would manifest concerning the uninsured individuals. Those without medical insurance would likely wait as late as possible to seek medical services as they attempt to avoid steep medical expenses at which point it might be too late. Such scenarios have been evident in terms of other infectious diseases and access to medical care.

Assuming all resources are directed towards containment and management of the virus, other areas of the state will be deprived of the fundamental inputs. Prolonged community lockdown will strain the food supply and delivery of drugs to the most affected regions. Such challenges would result in increased infections and mortalities across the city and Washington would most likely stagnate during the period. Businesses and schools would be closed, and public transportation would be disrupted, electricity switch off and piling of corpses in the streets. Supply of food and other amenities would run short, as the quantity of life-saving drugs that currently sustain people with diabetes, cardiac diseases, immunosuppressive conditions and different life-threatening ailments. Also, continued suffering will likely trigger criminal activities. People will resort to crime and violence as they strive to access scarce resources such as medication, food and other supplies essential in survival. However, with the current infrastructure and advances in healthcare, the probability of the situation reaching such severity levels is minimal.

Patently, an outbreak of Ebola or any viral infection will have adverse consequences for the affected community. Notable areas to be impacted are the healthcare system, economy, the education, transportation and local authorities as they attempt to contain the outbreak. The effects will be exacerbated by the restrictions on the movement of people and goods, scarcity of resources, and stress on the healthcare systems.

B4. Reporting Protocol for Ebola Outbreak in Tacoma

Consistent with the code of the District of Columbia, the Mayor is obligated to issue directives to contain and prevent the spread of infectious diseases upon the advice of the director of the department of health (District of Columbia, 2019). In the case of an Ebola incident, healthcare providers, healthcare amenities, clinical laboratories, veterinarians and others are obligated to report to the Washington state infectious disease office.  Ebola must be reported immediately by telephone upon preliminary diagnosis or the manifestations of suspicious symptom and confirmed through an online report submitted using DCRC within 24 hours.

As such, it is apparent that the Washington department of health is dependent on various stakeholders such as school nurses, laboratory and healthcare facility staff to avail information on public health concerns. The department utilizes the information in monitoring the health of residents, identification and investigation of possible outbreaks, assess the efficiency of public health interventions and contribute to the CDC database in national surveillance.

B5. Two Strategies to Prevent an Ebola Outbreak in Tacoma

Vaccinations

Empirical evidence reveals that vaccines are effective in minimizing infectious disease burdens. Contemporary vaccines have an enhanced safety record and are useful in eradicating diseases. Since the Ebola virus disease is sporadic in the United States and only occurs through human to human transmission, vaccination is an effective strategy in eliminating EVD in Tacoma. In this sense, vaccination of Tacoma residents will contribute towards eradication of Ebola virus disease, although there is a possibility of importation. However, pragmatic data indicates that local disease elimination is possible without global eradication of causative microorganism. Such progress has been effective in infections such as measles as the regional transmission was eliminated and importation does not culminate in a persistent spread of the virus. Efficacious vaccinations administered before exposure protect individuals. Although there is no licensed vaccine by food and drug administration (FDA) in the United States, there is an experimental vaccine rVSV-ZEBOV that is highly protective against the virus (Henao-Restrepo et al., 2015). The vaccine was launched by the World Health Organization (WHO) in 2015 for trails in guinea, and as such, vaccination is an effective strategy in the prevention of Ebola.

Community education

Community and patient empowerment is an effective strategy in infection management. Education is an active secondary prevention strategy as it emphasizes on early detection for enhanced chances of positive outcomes (Kpanake, Gossou, Sorum & Mullet, 2016). The first case of Ebola outbreak in the United States is attributable to importation which is an outcome of growth in international air travel. In this sense, education will assist the stakeholders in educating the community on effective responses should they find themselves in affected areas. For instance, members of the population will learn that Ebola is prevalent in sub-Saharan Africa that has occasional outbreaks. People will learn that the virus circulates at low rates through given animal species and as such if they intend to visit such areas should be vaccinated. On the other hand, if they find themselves in regions affected they will be keen to avoid contact with bodily fluids, items that have been in contact with infected people, not to attend funeral or burial rituals of infected people and avoid interaction with bats and nonhuman primates.

References

Agua-Agum, J., Ariyarajah, A., Aylward, B., Bawo, L., Bilivogui, P., & Blake, I. et al. (2016). Exposure Patterns Driving Ebola Transmission in West Africa: A Retrospective Observational Study. PLOS Medicine, 13(11), e1002170. doi: 10.1371/journal.pmed.1002170

District of Columbia. (2019). D.C. Law Library – § 7–131. Regulations to prevent spread of communicable diseases. Retrieved 18 October 2019, from https://code.dccouncil.us/dc/council/code/sections/7-131.html

Fallah, M., Skrip, L., Gertler, S., Yamin, D., & Galvani, A. (2015). Quantifying Poverty as a Driver of Ebola Transmission. PLOS Neglected Tropical Diseases, 9(12), e0004260. doi: 10.1371/journal.pntd.0004260

Henao-Restrepo, A., Longini, I., Egger, M., Dean, N., Edmunds, W., & Camacho, A. et al. (2015). Efficacy and effectiveness of an rVSV-vectored vaccine expressing Ebola surface glycoprotein: interim results from the Guinea ring vaccination cluster-randomised trial. The Lancet, 386(9996), 857-866. doi: 10.1016/s0140-6736(15)61117-5

Judson, S., Prescott, J., & Munster, V. (2015). Understanding Ebola Virus Transmission. Viruses, 7(2), 511-521. doi: 10.3390/v7020511

Karan, A., & Pogge, T. (2015). Ebola and the need for restructuring pharmaceutical incentives. Journal of Global Health, 5(1). doi: 10.7189/jogh.05.010303

Kpanake, L., Gossou, K., Sorum, P., & Mullet, E. (2016). Misconceptions about Ebola virus disease among lay people in Guinea: Lessons for community education. Journal of Public Health Policy, 37(2), 160-172. doi: 10.1057/jphp.2016.1

Lawrence, P., Danet, N., Reynard, O., Volchkova, V., & Volchkov, V. (2017). Human transmission of Ebola virus. Current Opinion in Virology, 22, 51-58. doi: 10.1016/j.coviro.2016.11.013

Osterholm, M., Moore, K., Kelley, N., Brosseau, L., Wong, G., & Murphy, F. et al. (2015). Transmission of Ebola Viruses: What We Know and What We Do Not Know. Mbio, 6(2). doi: 10.1128/mbio.00137-15

U.S. Department of Health & Human Services. (2019). 2014-2016 Ebola Outbreak in West Africa | History | Ebola (Ebola Virus Disease) | CDC. Retrieved 18 October 2019, from https://www.cdc.gov/vhf/ebola/history/2014-2016-outbreak/index.html

Vetter, P., Fischer, W., Schibler, M., Jacobs, M., Bausch, D., & Kaiser, L. (2016). Ebola Virus Shedding and Transmission: Review of Current Evidence. Journal of Infectious Diseases, 214(suppl 3), S177-S184. doi: 10.1093/infdis/jiw254

Weber, D., Fischer, W., Wohl, D., & Rutala, W. (2015). Protecting Healthcare Personnel from Acquiring Ebola Virus Disease. Infection Control & Hospital Epidemiology, 36(10), 1229-1232. doi: 10.1017/ice.2015.205

World Health Organization. (2019). Ebola virus disease. Retrieved 18 October 2019, from https://www.who.int/news-room/fact-sheets/detail/ebola-virus-disease