Ebola outbreak in West Africa, 2014 -2016: Epidemic timeline, differential diagnoses, determining factors, and lessons for future response

Abstract

The outbreak of Ebola virus disease (raging between 2014 and 2016) in the West African sub-region was one of the global epidemics that sparked international public health concerns in the last decade. Since the discovery of Ebola virus in 1976, 2014–2016 epidemic remains the worst episode with significant case fatality rates and socioeconomic impacts in the affected countries. This review looks at important health determinants that directly accounted for the spatial events of rapid spread and severity, in association with the consequent high fatality rates. It also brings up a time-point health determinant model to conceptualize understanding of this important outbreak with a view to enlightening the public, and in the end prospecting the future with valuable recommendations that may be crucial to preventing or urgently curtailing any future outbreak.

Full text

Please
cite
this
article
in
press
as:
Kamorudeen
RT,
et
al.
Ebola
outbreak
in
West
Africa,
2014
–
2016:
Epidemic
timeline,
differential
diagnoses,
determining
factors,
and
lessons
for
future
response.
J
Infect
Public
Health
(2020),
https://doi.org/10.1016/j.jiph.2020.03.014
ARTICLE IN PRESS
G Model
JIPH-1319;
No.
of
Pages
7
Journal
of
Infection
and
Public
Health
xxx
(2020)
xxx–xxx
Contents
lists
available
at
ScienceDirect
Journal
of
Infection
and
Public
Health
journa
l
h
om
epa
ge:
http://www.elsevier.com/lo
cate/jiph
Ebola
outbreak
in
West
Africa,
2014
–
2016:
Epidemic
timeline,
differential
diagnoses,
determining
factors,
and
lessons
for
future
response
Ramat
Toyin
Kamorudeena,b,
Kamoru
Ademola
Adedokunc,∗,
Ayodeji
Oluwadare
Olarinmoyed,e
aPublic
Health
Department,
University
of
South
Wales,
Pontypridd,
United
Kingdom
bChildren
Welfare
Unit,
Osun
State
Hospital
Management
Board,
Asubiaro,
Osogbo,
Osun
State,
Nigeria
cDepartment
of
Oral
Pathology,
King
Saud
University
Medical
City,
Riyadh,
Kingdom
of
Saudi
Arabia
dEngineer
Abdullah
Bugshan
Research
Chair
for
Dental
and
Oral
Rehabilitation
(DOR),
King
Saud
University,
Riyadh,
Kingdom
of
Saudi
Arabia
eCentre
for
Control
and
Prevention
of
Zoonoses
(CCPZ),
University
of
Ibadan,
Ibadan,
Nigeria
a
r
t
i
c
l
e
i
n
f
o
Article
history:
Received
24
January
2020
Received
in
revised
form
15
March
2020
Accepted
17
March
2020
Keywords:
Ebolavirus
Epidemic
Case
fatality
Health
determinant
model
West
Africa
a
b
s
t
r
a
c
t
The
outbreak
of
Ebola
virus
disease
(EVD)
that
raged
between
2014
and
2016
in
the
West
African
sub-
region
was
one
of
the
global
epidemics
that
spiked
international
public
health
concern
in
the
last
decade.
Since
the
discovery
of
ebolavirus
in
1976,
the
2014-2016
epidemics
have
been
the
worst
with
significant
case
fatality
rates
and
socioeconomic
impact
in
the
affected
countries.
This
review
looks
at
important
health
determinants
that
directly
accounted
for
the
spatial
events
of
rapid
spread
and
severity
of
EVD
in
West
Africa,
with
consequent
high
fatality
rates.
It
also
brings
up
a
time-point
health
determinant
model
to
conceptualize
understanding
of
this
important
outbreak
with
a
view
to
enlightening
the
public
and-
providing
valuable
recommendations
that
may
be
crucial
to
preventing
or
curtailing
any
future
outbreak
of
the
disease.
©
2020
The
Author(s).
Published
by
Elsevier
Ltd
on
behalf
of
King
Saud
Bin
Abdulaziz
University
for
Health
Sciences.
This
is
an
open
access
article
under
the
CC
BY-NC-ND
license
(http://creativecommons.
org/licenses/by-nc-nd/4.0/).
Contents
Introduction
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
00
Outbreaks
of
Ebolavirus
in
Africa:
Epidemic
Timeline
and
Impacts
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
00
Ebola
and
Other
Infectious
Diseases:
Differential
Diagnoses
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
00
The
Key
Health
Determinants
Associated
with
High
Mortality
Rate
of
2014-2016
West
African
Ebola
Epidemics
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
00
Medical
Attention
and
Government
Policy:
Combinatorial
Effects
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
00
Social
factors
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
00
Seasonal
and
Climatic
Factor.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.00
Physical
Environment
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
00
Health
Status
and
Human
Biology
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
00
Individual
risk
behaviour
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
00
Conclusion
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
00
Recommendations
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
00
References
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
00
∗Corresponding
author.
E-mail
address:
adeolokun@yahoo.com
(K.A.
Adedokun).
Introduction
Ebola
virus
disease
(EVD)
also
known
as
viral
hemorrhagic
fever
and
hereinafter
referred
to
as
Ebola,
is
a
rare
but
deadly
illness
which
primarily
occurs
as
a
result
of
the
transmission
of
a
deadly
ebolavirus
from
wild
animals
particularly
fruit
bats,
to
human
pop-
https://doi.org/10.1016/j.jiph.2020.03.014
1876-0341/©
2020
The
Author(s).
Published
by
Elsevier
Ltd
on
behalf
of
King
Saud
Bin
Abdulaziz
University
for
Health
Sciences.
This
is
an
open
access
article
under
the
CC
BY-NC-ND
license
(http://creativecommons.org/licenses/by-nc-nd/4.0/).

Please
cite
this
article
in
press
as:
Kamorudeen
RT,
et
al.
Ebola
outbreak
in
West
Africa,
2014
–
2016:
Epidemic
timeline,
differential
diagnoses,
determining
factors,
and
lessons
for
future
response.
J
Infect
Public
Health
(2020),
https://doi.org/10.1016/j.jiph.2020.03.014
ARTICLE IN PRESS
G Model
JIPH-1319;
No.
of
Pages
7
2
R.T.
Kamorudeen
et
al.
/
Journal
of
Infection
and
Public
Health
xxx
(2020)
xxx–xxx
Table
1
Mortality
and
Morbidity
Measures
of
Ebola
Outbreak
in
West
Africa
from
2014
to
2016.
Year
Country
Population
Cases
Death
Case
Fatality
Rate,
CFR
(%)
Incidence
Proportion
Per
100,000
2014
*DR
Congo
73,767,447
66
49
74.2
0.09
2014
Nigeria
176,404,902
20
8
40
0.01
2014–2015
Mali
16,934,214
8
6
75
0.04
2014–2016 *Sierra
Leone
7,328,834
14,124
3,956
28
192.7
*Liberia
4,243,000
10,675
4,809
45
251.6
*Guinea
11,738,441
3,811
2,543
66.7
32.5
Key:
*Countries
that
experienced
widespread
transmission.
ulations
[1].
Indeed,
the
predominant
feature
of
an
Ebola
outbreak
is
the
involvement
of
human-to-human
transmission.
Ebolavirus
is
a
genus
of
the
virus
family
Filoviridae.
Six
species
identified
from
the
genus
(ebolavirus)
are-
Zaire
virus,
Bundibugyo
virus,
Sudan
virus,
Taï
Forest
virus,
Reston
virus
and
Bombali
virus.
Of
these
species,
the
Zaire
virus
or
Zaire
ebolavirus
has
been
the
most
fatal
and
most
predominant
in
global
outbreaks
till
date.
Since1976,
when
Ebola
was
first
discovered
in
the
Democratic
Republic
of
Congo,
not
less
than
thirty-eight
outbreaks
have
been
reported
across
the
globe.
Although,
some
outbreaks
are
limited,
in
most
cases
Ebola
outbreaks
are
widespread
[2].
It
is
important
to
know
that
most
Ebola
outbreaks
were
success-
fully
put
under
control
in
a
short
time.
However,
the
2014-2016
Ebola
outbreaks
in
West
Africa
matchlessly
reached
epidemic
pro-
portions
with
more
than
11,000
deaths
recorded
as
a
result
of
rapid
spread,
and
involvement
of
several
countries,
among
other
factors
[2,3].
Indeed,
the
Ebola
outbreaks
across
West
Africa
resulted
in
significant
human
fatalities
(till
date
the
worst
on
record),
and
it
had
a
huge
impact
on
lives
and
livelihoods
of
residents
of
countries
such
as
Guinea,
Liberia,
and
Sierra
Leone,
where
major
outbreaks
occurred.
Those
Ebola
outbreaks
led
to
the
World
Health
Organization
(WHO)
declaration
of
a
Public
Health
Emergency
of
International
Concern
in
2014
that
was
later
ended
in
2016,
albeit,
with
many
cases
subsequently
recorded
and
attributed
to
flare-ups
[3–5].
Although,
many
Ebola
outbreaks
preceded
the
massive
2014-
2016
epidemics
across
West
Africa,
in
a
spatiotemporal
context,
it
is
desirable
to
know
what
really
triggered
its
rapid
spread
across
the
sub-region,
despite
an
awareness
of
what
it
took
to
successful
halt
its
spread
elsewhere
on
the
continent
[2].This
review
takes
a
critical
look
at
some
important
health
determinants
that
may
have
facilitated
the
epidemic
in
contrast
to
previous
outbreaks.
It
utilizes
a
health
determinant
model
(HDM)
consisting
of
both
micro-determinants
(such
as
religious
rites,
health
provider
com-
petency
and
nearness
to
forest)
and
macro-determinants
(such
as
culture
and
tradition,
health
quality
system,
and
port
of
entry
security),
to
further
enhance
the
conceptual
understanding
of
this
important
epidemic.
Most
importantly
and
based
on
lessons
learnt
from
previous
Ebola
outbreaks,
it
offers
useful
recommendations
through
adequate
barriers,
early
and
accurate
diagnosis,
improved
strategic
response
management,
and
preventive
measures
against
its
recurrence
through
adequate
follow-ups
of
survivors.
Outbreaks
of
Ebolavirus
in
Africa:
Epidemic
Timeline
and
Impacts
Ebola
virus
was
first
documented
in
1976,
with
two
concurrent
outbreaks
in
Nzara
town,
South
Sudan
(Sudan
ebolavirus)
and
Yam-
buku
town,
the
neighborhood
of
a
river
called
Ebola
river
in
D.R
Congo(Zaire
ebolavirus).
Following
these
cases,
within
some
weeks
of
the
first
incidence,
about
318
Ebola
cases
were
reported
with
a
fatality
rate
of
88%
[6].
In
1994,
another
52
cases
of
Zaire
ebolavirus
were
reported
in
Mekouka
town,
Gabon,
with
31
deaths
recorded.
In
the
same
year,
one
case
of
new
specie
(Taï
Forest
ebolavirus)
was
recorded
in
Côte
d’Ivoire,
although
it
was
later
successfully
treated.
Overall,
no
less
than
20
Ebola
outbreaks
with
about1,
743
reported
human
cases
were
recorded
in
Africa,
between
1977
and
2014
[2].
However,
an
outbreak
which
began
in
late
2013
(but
spread
widely
between
2014
and
2016)
was
the
largest
and
first
outbreak
that
reached
epidemic
level
and
it
involved
a
few
West
African
countries
(see
Table
1).This
outbreak
was
the
deadliest
and
it
prompted
inter-
national
public
health
concern
by
August
of
2014.
It
resulted
in
over
28,600
laboratory
confirmed
cases
and
nearly
11,300deaths
within
a
short
period
in
the
three
worst
affected
countries
-
Guinea,
Liberia,
and
Sierra
Leone
–and
an
economic
cost
of
about
$4.3billion
US
Dollars[2,7].
Another
report
documented
the
death
of
many
health
workers
in
Guinea,
Liberia
and
Sierra
Leone
[8].
It
is
important
to
mention
that
apart
from
these
epicenters
of
the
disease,
minor
outbreaks
also
occurred
in
other
West
African
countries
including
Nigeria,
Mali
and
Senegal.
Nigeria
recorded
the
first
case
of
Ebola
in
July
2014
when
an
infected
Liberian-American
flew
into
Lagos,
a
highly
populated
city
in
the
southwest
region
of
the
country.
Following
this,
a
nurse
who
attended
to
the
Liberian
later
died
after
contracting
the
disease
[9].
Ebola
briefly
spread
to
other
cities
before
Nigeria
undertook
a
fran-
tic
effort
to
forestall
further
spread.
Altogether,
Nigeria
recorded
8
deaths
out
of
20
cases
of
Ebola.
Four
health
workers
(50%
of
all
infected)
were
among
those
that
succumbed
to
the
infection.
The
effort
at
curtailing
the
spread
of
Ebola
in
Nigeria
was
regarded
as
a
spectacular
success,
according
to
the
WHO’s
representative
who
finally
declared
Nigeria
Ebola
free
in
October
2014,
exactly
4
months
after
the
first
case
was
reported.
Nigeria
became
the
first
African
nation
to
be
officially
confirmed
Ebola
free
[10,11].
Apart
from
Nigeria,
Mali
and
Senegal
also
had
a
few
cases,
8
and
1,
respectively
[2].
Although,
the
2014-2016
Ebola
epidemics
were
initially
believed
to
be
caused
by
Zaire
ebolavirus
[12],
investigations
later
linked
this
outbreak
with
two
viruses,
Sudan
and
Zaire
ebolaviruses
[1].
In
addition,
far
from
West
Africa,
cases
of
Reston
ebolavirus
were
linked
with
monkeys
imported
to
the
United
States
from
the
Philippines
[1].
Even
though,
the
2014-2016
Ebola
epidemics
appears
to
have
fully
put
under
control,
yet
since
2016,
cases
of
Zaire
ebolavirus
have
not
ceased
to
occur.
In
2017,
8
cases
and
4
deaths
of
Ebola
were
reported
in
Likati
town,
D.R
Congo.
Again,
in
201854
cases
and
33
deaths
were
recorded
in
Bikoro,
another
town
in
D.R
Congo.
Worse
still,
during
2019,
Ebola
cases
were
still
being
reported
in
both
D.R
Congo
and
Uganda
despite
several
interven-
tions
by
international
aid
agencies
[2].
Ebola
and
Other
Infectious
Diseases:
Differential
Diagnoses
Ebola
is
commonly
associated
with
high
death
risk
which
is
largely
due
to
the
severity
of
body
fluid
loss
and
dehydration,
lead-
ing
to
hypovolemic
shock
on
account
of
low
blood
pressure.
It
is
noteworthy
that
low
blood
pressure
is
generally
associated
with
clinical
symptoms
such
as
diarrhea
and
vomiting
in
other
infec-
tious
diseases,
like
cholera
[12].
Other
symptoms
of
Ebola
include
fever,
sore
throat,
muscular
pain,
and
headaches
and
these
are
all
common
early
signs
and
symptoms
of
Ebola
(from
first
few
days
up
to
first
three
weeks
after
ebolavirus
infection)
but
are
also
common

Please
cite
this
article
in
press
as:
Kamorudeen
RT,
et
al.
Ebola
outbreak
in
West
Africa,
2014
–
2016:
Epidemic
timeline,
differential
diagnoses,
determining
factors,
and
lessons
for
future
response.
J
Infect
Public
Health
(2020),
https://doi.org/10.1016/j.jiph.2020.03.014
ARTICLE IN PRESS
G Model
JIPH-1319;
No.
of
Pages
7
R.T.
Kamorudeen
et
al.
/
Journal
of
Infection
and
Public
Health
xxx
(2020)
xxx–xxx
3
with
other
health
conditions.
Hence,
it
is
important
to
note
that
body
rash
and
internal
and
external
bleedings
(haemorrhages)
are
important
symptoms
of
EBOV
that
help
to
differentiate
it
clinically
from
other
infectious
diseases,
such
as
meningitis,
malaria,
typhoid
fever,
and
cholera
[12].
Confirmatory
diagnosis
of
early
infection
with
ebolavirus
may
involve
testing
for
viral
RNA
and
assays
for
Ebola-specific
immune
antibodies,
to
urgently
save
the
patient
and
the
public
from
the
spread
of
the
disease.
The
Key
Health
Determinants
Associated
with
High
Mortality
Rate
of
2014-2016
West
African
Ebola
Epidemics
Generally
speaking,
a
number
of
factors
could
determine
the
rapid
spread
of
Ebola
in
several
African
populations.
These
factors
may
include
social
and
economic
factors,
poverty,
malnutrition,
poor
sanitation,
intercurrent
diseases,
individual
health
status,
health
literacy,
and
other
education-related
factors,
among
others.
In
the
2014-2016
West
African
epidemics,
some
of
these
factors
were
peculiar
and
occurred
concurrently
with
others
that
are
well
established,
to
determine
the
transmission,
spread,
and
outcomes
such
as
degree
of
morbidity
and
mortality
rates.
These
factors
can
be
categorized
as
micro-
and
macro-determinants
and
modeled
into
a
conceptual
prism
to
indicate
how
they
interconnect,
for
a
better
understanding
of
the
epidemic
(see
fig.1).
Critical
health
deter-
minants,
which
militated
against
the
control
of
2014-2016
Ebola
outbreaks,
are
discussed
below;
Medical
Attention
and
Government
Policy:
Combinatorial
Effects
Ebola
is
an
emergency
that
requires
quick
and
urgent
reactions.
It
was
in
reverse
that
many
western
African
countries
where
the
epidemics
of
Ebola
struck
really
lacked
rapid
response
and
were
aback
from
the
use
of
adequate
resources
to
combat
the
emergency.
In
addition,
majority
of
these
countries
had
relaxed
immigration
policies
which
worsened
the
spread
across
the
regional
boundaries,
apart
from
common
vector-agent
migration
[2,13].
Nigeria,
though
abundant
in
vector
agents
of
Ebola
never
experi-
enced
any
case
between
1976
and
2014
when
there
were
consistent
records
in
the
neighboring
West
African
countries
[14].The
disease
was
eventually
imported
by
an
infected
individual
who
traveled
from
Liberia,
without
any
evidence
of
adequate
screening
of
his
health
status
at
the
port
of
entry
in
Lagos.
However,
the
public
health
system
involving
Emergency
Operations
Center,
National
Public
Health
Institute
and
Incident
Management
System
had
been
in
place
two
years
before
the
epidemic
of
Ebola
struck.
Nigeria
had
earlier
declared
public
health
state
of
emergency
against
polio,
another
viral
disease,
and
the
structures
and
mechanisms
that
were
in
place
already
were
promptly
activated
in
mitigating
the
spread
of
Ebola
within
the
country
[6,13].In
other
words,
rapid
health
inter-
ventions,
healthcare
quality,
political
commitment,
operational
and
strategic
changes
helped
Nigerian
public
health
system
with
Emergency
Operation
Centers
and
Incident
Management
System,
among
others,
and
greatly
contributed
to
the
rapid
response
to
Ebola
and
its
effectiveness.
This
limited
the
epidemic
to
twenty
cases,
as
established
from
the
laboratory
results
of
confirmatory
tests
performed
on
the
suspected
victims
(Table
1).
In
addition,
it
restricted
the
increase
and
spread
of
the
virus
due
to
stable
pub-
lic
health
institutions,
apart
from
the
rapid
interventional
method
[13].
Notwithstanding,
the
epidemic
itself
was
not
without
any
consequence.
Despite
the
apparent
quality
health
and
rapid
inter-
vention,
apprehension
of
Ebola
led
to
misconceptions
in
some
parts
of
the
country.
The
fear
of
Ebola
and
poor
health
education
resulted
in
various
health
problems
and
challenges,
down
to
self-prescribed
preventive
measures
such
as
the
drinking
and
bathing
with
salty
water,
among
others
[15].It
was
indeed
an
aftermath
of
the
Ebola
threat
that
predisposed
many
Nigerians
to
hypertension,
cardiac
challenges,
and
kidney
problems,
and
worsened
the
plight
of
those
that
were
on
dialysis.
Furthermore,
many
Nigerians,
particularly
those
residents
in
the
rural
areas,
failed
to
adhere
to
government
and
expert
recommendations
against
contracting
the
disease,
even
though
public
campaigns
were
intense.
In
contrast
to
the
health
systems
in
Nigeria,
those
in
some
other
western
African
countries
including
Sierra
Leone,
Liberia
and
Guinea,
were
inadequate
and
the
few
functional
health
sys-
tems
that
were
crucial
to
preventing
the
spread
of
Ebola
failed
to
perform
optimally.
Health
workers,
particularly
the
skilled
ones,
were
also
insufficient
in
number
[16].
Government
infrastructure,
government-enforced
quarantine,
health
record,
and
drug
supply
were
practically
inadequate
[16].
In
addition,
government
response
which
was
expected
to
be
central
to
reducing
the
rate
of
transmis-
sion
and
preventing
the
spread
of
Ebola,
was
weak
in
many
West
African
countries
[17,18].
An
important
micro-determinant
of
the
rapid
and
extensive
spread
of
Ebola
in
West
Africa
was
the
occurrence
of
the
infection
in
medical
settings.
Such
infections
otherwise
termed
nosocomial
infections
were
largely
due
to
failures
in
established
procedures
of
infection
control
and
breach
of
standard
barrier
precautions[19,20],
attributable
to
poor
safety
orientation,
inexperience
and
lack
of
skilled
workers,
and
poor
financing
of
healthcare
systems
and
infrastructure.
These
inadequacies
may
be
attributed
to
poor
gov-
ernment
policies,
poor
medical
attention,
and
weak
economic
state
of
almost
all
of
the
affected
countries
(Fig.
1).
Social
factors
Social
factors,
such
as
culture,
tradition,
and
occupational
hazard
also
played
significant
roles
in
the
spread
of
2014-2016
Ebola
out-
breaks
in
West
Africa.
According
to
a
report,
many
people
through
attendance
of
funerals
in
Sierra
Leone
contracted
the
disease
and
helped
in
the
spread
to
their
families
and
friends
[21].
Similarly,
in
Guinea,
traditional
burial
method
which
is
a
common
practice
in
which
dead
bodies
are
washed
and
touched
unprotected
or
some-
times
unsuitably
protected,
resulted
in
the
spread
of
Ebola
and
the
high
death
rates
recorded[22].
The
modern
practice
of
embalm-
ment
of
corpses
could
also
have
contributed
to
the
spread
of
Ebola
in
parts
of
West
African
countries
[23].
Occupational
risks
also
con-
tributed
to
the
increased
Ebola
mortality
rate
and
was
the
main
risk
of
transmission
of
the
virus
to
healthcare
workers
who
attended
to
Ebola
patients
[23].The
imported
case
of
Ebola
in
Nigeria
was
first
transmitted
by
the
attending
nurse
who
later
died
[11].
It
is
believed
that
some
occupations
are
more
contributory
to
the
transmission
than
the
other.
Although,
the
risk
becomes
higher
when
proper
use
of
the
protective,
such
as
gloves,
masks,
and
eye-protection
is
disregarded,
as
was
the
situation
in
many
of
the
African
countries
where
the
disease
struck
[24].
In
other
words,
one
may
conclude
that
social
factors
including
occupational
hazard
and
safety
failures
involving
the
use
of
personal
protective
equipment
were
instru-
mental
to
the
rapid
and
widespread
transmission
of
Ebola
in
West
Africa,
2014-2016
(Fig.
1).
Seasonal
and
Climatic
Factor
It
has
been
reported
that
the
annual
dry
season,
which
runs
between
December
to
May
(longest
period
of
the
year)
is
a
breeding
season
for
fruit
bats,
a
reservoir
of
ebolavirus
with
high
poten-
tial
to
replicate
and
thus
enhances
transmission
[25].An
increase
in
the
number
of
bats
(species)
is
said
to
influence
viral
load
and
interspecies
fighting
which
may
both
enhance
viral
transmission.
It
is
believed
that
a
favourable
climate
indirectly
leads
to
more
spillovers
from
swarming
Ebola
reservoirs
and
may
also
force
inter-

Please
cite
this
article
in
press
as:
Kamorudeen
RT,
et
al.
Ebola
outbreak
in
West
Africa,
2014
–
2016:
Epidemic
timeline,
differential
diagnoses,
determining
factors,
and
lessons
for
future
response.
J
Infect
Public
Health
(2020),
https://doi.org/10.1016/j.jiph.2020.03.014
ARTICLE IN PRESS
G Model
JIPH-1319;
No.
of
Pages
7
4
R.T.
Kamorudeen
et
al.
/
Journal
of
Infection
and
Public
Health
xxx
(2020)
xxx–xxx
Fig.
1.
A
Model
of
Eight
Cardinal
Health
Determinants
Associated
with
Epidemic
of
Ebola
Outbreak
in
West
Africa
from
2014
to
2016.
(A:
Determinant
categories;
B:
Macro-determinants;
C:
Micro-determinants).
Fig.
2.
Effect
of
Climatic
Changes
and
Human
Activities
on
Ebolavirus
Transmission.

Please
cite
this
article
in
press
as:
Kamorudeen
RT,
et
al.
Ebola
outbreak
in
West
Africa,
2014
–
2016:
Epidemic
timeline,
differential
diagnoses,
determining
factors,
and
lessons
for
future
response.
J
Infect
Public
Health
(2020),
https://doi.org/10.1016/j.jiph.2020.03.014
ARTICLE IN PRESS
G Model
JIPH-1319;
No.
of
Pages
7
R.T.
Kamorudeen
et
al.
/
Journal
of
Infection
and
Public
Health
xxx
(2020)
xxx–xxx
5
action
of
the
bats
with
other
wildlife
species,
especially
under
high
forage
and
wildlife
distributions
[25].
Ebola
is
mainly
found
within
10◦equator
where
the
climatic
condition
in
conjunction
with
other
factors,
favoured
the
intensity
of
spread
of
the
virus
from
2014
to
2016[26].
Another
factor
is
human
activities
such
as,
deforestation.
Habitat
destruction
through
human
activities
such
as
tree
felling,
bush
clearing
and
burning,
could
lead
to
the
wider
dispersion
of
wildlife
reservoirs
of
Ebola.
This
coupled
with
the
usual
practice
of
hunting
of
wildlife
animals(Fig.
2).
Physical
Environment
Physical
environment
is
an
important
determining
factor
in
the
spread
of
ebolavirus.
It
may
include
closeness
of
residential
sites
to
the
harbouring
forest
where
wildlife
with
potential
influence
of
transmission
are
located.
Aside
from
location
as
a
determinant
of
Ebola
transmission,
residential
quality
is
a
possible
enabling
deter-
minant
for
the
spread
of
ebolavirus
(Fig.
1).
It
is
reported
that
poor
structural
housing
quality,
poor
access
to
safe
water,
overcrowding,
sanitation,
and
insecure
residential
status,
among
other
infrastruc-
tural
inadequacies
are
favourable
stimuli
for
transmission
of
Ebola.
Again,
data
shows
that
outbreaks
of
Ebola
took
place
in
rural
and
among
the
geographically
isolated
populations
riddled
in
poor
res-
idential
quality
[27].
In
addition,
interaction
or
closeness
with
animals,
such
as;
animal
petting
and
domestication
are
possible
ways
for
animal-to-
human
transmission.
Also,
most
times,
different
animals
are
found
in
the
farm
feeding
on
agricultural
products
and
transmit
the
virus
on
leftovers.
Although,
there
is
a
debate
whether
ebolavirus
can
be
transmitted
through
food,
ebolavirus
can
spread
through
inges-
tion
of
fruit
already
contaminated
with
ebolavirus-infected
saliva
or
faeces
of
the
reservoirs.
Thus,
some
habits
of
local
food
process-
ing
or
preservation
such
as
open
silos
method
or
traditionally
store
silage
in
the
rural
areas
could
be
a
potential
route
of
transmission
(Fig.
1).
In
addition,
fruit
bat
spillovers
could
also
be
a
different
route
in
transmitting
the
virus
to
other
wildlife
species
(such
as
duiker,
nonhuman
primates)
or
even
humans
[28].
Health
Status
and
Human
Biology
Human
biology
and
nutritional
status
are
two
important
deter-
minants
that
may
determine
the
transmission
of
Ebola.
It
is
understood
that
ebolavirus
may
remain
protected
from
host
immu-
nity
in
the
body
by
penetrating
immune-priviledged
sites.
In
this
way,
some
organs
including
testicles,
eyes,
fetus,
placenta,
among
others,
are
immune-protected,
and
thus
referred
to
as
immune-
privileged
in
the
body.
In
other
words,
this
means
that
they
tolerate
any
inflow
of
antigens
without
eliciting
immune
response.
This
pathway
is
an
opportunity
for
ebolavirus
antigen
to
be
free
from
host
immunity
and
may
be
the
reason
why
semen
of
male
patients
suffering
from
Ebola
may
subject
them
to
high
risk
of
transmission
of
the
virus
after
recovery
[29].
In
addition,
report
(after
follow-up)
from
the
2014
Ebola
epi-
demic
establishes
that
survivors
who
recover
can
harbour
the
viral
RNA
in
their
semen
for
minimum
of
2.5
years,
with
high
chance
of
transmitting
the
virus
by
sexual
intercourse
during
that
time[30].
This
brings
Ebola
to
the
limelight
of
sexually
transmission
diseases.
Keita
and
coworkers
[31]
reported
that
in
Guinea,
many
survivors
of
Ebola
were
found
with
persistence
of
the
viral
RNA
in
semen
(men)
and
breast
milk
(female)
after
several
months.
Individual
risk
behaviour
Unfortunately,
sexual
violence
and
exploitation
are
common
habits
that
pose
high
risk
of
transmission
in
the
three
major
coun-
tries
(Guinea,
Liberia
and
Sierra
Leone)
with
reported
widespread
cases
[32,33].
Sexual
exploitative
relationship
is
a
common
basic
means
of
survival
among
many
people
including
the
refugees
for
a
long
period
of
time,
and
it
involves
many
agency
staff
like
NGO’s
workers.
This
is
grossly
attributed
to
poverty,
and
lack
of
livelihood
option
to
survive.
According
to
a
report
through
a
sexually
exploited
woman
in
Guinea,
indiscriminate
sexual
involvement
has
no
ugly
meaning.
Likewise
in
Liberia,
another
place
with
rampant
spread
of
Ebola,
sex-for-money
activities
are
common
practices
[32].
Strong
association
between
Ebola
transmission
and
sexual
behaviour
has
been
reported
[33,34].
Therefore,
there
is
indication
that
persistent
recurrence
of
Ebola
in
some
of
these
notable
West
African
countries
could
be
as
a
result
of
viral
persistence
and
sexual
risk
behaviour.
Conclusion
It
is
very
obvious
that
many
factors
mitigated
against
the
control
of
2014-2016
Ebola
epidemic,
involving
poverty,
failed
government
policies,
individual
risk
behaviours,
poor
health
system,
among
oth-
ers.
In
the
hardest
hit
countries,
the
situation
went
downheartedly
evoking
economic
impacts
in
spite
of
many
international
aids
for
logistic
supplies
and
other
response
activities.
Unfortunately,
today
Ebola
outbreak
remains
unabated
in
some
of
these
affected
coun-
tries,
although
with
limited
cases.
Importantly,
evidences
show
that
Ebola
is
a
sexually
transmitted
disease
and
tend
to
persist
long
among
the
survivors,
even
after
recovery,
thus
the
chance
of
re-transmission
is
still
highly
probable
especially
with
indiscrim-
inate
sexual
activities.
It
is
therefore
important
for
every
country
involved
to
focus
inwards
on
some
health
determinants
associated
with
Ebola
outbreak
in
other
to
eradicate
the
disease
and
to
prevent
future
recurrence.
Recommendations
From
the
previous
lessons
of
outbreaks
in
West
African
coun-
tries,
some
health
determining
factors
may
need
to
be
addressed,
to
finally
put
the
continual
outbreak
of
Ebola
to
rest.
I
As
a
policy
tool
and
an
important
check-up,
screening
of
immi-
grant
health
status
with
detailed
health
condition
should
not
be
taken
for
granted
before
visa
approval,
especially
in
an
Ebola-free
zone,
not
even
within
the
region
where
visa
is
abolished.
It
is
believed
that
a
detailed
health
screening
plan
will
prevent
importation
of
deadly
disease
agents.
Some
viral
diseases
including
Ebola,
COVID-19,
and
others
have
become
global
health
threats
and
causes
for
concern
with
high
risk
of
morbidity
and/or
mortality
rates
through
contact
transmis-
sion.
Thus,
enforcing
immigration
regulation
on
detailed
health
screening
policy
will
prevent
case
importation
and
forestall
epidemic
especially
through
the
port
of
entry.
II
Apart
from
enforcing
immigration
regulation,
physical
envi-
ronment
favouring
the
transmission
of
Ebola
in
West
African
sub-regions
is
an
important
factor
to
handle
properly.
In
many
areas,
where
there
are
flocks
of
vector-agent
reservoirs
in
the
neighbourhood,
ecological
interventions
may
be
con-
sidered
necessary
to
check
and
manage
zoonotic
pathogen
spillovers.
This
may
be
achieved
if
the
habitat
is
precondi-
tioned
unfavourable
for
the
reservoirs
and
by
disconnecting
the
food
chain,
particularly
against
the
fruit
bats
that
are
com-
mon
host
for
many
viral
pathogens,
to
prevent
spillovers
and
transmission
to
other
wildlife
species.
III
Also,
to
foster
the
degree
of
preparedness
and
prevention
con-
trol,
vaccination
is
an
important
measure
that
should
be
made
available,
especially
in
the
prone
areas
where
media
campaign
and
other
awareness
programs
may
not
totally
prevent
human
risk
behaviours.
Likewise,
funding
of
research
on
emerging

Please
cite
this
article
in
press
as:
Kamorudeen
RT,
et
al.
Ebola
outbreak
in
West
Africa,
2014
–
2016:
Epidemic
timeline,
differential
diagnoses,
determining
factors,
and
lessons
for
future
response.
J
Infect
Public
Health
(2020),
https://doi.org/10.1016/j.jiph.2020.03.014
ARTICLE IN PRESS
G Model
JIPH-1319;
No.
of
Pages
7
6
R.T.
Kamorudeen
et
al.
/
Journal
of
Infection
and
Public
Health
xxx
(2020)
xxx–xxx
communicable
viral
diseases
of
much
global
concern
includ-
ing
Ebola,
and
other
haemorraghic
fevers
such
as
Lassa
fever,
among
other
relatively
neglected
and
under-reported
diseases,
should
receive
more
attention
in
national
budgets.
IV
In
addition,
pathogens
have
been
reported
to
be
spread
in
the
body
through
massive
lymphohematogenous
dissemination
[35].
Ebolavirus
is
a
blood
borne
pathogen
and
may
as
well
be
disseminated
in
the
same
way.
There
is
high
plausibility
that
body
fluids
may
be
affected
in
Ebola.
Hence,
detailed
studies
of
the
viral
persistence
in
the
vital
body
fluids
such
as
semen
and
breast
milk
will
be
an
important
area
to
explore
to
assess
the
length
of
time
in
shedding
the
virus
and
the
extent
of
detection
of
RNA
in
survivors,
for
preventive
measures.
In
other
words,
neglecting
survivors
after
recovery
may
be
a
ticking
time
bomb
for
resurgence.
More
so,
blood
transfusion
involving
survivors
with
recent
Ebola
experience
should
be
disregarded.
There-
fore,
knowledge
of
viral
persistence
in
the
body
milieu
and
due
follow-ups
after
recovery
are
considered
key
areas
to
prevent
re-explosion
and
recurrent
outbreaks.
V
Moreover,
improvement
on
emergency
preparedness
and
response
operations
are
vital
strategies
to
prevent
spread
of
Ebola
and
many
similar
diseases
of
public
health
concern,
par-
ticularly
when
an
incident
is
recorded.
Of
recent,
reports
show
the
level
of
emergency
preparedness
and
response
operations
in
Nigeria
against
COVID-19
[36]
and
polio
[13],
and
how
this
has
greatly
helped
Nigeria
in
combating
the
spread
of
COVID-
19
through
strategic
response
management
and
improved
technical
and
human
resources.
An
important
area
of
emer-
gency
preparedness
is
provision
of
health
facilities
at
every
quarantine
center.
This
will
greatly
help
in
rapid
response
to
contain
new
case
record.
Similarly,
emergence
of
new
cases
of
Ebola
in
zero-record
areas
should
be
rapidly
restricted
from
spreading
while
contact
tracing
should
be
immediately
acti-
vated.
VI
Furthermore,
interrupting
the
chain
or
transmission
pathways
of
ebolavirus
would
be
an
important
target
to
combat
the
wild
spread
via
preventive
measures
and
surveillance
approaches.
By
blocking
the
portals
of
entry
and
exit
of
the
virus
as
well
as
preventing
contact
with
body
fluid
of
an
infected
patient,
will
help
interrupting
possible
transmission.
VII
In
the
meantime,
Ebola
should
be
treated
as
a
sexually
trans-
mitted
disease
to
prevent
fruitless
efforts
from
preventive
interventions
against
other
routes
of
transmission.
The
knowl-
edge
and
awareness
campaigns
against
indiscriminate
sexual
activities
and
with
adequate
follow-ups
may
prevent
future
resurgence
from
previous
epidemics.
VIII
Finally,
training
and
retraining
of
public
health
and
other
health
practitioners
will
expose
them
to
better
handling.
References
[1]
World
Health
Organization.
Ebola
virus
disease.
Press
release
2018.
(Accessed:
January
11,
2020).
[2]
Centers
for
Disease
Control
and
Prevention
(CDC).
National
Center
for
Emerg-
ing
and
Zoonotic
Infectious
Diseases
(NCEZID),
Division
of
High-Consequence
Pathogens
and
Pathology
(DHCPP),
Viral
Special
Pathogens
Branch
(VSPB);
2019
(Accessed:
02
January,
2020).
[3]
Brown
CS,
Mepham
S,
Shorten
RJ.
Ebola
Virus
Disease:
An
Update
on
Epi-
demiology,
Symptoms,
Laboratory
Findings,
Diagnostic
Issues,
and
Infection
Prevention
and
Control
Issues
for
Laboratory
Professionals.
Clin
Lab
Med
2017;37(2):269–84,
http://dx.doi.org/10.1016/j.cll.2017.01.003.
[4]
Hoenen
T,
Groseth
A,
Falzarano
D,
Feldmann
H.
Ebola
virus:
unravelling
patho-
genesis
to
combat
a
deadly
disease.
Trends
Mol
Med
2006;12(5):206–15.
[5]
Sharma
N,
Cappell
MS.
Gastrointestinal
and
Hepatic
Manifestations
of
Ebola
Virus
Infection.
Dig
Dis
Sci
2015;60(9):2590–603,
http://dx.doi.org/10.1007/
s10620-015-3691-z.
[6]
World
Health
Organization
(WHO).
Ebola
virus
disease
Fact
sheet
N◦103.
2014.
(Accessed:
December
15,
2019).
[7]
International
Development
Research
Center
(IDRC).
Available
at:
https://
www.idrc.ca/en/project/role-social-cultural-and-environmental-factors-
improving-ebola-virus-disease-response-and.
2019.
(Accessed:
02
January,
2020).
[8]
World
Health
Organization
(WHO).
Health
worker
Ebola
infections
in
Guinea,
Liberia
and
Sierra
Leone:
A
Preliminary
Report;
2015.
Available
at:
http://www.
who.int/hrh/documents/21may2015
web
final.pdf.
(Accessed:
December
20,
2019).
[9]
Monica
M.
Ebola
Outbreak:
Nurse
who
Treated
First
Victim
in
Nigeria
Dies.
Nigeria:
The
Guardian;
2014
(Accessed:
January
11,
2020).
[10]
World
Health
Organization
(WHO).
WHO
Declares
Nigeria
Ebola-Free
(Report);
2016
(Accessed:
January
11,
2020).
[11]
World
Health
Organization
(WHO).
Nigeria
is
now
free
of
Ebola
virus
transmis-
sion
(Report);
2014
(Accessed:
January
12,
2020).
[12]
World
Health
Organization
(WHO).
Ebola
virus
disease
(Press
release);
2018.
Available
at:
https://www.who.int/en/news-room/fact-sheets/detail/
ebola-virus-disease.
Updated:
May,
2019.
(Accessed:
January
12,
2020).
[13]
Shuaib
F,
Gunnala
R,
Musa
EO,
Mahoney
FJ,
Oguntimehin
O,
Nguku
PM,
et
al.
Centers
for
Disease
Control
and
Prevention
(CDC).
Ebola
virus
disease
outbreak
-
Nigeria,
July-September
2014.
MMWR
Morb
Mortal
Wkly
Rep
2014;63(39):867–72.
[14]
National
Academies
of
Sciences,
Engineering,
and
Medicine,
Health
and
Medicine
Division,
Board
on
Global
Health,
Forum
on
Microbial
Threats,
2,
The
Outbreak.
Available
from:
https://www.ncbi.nlm.nih.gov/books/NBK401927/,
2016.
[15]
Umeora
OU,
Emma-Echiegu
NB,
Umeora
MC,
Ajayi
N.
Ebola
viral
disease
in
Nigeria:
The
panic
and
cultural
threat.
Afr
J
Med
Health
Sci
2014;13:1–5.
[16]
World
Health
Organization
(WHO).
Global
HealthObservatory,
Geneva
[Inter-
net].
2014.
Available
at:
http://www.who.int/gho/en/
[Accessed:
January
11,
2020].
[17]
Kieny
M,
Evans
DB,
Schmets
G,
Kadandale
S.
Health-system
resilience:
reflections
on
the
Ebola
crisis
in
western
Africa.
Bull
World
Health
Organ
2014;92:850,
http://dx.doi.org/10.2471/BLT.14.149278.
[18]
Government
of
Liberia,
President
Sirleaf
Meets
with
Healthcare
Workers;
Promised
to
Settle
all
Outstanding
Incentives
Beginning
This
Week.
Press
Release
[August
10,
2014.
Accessed:
January
17].
[19]
Kerstiëns
B,
Matthys
F.
Interventions
to
control
virus
transmission
during
an
outbreak
of
Ebola
hemorrhagic
fever:
experience
from
Kikwit,
Democratic
Republic
of
the
Congo,
1995.
J
Infect
Dis
1999;179(Suppl
1):S263–7,
http://
dx.doi.org/10.1086/514320.
[20]
Muyembe-Tamfum
JJ,
Kipasa
M,
Kiyungu
C,
Colebunders
R.
Ebola
outbreak
in
Kikwit,
Democratic
Republic
of
the
Congo:
discovery
and
control
measures.
J
Infect
Dis
1999;179(Suppl
1):S259–62,
http://dx.doi.org/10.1086/514302.
[21]
Gire
SK,
Goba
A,
Andersen
KG,
Sealfon
RS,
Park
DJ,
Kanneh
L,
et
al.
Genomic
surveillance
elucidates
Ebola
virus
origin
and
transmission
during
the
2014
outbreak.
Science
2014;345(6202):1369–72,
http://dx.doi.org/10.1126/
science.1259657.
[22]
Chan
M.
Ebola
virus
disease
in
West
Africa–no
early
end
to
the
outbreak.
N
Engl
J
Med
2014;371(13):1183–5,
http://dx.doi.org/10.1056/NEJMp1409859.
[23]
Centers
for
Disease
Control
and
Prevention
(CDC).
https://www.cdc.gov/media/
releases/2014/t0728-ebola.html,
2014,.
Updated:
July
24,
2014.
[Accessed:
January
11,
2020].
[24]
Salaam-Blyther
T.
The
2014
Ebola
Outbreak:
International
and
U.S.
Response;
2014.
Available
at:
https://reliefweb.int/report/world/2014-ebola-outbreak-
international-and-us-responses.
[Accessed:
January
11,
2020].
[25]
Alexander
KA,
Sanderson
CE,
Marathe
M,
Lewis
BL,
Rivers
CM,
Shaman
J,
et
al.
What
factors
might
have
led
to
the
emergence
of
Ebola
in
West
Africa?
PLoS
Negl
Trop
Dis
2015;9(6):e0003652,
http://dx.doi.org/10.1371/journal.
pntd.0003652.
[26]
Liu
WB,
Li
ZX,
Du
Y,
Cao
GW.
Ebola
virus
disease:
from
epidemiology
to
pro-
phylaxis.
Mil
Med
Res
2015;2:7,
http://dx.doi.org/10.1186/s40779-015-0035-
4.
[27]
Roddy
P,
Howard
N,
Van
Kerkhove
MD,
Lutwama
J,
Wamala
J,
Yoti
Z,
et
al.
Clin-
ical
manifestations
and
case
management
of
Ebola
haemorrhagic
fever
caused
by
a
newly
identified
virus
strain,
Bundibugyo,
Uganda,
2007-2008.
PLoS
One
2012;7(12):e52986,
http://dx.doi.org/10.1371/journal.pone.0052986.
[28]
Leroy
EM,
Epelboin
A,
Mondonge
V,
Pourrut
X,
Gonzalez
JP,
Muyembe-Tamfum
JJ,
et
al.
Human
Ebola
outbreak
resulting
from
direct
exposure
to
fruit
bats
in
Luebo,
Democratic
Republic
of
Congo,
2007.
Vector
Borne
Zoonotic
Dis
2009;9(6):723–8,
http://dx.doi.org/10.1089/vbz.2008.0167.
[29]
Centers
for
Disease
Control
and
Prevention.
Preliminary
study
finds
that
Ebola
virus
fragments
can
persist
in
the
semen
of
some
survivors
for
at
least
nine
months;
2015
(Accessed:
January
12,
2020).
[30]
Bart
SM,
Cohen
C,
Dye
JM,
Shorter
J,
Bates
P.
Enhancement
of
Ebola
virus
infec-
tion
by
seminal
amyloid
fibrils.
Proc
Natl
Acad
Sci
USA
2018;115(28):7410–5,
http://dx.doi.org/10.1073/pnas.1721646115.
[31]
Keita
AK,
Vidal
N,
Toure
A,
Diallo
MSK,
Magassouba
N,
Baize
S,
et
al.
A
40-
Month
Follow-Up
of
Ebola
Virus
Disease
Survivors
in
Guinea
(PostEbogui)
Reveals
Long-Term
Detection
of
Ebola
Viral
Ribonucleic
Acid
in
Semen
and
Breast
Milk.
Pen
Forum
Infect
Dis
2019;6(12),
http://dx.doi.org/10.1093/ofid/
ofz482,
ofz482.
[32]
UNHCR
and
Save
the
Children.
Sexual
violence
and
exploitation
-
The
experi-
ence
of
refugee
children
in
Guinea.
Liberia
and
Sierra
Leone;
2002,
16.
[33]
Lee
H,
Nishiura
H.
Sexual
transmission
and
the
probability
of
an
end
of
the
Ebola
virus
disease
epidemic.
J
TheorBiol
2019;471:1–12,
http://dx.doi.org/10.
1016/j.jtbi.2019.03.022.

Please
cite
this
article
in
press
as:
Kamorudeen
RT,
et
al.
Ebola
outbreak
in
West
Africa,
2014
–
2016:
Epidemic
timeline,
differential
diagnoses,
determining
factors,
and
lessons
for
future
response.
J
Infect
Public
Health
(2020),
https://doi.org/10.1016/j.jiph.2020.03.014
ARTICLE IN PRESS
G Model
JIPH-1319;
No.
of
Pages
7
R.T.
Kamorudeen
et
al.
/
Journal
of
Infection
and
Public
Health
xxx
(2020)
xxx–xxx
7
[34]
Den
Boon
S,
Marston
BJ,
Nyenswah
TG,
Jambai
A,
Barry
M,
Keita
S,
et
al.
Ebola
Virus
Infection
Associated
with
Transmission
from
Survivors.
Emerg
Infect
Dis
2019;25(2):249–55,
http://dx.doi.org/10.3201/eid2502.181011.
[35]
Eziyi
AK,
Oluogun
WA,
Adedokun
KA,
Oyeniyi
GA.
Prostate
tuberculosis:
A
rare
complication
of
pulmonary
tuberculosis
with
malignant
features
mimicking
prostate
cancer.
UrolSci
2020;31:36–8,
http://dx.doi.org/10.4103/UROS.UROS
80
19.
[36]
Mustapha
JO,
Adedokun
KA,
Abdullahi
IN.
Public
health
preparedness
towards
COVID-19
outbreak
in
Nigeria.
Asian
Pac
J
Trop
Med
2020;13,
http://dx.doi.org/
10.4103/1995-7645.279650.