Beruflich Dokumente
Kultur Dokumente
A thesis submitted to
The Postgraduate Academic Board of Studies
University of Public Health, Yangon
for the partial fulfillment of the requirements
for the Degree of Master of Public Health (MPH)
This thesis has been approved and passed by the Board of Examiners.
Chief Examiner
-------------------------------
External Examiner
Co-Examiner
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ACKNOWLEDGEMENTS
ABSTRACT
TABLE OF CONTENTS
Page
ACKNOWLEDGEMENT
ABSTRACT
iii
TABLE OF CONTENTS
iv
LIST OF ABBREVIATIONS
vi
LIST OF TABLES
viii
LIST OF FIGURES
CHAPTER 1 INTRODUCTION
1.1
Background information
1.2
Problem statement
1.3
Justification
12
CHAPTER 3 OBJECTIVES
3.1
General objective
28
3.2
Specific objectives
28
3.3
Research hypothesis
28
3.4
Conceptual framework
29
Study design
30
4.2
Study area
30
4.3
Study period
30
4.4
Study population
30
4.5
31
4.6
Sampling method
31
4.7
Sampling procedure
31
4.8
32
4.9
33
34
CHAPTER 5 FINDINGS
35
CHAPTER 6 DISCUSSION
67
CHAPTER 7 CONCLUSION
83
CHAPTER 8 RECOMMENDATION
85
REFERENCES
ANNEXES
Annex (1)
Annex (2)
Annex (3)
Annex (4)
Scoring system
Annex (5)
Gantt chart
Annex (6)
Curriculum Vitae
LISTS OF ABBREVIATIONS
MOH
- Ministry of Health
WHO
CDC
AFRO
EMRO
DRC
ROC
-Republic of Congo
OHS
EVD
EBOV
-Ebola virus
EHF
MVD
VHF
BDBV
EBOV
RESTV
SUDV
TAFV
GAR
LISTS OF ABBREVIATIONS
IHR
PPE
HCWs
HCPs
NFPs
NHP
-Non-human primates
PHEIC
SARS
SOP
NHL
ELISA
PCR
AST
-Aspartate Aminotransferase
ALT
-Alanine Aminotransferase
PT
-Prothrombin
PTT
DIC
95%CI
ANOVA
-Analysis of Variance
10
LIST OF TABLES
Table
Page
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46
48
48
49
10
49
11
50
12
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51
13
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14
52
15
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17
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20
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21
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59
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28
63
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31
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64
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65
33
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35
Ebola disease
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12
LIST OF FIGURES
Figure
Page
29
31
36
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41
10
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CHAPTER 1
INTRODUCTION
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As of 22nd August 2014, the West African outbreak has resulted in 2615 cases
and 1427 deaths and is unprecedented because it has continued for more than double
the length of time of the largest previous outbreak in Uganda in 2000 (3 months vs. 8
months), has resulted in more than six times as many cases (425 cases vs. 2615 cases),
and has for first time occurred in more than one country simultaneously and in capital
cities (Okware et al., 2002, WHO, 2014). Among the total cases, 1251 have been
laboratory confirmed, and genetic sequencing has showed that the similarity of the
virus to the Zaire EV is 97% (Baize et al., 2014).
Unlike past outbreaks, the current outbreak of EVD has not been contained
and has resulted in social unrest, breakdown in law and order, shortages of personal
protective equipment (PPE) and depletion of the healthcare workforce, with over 240
health care workers (HCWs) becoming infected and 120 HCW deaths as of 25th
August 2014 (WHO, 2014). The inability to contain this outbreak has been blamed
variously on lapses in infection control, shortages of PPE and other supplies, myths
and misconceptions about EVD, and the fact that it is occurring in large cities rather
than small villages.
The risks persons are people exposed to and handling wild animals; people
depending on wild animals such as bats as a food source; mortuary attendants; health
workers caring for EVD patients; health workers in hospital settings with poor basic
hygiene and sanitation practices; family members of an infected patient; people that
go to hospitals with poor hygiene and sanitation practices; (1) avoid contact with the
blood/secretions of Ebola infected animals and humans or dead bodies by: maintain
good hygiene and sanitation practices in hospitals; isolate Ebola infected patients;
dispose of dead bodies of Ebola patients properly in a safe manner and avoid local
traditional burial rituals such as embalming for Ebola patients; (2) health workers and
visitors caring for Ebola patients should:(i) wear proper personal protective equipment
such as disposable face mask, gloves, goggles,(ii) and gown always;(iii) use
disposable needles;(iv) avoid reuse of needles or use of inadequately sterilized
needles; and (v) avoid embalming of a deceased Ebola patient (WHO, 2014).
The current Ebola epidemic among health care workers has presented
challenges both medical and ethical. Although we have known epidemics of
untreatable diseases in the past, this particular one may be unique in the intensity and
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rapidity of its spread, as well as ethical challenges that it has created, exacerbated by
its geographic location (Donovan, 2014).Therefore, everybody especially all health
care personnel must have essential knowledge on transmission and prevention of
Ebola virus and involve in highlights prevention and control activities to fight against
Ebola outbreak.
1.2 Problem Statement
2014 outbreak in West Africa, by far the largest outbreak of Ebola virus
disease ever recorded is currently occurring in West Africa with the Zaire species of
the virus. Although most previous Ebola outbreaks occurred in Central Africa, this
outbreak started in the West African nation of Guinea in late 2013 and was confirmed
by WHO in March 2014. The outbreak subsequently spread to Liberia, Sierra Leone,
Nigeria, and Senegal. Sequence analysis of viruses isolated from patients in Sierra
Leone indicates that the epidemic has resulted from sustained person-to-person
transmission, without additional introductions from animal reservoirs (WHO, 2014).
On August 8 2014, the World Health Organization (WHO) Director-General
Margaret Chan declared the West Africa Ebola crisis a public health emergency of
international concern,1 st triggering powers under the 2005 International Health
Regulations (IHR). The IHR requires countries to develop national preparedness
capacities, including the duty to report internationally significant events, conduct
surveillance, and exercise public health powers, while balancing human rights and
international trade (Lawrence, 2014 & WHO, 2014).
Years of civil unrest and weak development have left West Africa with fragile
health systems as it faces a crisis. Although the director general urged international
solidarity, global governance once again was weakened from a lack of capacity in
developing countries. A sustainable solution to EVD, and other emerging threats,
requires binding commitments for funding and technical assistance to build national
preparedness capabilities, including surveillance, laboratories, health systems, and
rapid response (Lawrence, 2014).
The Ebola outbreak that is ravaging parts of West Africa is the largest, most
severe and most complex in the nearly four-decade history of this disease, Margaret
Chan, World Health Organizations director general, told that by The number of new
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cases is moving far faster than the capacity to treat them. In Geneva, after declaring
the Ebola outbreak in West Africa a global health emergency, the WHO warned on
18th September, 2014 that the disease is still outpacing the international response to
contain.
A total of 18603 confirmed, probable and suspected cases of EVD have been
reported in six affected countries (Guinea, Liberia, Mali, Sierra Leone, Spain and the
United States of America) and two previously affected (Nigeria, Senegal) up to the
end of 17 December 2014 and there have been total mortality 6915 cases. The World
Health Organization (WHO) has estimated the mortality of the current outbreak of
EVD in West Africa to be approximately 55%, but appears to be as high as 75% in
Guinea (CDC, 2014). Over 70% of patients with EVD in Guinea are isolated, while
over 80% of required safe and dignified burial teams are in place, Liberia and Sierra
Leone report that fewer than 70% of patients are isolated, though local variations
mean capacity is still insufficient to stop transmission in some areas. Case incidence is
increasing in Guinea, stable or declining in Liberia, but may still be increasing in
Sierra Leone (WHO, 2014).
1.2.1 Global Situation
With a fast spreading Ebola and threatening all over countries, more can be
done to combat the disease. The Ebola virus has evolved since its first outbreak in
Central Africa. While transmission used to be limited to forested, remote and rural
areas in West Africa, the latest outbreaks are now seen in urban areas. The reported
rapid rate of infection has been caused by the weak and often substandard health
systems in these countries. Since Ebola has similar symptoms to malaria, typhoid
fever and meningitis, effective diagnosis has proven to be a tough challenge. There is
growing concern in Sub-Saharan Africa about the spread of the Ebola virus disease
(EVD), formerly known as Ebola hemorrhagic fever, and the public health burden that
it ensues. Since 1976, there have been 885,343 suspected and laboratory confirmed
cases of EVD and the disease has claimed 2,512 cases and 932 fatalities in West
Africa. There are certain requirements that must be met when responding to EVD
outbreaks and this process could incur certain challenges (Tambo et al., 2014).
The deadly Ebola virus has already killed about 4,000 people in West Africa
since its outbreak earlier this 2014 year. With the alarming rate of infection, despite
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to control the outbreak by closing borders and quarantining some of the worstaffected areas (Green, 2014).Therefore, Ebola disease is still threatening globally and
needed to prepare and alarm to control current outbreak.
1.2.2 Situation in South-East Asia Region
Malaysia, the Philippines and Thailand are the most vulnerable because of
their large migrant population working in the Middle East, only a short plane ride
from West Africa. Moreover, seven of the worlds 10 busiest air routes and air
passengers are in the Asia-Pacific region, accounting for almost 30 per cent of global
air traffic. Because of this, the fear of infection has spread around the world much
faster than the virus itself, according to South East Asia region is in a better position
now to respond to any outbreak, stressing that communication is the first line of
defense. To make a long story short, irrational fear drives health epidemics like severe
acute respiratory syndrome (SARS) and Ebola. That makes communication really the
first line of defense against epidemics like Ebola. Studies tell us that SARS spreads
faster than Ebola because SARS is a flu virus that is spread through the air by
coughing, while the Ebola virus is spread through contact with bodily fluids such as
blood, urine, and saliva and mucous. In short, Ebola does not spread as easily as
SARS and other airborne viruses, and people should not succumb to irrational fears.
The WHO says it has round-the-clock monitoring of the regional and global situation,
and is supporting each country to develop plans to contain the Ebola virus (Anthony
& Amul 2014).
Even Asian countries that have no direct flights to West Africa, and have
limited ties to the region, are wary of being caught off guard. The only thing to fear is
fear itself. This can be overcome with effective communication, which experts call by
a more technical term: risk communication, defined as communicating threats to
society like terrorism and epidemics. Risk communication involves identifying the
risks, how the public processes the risks, involves the community in disseminating
preparedness messages, and provides specific response strategies(SciDev.Net, 2014).
As Ebola continues to play global hopscotch, Asian countries are seeking to make
good on the advanced notice that the deadly Ebola virus could turn up anywhere,
anytime.
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Asian nations also have an edge in that they have been through epidemics
before: SARS tore through the West Pacific in 2003, killing almost 800 people
worldwide, mostly in Hong Kong and mainland China. Avian flu also pummeled this
area around the same time, and outbreaks of virulent influenza strains perennially
menace the region. Still, Asia has some advantages as it readies itself for Ebola. Flight
patterns suggest that the influx of travelers from Ebola-stricken West African
countries to the Asian continent is far less than it is to Africa, Europe or North
America (Barber, 2014). Governments in South-east Asia are increasingly on the alert
as Ebola spreads beyond West Africa, though the consensus is that the region is at
"low-risk" of catching the virus.
East and Central Africa and South and Southeast Asia focus on: (i) viral
detection-identification of viruses in wildlife, livestock, and human populations that
may be public health threats;(ii) risk determination-characterization of the potential
risk and method of transmission for specific viruses of animal origin;
institutionalization of a one health approach-integration of a multi-sector approach
to public health (including animal health and environment);(iii) outbreak response
capacity-support for sustainable, country-level response to include preparedness and
coordination; and (iv) risk reduction-promotion of actions that minimize or eliminate
the potential for the emergence and spread of new viral threats (Salaam-Blyther,
2014).
1.2.3 Situation in Myanmar
In Myanmar, a 22-year-old local man was taken to hospital in Yangon after
arriving home from Africa via Bangkok on the night of August 19, 2014. Myanmar
Centre for Disease Control (CDC) and Prevention said in a statement on its official
media. It said he is believed to have returned from Guinea, having also travelled to
Liberia. He was transported from Yangon International Airport to Waibargi Hospital
in North Okkalapa Township and placed in isolation. He had spent the previous 13
months working in Guinea and Liberia, two countries hit hardest by the ongoing
Ebola outbreak. He arrived at the airport with a fever and had lost consciousness
while he was travelling (Pandey, 2014).
Ministry of Health, Myanmar (MOH) confirmed that no Ebola virus was
found in the patient after a series of blood tests at Yangons Waibagi Hospital were
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Myanmar, which began emerging from harsh junta rule in 2011, has one of the
worlds worst funded and poorly equipped healthcare systems, with many people cut
off from even basic medical help (The Sunday times, 2014). Many people there do not
even have access to basic medical care. Ebola is spread through direct contact with
the bodily fluids of sick patients, making doctors and nurses especially vulnerable to
contracting the virus that has no vaccine or approved treatment. During the outbreak,
the highest risks persons are health workers. Therefore, this study was conducted and
assessed the knowledge and perceptions towards Ebola disease among health care
workers especially nurses in Myanmar.
1.3 Justification
Ebola, global public health problem is an infectious and generally fatal
disease; fatality rates are between 50% and 100% (Adrian et al., 2011). The 2014
Ebola outbreak is one of the largest Ebola outbreaks in history and the first in West
Africa. Health care workers (HCWs), many of whom are nurses, are on the frontline
of the response, and their occupational health and safety is critical to control of the
outbreak and maintenance of the health workforce during a crisis. Nowadays, healthcare workers have frequently been infected while treating patients with suspected or
confirmed Ebola virus disease. This has occurred through close contact with patients
when infection control precautions are not strictly practiced, making doctors and
nurses especially vulnerable to contracting the virus that has no licensed vaccine or
approved treatment. WHO guidance with standard healthcare precautions, HCWs
should apply infection control measures to minimize exposure to infected fluids.
Therefore, the highest risk persons are HCWs who may face to fight Ebola threats by
treating and provision of care of patients.
Nurses were fearful for their own lives, their families lives; they lacked
protective gear, had few resources, families and colleagues shunned them but they
remained committed to their profession. As they had some biomedical training and
knowledge, which made them feel somewhat less vulnerable, they wanted to use this
knowledge to try to stop a rapid killing disease. Nurses expressed the importance of
knowledge because with knowledge, stigmatization decreased and cooperation
increased. Knowledge enabled them and other national and international health care
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workers to feel secure and provide assistance in spite of being surrounded by their
own and others fears (Hewlett, 2005).
Moreover, health care system in affected countries have been suffered scarce
resources such as health personnel and health facilities that it has been still burden and
can not be used efficiently and effectively to control outbreak. Not only West Africa
but also Western countries, these conditions are threatening South East Asia countries
in the world including Myanmar where one suspected case of Ebola was detected in
this period of time. In fact, it still needed to combat Ebola outbreak so everybody
especially health care workers must have essential knowledge, perception and practice
to combat Ebola outbreak. There is currently a gap to assess the essential knowledge
and perceptions to highlights on how to prevent and control Ebola among general
population as well as health personnel. Health care workers are more prone to highly
fatal and seriously infectious than general population. So, they should have adequate
knowledge and perception towards Ebola disease to fight against Ebola disease. Up to
date, there are not enough previous studies and relevant researches and literatures
about Ebola disease and then few literature reviews in other countries were conducted
and assessed about it.
In Myanmar, but amount of scientific researches and studies are still needed to
combat Ebola disease efficiently following International Health Regulation guidelines
as Ebola disease is threatening in there. So this study will support and benefit to the
plans of emerging and remerging disease and prevention and control program in near
future. On the other hand, this study will also support reliable and scientifically sound
data for next studies. And then there is an opportunity is provided within which to
learn valuable information in how to deal more effectively with disease control.
Furthermore, this study was done in nurses, who should also have been
essential knowledge and perception towards Ebola outbreak. Those nurses or nursing
students (Bridge Course) at University of Nursing, Yangon, who have backgrounds
clinical or public health experiences before university students life. Moreover all of
them had got nursing diploma as they are government employee. Besides that, they
came from various stages of hospitals and health centers all over Myanmar in fact that
this study have been highlighted and usefully contributed to information gathering
and disseminating to other health care workers and people in Myanmar about the
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CHAPTER 2
LITERATURE REVIEW
Ebola virus (EV) is a filovirus which causes viral haemorrhagic fever (VHF)
in humans (WHO, 2014). Ebola virus disease (EVD) is a severe, often fatal disease
that was first detected near the Ebola River in the Democratic Republic of the Congo
(DRC) in 1976. Originating in animals, EVD is spread to and among humans through
contact with the blood, secretions, organs, or other bodily fluids of those infected. It is
not transmitted through the air. The Ebola virus that is circulating in West Africa is
not new, but the current Ebola outbreak has infected and killed more people than all
previous Ebola outbreaks combined. Since then, outbreaks have appeared sporadically
in several African countries. The Filo virus family includes three genera: Ebola virus,
Marburg virus, and Cueva virus (newly discovered in Spanish bats). There are five
strains of Ebola virus but the Zaire strain is the most severe, with a case-fatality rate
up to 90%. The Ebola virus genus includes 5 species: Reston virus (RESTV), Sudan
virus (SUDV), Ebola virus (EBOV; formerly Zaire virus), Tai Forest virus (TAFV;
formerly CotedIvoire virus), and Bundibugyo virus (BDBV) (WHO, 2014).
Mortality rates of up to 80% were recorded and more recent outbreaks in
Democratic Republic of Congo (DRC, formerly Zaire) and Gabon in 19951996.
Epidemiologic data from recent outbreaks indicate that close contact is necessary for
efficient transmission of Ebola virus from one individual to another. Little genetic
difference has been detected between Ebola-Zaire viruses isolated 20 years apart and
from locations over 1,000 km from one another, suggesting that ecological rather than
genetic factors may play the dominant role in initiation of Ebola hemorrhagic fever
outbreaks (Nicho, 1998).
Ebola hemorrhagic fever (EHF) is an acute viral syndrome that presents with
fever and an ensuing bleeding diathesis that is marked by high mortality in human and
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nonhuman primates. Fatality rates are between 50% and 100%. Due to its lethal
nature, this Filo virus is classified as a biological class 4 pathogen. Since there is no
specific treatment outside of supportive management and palliative care, containment
of this potentially lethal virus is paramount. In almost all outbreaks of EHF, the
fatality rate among health care workers with documented infections was higher than
that of nonhealth care workers (Adrian et al., 2011).
2.1 Mode of Transmission
Ebola is introduced into the human population through close contact with the
blood, secretions, organs or other bodily fluids of infected animals. In Africa,
infection has been documented through the handling of infected chimpanzees,
gorillas, fruit bats, monkeys, forest antelope and porcupines found ill or dead or in the
rainforest. Health-care workers have frequently been infected while treating patients
with suspected or confirmed EVD (WHO, 2014).
Ebola virus disease could be spread through the following: direct contact with
an infected animal or human; direct contact with the blood and or secretions of an
infected person especially within families; contact with contaminated medical
equipment such as needles; reuse of unsterilized needles in hospital; eating or
handling of the carcass of infected animals; inhalation of contaminated air in hospital
environment; use of infected non human primate/bats as food source; and non
implementation of universal precautions. Burial ceremonies in which mourners have
direct contact with the body of the deceased person can also play a role in the
transmission of Ebola. Men who have recovered from the disease can still transmit the
virus through their semen for up to 7 weeks after recovery from illness (CDC, 2014).
Job-specific attack rates estimated for Kikwit General Hospital, the epicenter
of the EHF epidemic, were 31% for physicians, 11% for technicians/room attendants,
10% for nurses, and 4% for other workers. Among 402 workers who did not meet the
EHF case definition, 12 had borderline positive antibody test results; subsequent
specimens from 4 of these tested negative. Although an old infection with persistent
Ebola antibody production or a recent atypical or asymptomatic infection cannot be
ruled out, if they occur at all, they appear to be rare. This survey demonstrated that
opportunities for transmission of Ebola virus to personnel in health facilities existed in
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Kikwit because blood and body fluid precautions were not being universally followed
(Oyewale, 1995 & Tomori et al., 1999).
A retrospective descriptive survey of hospital records for hospitalized children
and adolescents under 18 years on the isolation wards in Gulu, Northern Uganda was
conducted. Analysis revealed that 90 out of the 218 national laboratory confirmed
Ebola cases were children and adolescents with a case fatality of 40%. The mean age
was 8.2 years SD 5.6 with a range of 16.99 years. All (100%) Ebola positive
children and adolescents were febrile while only 16% had hemorrhagic
manifestations. Similar to previous Ebola outbreaks, a relative sparing of children in
this outbreak was observed. The under fives were at an increased risk of contact with
the sick and dying. Strategies to shield children from exposure to dying and sick
Ebola relatives are recommended in the event of future Ebola outbreaks. Health
education to children and adolescents to avoid contact with sick and their body fluids
should be emphasized (Mupere et al., 2001).
2.2 Clinical Presentation and Clinical Course
Patients with EVD generally have abrupt onset of typically 8-10 days after
exposure (mean 4-10 days in previous outbreaks, range 2-21 days). Initial signs and
symptoms are nonspecific and may include fever, skin rashes, chills, myalgias, and
malaise. Fever, anorexia, asthenia/weakness are the most common signs and
symptoms. Patients may develop a diffuse erythematous maculopapular rash by day 5
to 7 (usually involving the face, neck, trunk, and arms) that can desquamate (Casillas
et al., 2003 & CDC, 2014).
Due to these nonspecific symptoms particularly early in the course, EVD can
often be confused with other more common infectious diseases such as malaria,
typhoid fever, meningococcemia, and other bacterial infections (e.g., pneumonia).
Patients can progress from the initial non-specific symptoms after about 5 days to
develop gastrointestinal symptoms such as severe watery diarrhea, nausea, vomiting
and abdominal pain. Other symptoms such as chest pain, shortness of breath,
headache or confusion, may also develop. Patients often have conjunctival injection.
Hiccups have been reported. Seizures may occur, and cerebral edema has been
reported. Bleeding is not universally present but can manifest later in the course as
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and the surrounding area. The difference in the overall prevalence of EHF antibodies
may indicate that villagers have a greater chance of exposure to EHF virus compared
with those living in and in close proximity to cities (Kristina et al., 1995).
2.5 Preventive Measures
Health-care workers caring for patients with suspected or confirmed Ebola
virus should apply, in addition to standard precautions and other infection control
measures. When in close contact (within 1 meter) of patients with EBV, health-care
workers should wear face protection (a face shield or a medical mask and goggles), a
clean, non-sterile long sleeved gown, and gloves (sterile gloves for some procedures)
and should frequently perform hand hygiene before and after patient contact, contact
with potentially infectious material, and before putting on and after removing PPE,
including gloves. Laboratory workers are also at risk. Samples taken from suspected
human and animal Ebola cases for diagnosis should be handled by trained staff and
processed in suitably equipped laboratories. Additionally, certain job responsibilities
and tasks, such as attending to dead bodies, may also require different personal
protective equipments (PPE) than what is used when providing care for infected
patients in a hospital. A person infected with Ebola is not contagious until symptoms
appear (WHO, 2014).
In studies, facemasks have been recommended for HCWs by CDC and WHO
because of the assumption that EV is not transmitted via the airborne route. However,
there is uncertainty about transmission, the consequences of EVD infection are
severe, and there is no proven treatment, vaccine or post-exposure prophylaxis.
Recommending a surgical mask for EVD has much more serious implications than for
influenza, which has a far lower case-fatality rate and for which there are easily
accessible vaccines and antiviral therapy. Further, numerous HCWs have succumbed
to EVD during this epidemic, including senior physicians experienced in treating
EVD and presumably less likely to have suffered lapses in infection control (WHO,
2014).
Moreover, a clear description of risk should be provided to HCWs (Jackson et
al., 2014). Given the predominant mode of transmission, every HCW death from
Ebola is a potentially preventable death. It is highly concerning that a recent
commentary suggests HCWs do not need a mask at all to speak with conscious
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Ebola remains supportive therapy. This includes the following measures: balancing
the patients' fluids and electrolytes; maintaining their oxygen status and blood
pressure; and treating them for any complicating infections. The manufacturer of this
experimental treatment continues to research and evaluate the products safety and
effectiveness and much more study is needed (CDC, 2014).
Information is presented that is needed to educate patients and to protect
oneself, staff, and other patients in the event a patient with suspected Ebola presents
for medical care. A screening tool is provided, as well as a concise method to
eliminate differential diagnoses related to this dreaded disease. Diagnostic testing and
initial treatment requirements are outlined. In the event a patient presents to primary
care, guidance is given for initial steps and precautions necessary to contain and
manage a patient with Ebola (Jarrett, 2014).
2.6 Infection Control Measures
Ebola viruses can survive in liquid or dried material for a number of days.
However, Ebola virus can be inactivated by UV radiation, gamma irradiation, heating
for 60 minutes at 60 C or boiling for five minutes. The virus is susceptible to sodium
hypochlorite and disinfectants. Freezing or refrigeration will not inactivate Ebola
virus. Ebola virus is easily killed by soap, bleach, sunlight, or drying. Machine
washing clothes that have been contaminated with fluids will destroy Ebola virus.
Ebola virus survives only a short time on surfaces that are in the sun or have dried
(CDC, 2014).
In addition, the availability of pre- and post-exposure prophylaxis or treatment
must be considered. The immune status and co-morbidities in HCWs should also be
considered, as some HCWs may be innately more vulnerable to infection. As the
ageing of the nursing workforce occurs in developed countries, there is likely to be a
high proportion of HCWs with chronic conditions. In this case, facemasks have been
recommended for HCWs by Center of disease control and prevention (CDC) and
WHO because of the assumption that Ebola virus disease (EVD) is not transmitted via
the airborne route. However, there is uncertainty about transmission, the
consequences of EVD infection are severe, and there is no proven treatment, vaccine
or post-exposure prophylaxis.
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Keep the regulatory authorities (e.g. national civil aviation authority) informed
and involved in decision-making.
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blood or body fluids. If you stayed in the areas where Ebola cases have been recently
reported seek medical attention if you feel sick (fever, headache, achiness, sore throat,
diarrhea, vomiting, stomach pain, rash, or red eyes) (Africa, 2014).
If you are in or traveling to an area affected by the Ebola outbreak, protect
yourself by doing the following: wash hands frequently, avoid contact with blood and
body fluids of any person, particularly someone who is sick, do not handle items that
may have come in contact with an infected persons blood or body fluids, do not
touch the body of someone who has died from Ebola, do not touch bats and
nonhuman primates or their blood and fluids and do not touch or eat raw meat
prepared from these animals, avoid hospitals where Ebola patients are being treated,
seek medical care immediately if you develop fever (temperature of 101.5 F/ 38.6 C)
and any of the other following symptoms: headache, muscle pain, diarrhea, vomiting,
stomach pain, or unexplained bruising or bleeding and limit your contact with other
people until and when you go to the doctor. Do not travel anywhere else besides a
healthcare facility (WHO, 2014).
Any hospital that is following CDCs infection control recommendations and
can isolate a patient in their own room with a private bathroom is capable of safely
managing a patient with Ebola. These patients need intensive supportive care; any
hospital that has this capability can safely manage these patients. Standard, contact,
and droplet precautions are recommended. CDC is providing information to partners,
such as Customs and Border Protection and airlines, on signs and symptoms to look
for in travelers arriving from Ebola outbreak-affected countries that should be
reported to CDC quarantine station staff. Advance notice will help your doctor care
for you and protect other people who may be in the office (CDC, 2014).
WHO provides technical advice to countries and communities to prepare for
and respond to Ebola outbreak. WHO actions include: disease surveillance and
information-sharing across regions to watch for outbreaks; technical assistance to
investigate and contain health threats when they occur such as on-site help to identify
sick people and track disease patterns; advice on prevention and treatment options;
deployments of experts and the distribution of health supplies (such as personal
protection gear for health workers) when they are requested by the country;
communications to raise awareness of the nature of the disease and protective health
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measures to control transmission of the virus; and activation of regional and global
networks of experts to provide assistance, if requested, and mitigate potential
international health effects and disruptions of travel and trade (WHO, 2014).
During an Ebola outbreak, the affected countrys public health authority
reports its disease case numbers and deaths daily. Case numbers reflect both
suspected cases and laboratory-confirmed cases of Ebola. Sometimes numbers of
suspected and confirmed cases are reported together. Sometimes they are reported
separately. Thus, numbers can shift between suspected and confirmed cases.
Analyzing case data trends, over time, and with additional information, is generally
more helpful to assess the public health situation and determine the appropriate
response. During outbreak, WHO reviewed the public health situation regularly and
recommended to any travel or trade restrictions if necessary.
The risk of infection for travelers is very low since person-to-person
transmission results from direct contact with the body fluids or secretions of an
infected patient. WHOs general travel advice -travelers should avoid all contact with
infected patients, health workers traveling to affected areas should strictly follow
WHO-recommended infection control guidance, anyone who has stayed in areas
where cases were recently reported should be aware of the symptoms of infection and
seek medical attention at the first sign of illness, and clinicians caring for travelers
returning from affected areas with compatible symptoms are advised to consider the
possibility of Ebola virus disease (WHO, 2014).
2.9 Global Outbreak Management
Ebola or Marburg virus disease outbreaks constitute a major public health
issue in Sub-Saharan Africa. Of the 2 870 Marburg and Ebola cases documented
between June 1967 and June 2011, 270 (9%) were health-care workers. In order to
provide health-care workers in risk areas with a working tool to combat Ebola Virus
Disease (EVD) or Marburg Virus Disease (MVD) effectively, the WHO Regional
Office for Africa (AFRO), the WHO Regional Office for the Eastern Mediterranean
(EMRO), WHO Headquarters and their partners have produced this document: Ebola
and Marburg virus disease epidemics: preparedness, alert, control and evaluation. The
main target audience of this document are district-level health-care workers (doctors,
nurses, and paramedics), as well as intermediate- and central-level health-care
38
workers responsible for epidemic control, and International Health Regulations (IHR)
National Focal Points (NFPs). The objective of this document is to describe
preparedness, prevention, and control measures that have been implemented
successfully during previous epidemics. These measures must be implemented during
the following four phases: pre-epidemic preparedness, alert (identify, investigate,
evaluate risks), outbreak response and containment operations and post-epidemic
evaluation (WHO, 2014).
The first meeting of the Emergency Committee convened by the DirectorGeneral under the International Health Regulations (2005) [IHR (2005)] regarding the
2014 Ebola Virus Disease (EVD) outbreak in West Africa was held by teleconference
that emphasized the importance of continued support by WHO and other national and
international partners towards the effective implementation and monitoring of these
recommendations. There should be no general ban on international travel or trade;
restrictions outlined in these recommendations regarding the travel of EVD cases and
contacts should be implemented. States should provide travelers to Ebola affected and
at-risk areas with relevant information on risks, measures to minimize those risks, and
advice for managing a potential exposure. States should be prepared to detect,
investigate, and manage Ebola cases; this should include assured access to a qualified
diagnostic laboratory for EVD and, where appropriate, the capacity to manage
travelers originating from known Ebola-infected areas that arrive at international
airports or major land is crossing points with unexplained febrile illness. The general
public should be provided with accurate and relevant information on the Ebola
outbreak and measures to reduce the risk of exposure. States should be prepared to
facilitate the evacuation and repatriation of nationals (e.g. health workers) who have
been exposed to Ebola (WHO, 2014).
Understanding the unending risks of transmission dynamics and resurgence is
essential in implementing rapid effective response interventions tailored to specific
local settings and contexts. Therefore, the following actions are recommended: (i)
national and regional inter-sectorial and trans-disciplinary surveillance response
systems that include early warnings, as well as critical human resources development,
must be quickly adopted by allied ministries and organizations in African countries in
epidemic and pandemic responses; (ii) harnessing all stakeholders commitment and
39
40
CHAPTER 3
OBJECTIVES
41
disease
disease
Causal agent
Mode of transmission
Signs and symptoms
Complications
Diagnostic measures
High risks personnel
Prevention measures
Infection control measures
Waste control measures
Reporting
Information
Media (TV, Radio, Newspaper,
Pamphlets and posters)
Social networking
Health education program
Training
Infection control training
Personal protective equipment
training
Figure 1. Conceptual framework of the study
42
CHAPTER 4
RESEARCH METHODOLOGY
43
2 (Bridge) Classes
44
45
current posting and infection control training (B) sources of information about Ebola
disease (C) questions regarding knowledge on Ebola disease which encompassed 42
items including 26 positive statements and 16 negative statements (True/False/Dont
know questions) and (D) questions regarding the perception towards Ebola disease
which involved 12 items including 5 positive perceptions and 7 negative perceptions
(four-point Likert type scale). The questionnaire was distributed to the participants
and requested them to answer all the questions frankly and honestly. The duration of
responding to the questionnaire was taken place 30 to 40 minutes. Then, the
completed questionnaires were compiled in back by the researcher.
46
47
CHAPTER 5
FINDINGS
This analytical cross-sectional study aimed to find out the association between
knowledge and perceptions towards Ebola virus disease among nursing students in
University of Nursing, Yangon. The ages of the respondents were between 26 and 49
years old and total 170 students who met the inclusion criteria were recruited from
nursing students in University of Nursing, Yangon by simple random sampling
method and answered by self-administered structured questionnaires.
For this study, descriptive statistics were used to describe the results of
different variables by reporting frequency, percentage, mean, median, mode, range
and standard deviation. To describe the associations between dependent and
independent variables, chi square test, independent samples t test and ANOVA
statistics were used. The significance level used in hypothesis tests was set at 95%.
The results of this study were divided into 4 parts and presented as follow;
(1) Socio-demographic characteristics - independent variables (gender, academic year,
age group, race, religion, marital status, total years of service in government, other
qualification, current posting and infection control training)
(2) Source of information about Ebola disease (Television, radio, internet news,
posters and pamphlets and friends)
(3) Knowledge about Ebola disease - dependent variables (causal agent, mode of
transmission, signs and symptoms and complications, diagnostic and preventive
measures, incubation period, high risk persons, infection control and waste control
measures and reporting)
(4) Perceptions towards Ebola disease - dependent variables (positive perceptions and
negative perceptions)
(5) Associations between independent variables and knowledge about Ebola disease
48
(6) Associations between independent variables and perception towards Ebola disease
(7) Associations between knowledge and perception towards Ebola disease
5.1 Socio-demographic Characteristics
5.1.1 Gender of the respondents (n=170)
Gender
Male
Female
1.2%
98.8%
49
Second year
40%
60%
Frequency
Percent
21 to 30 years
67
39.4
31 to 40 years
93
54.7
41 to 50 years
10
5.9
Total
170
100
50
Ethnic groups
1.2%
Others
27%
71.8%
Christian Hinduism
0.6% 0.6%
9.4%
Islam
89.4%
51
Married
23%
77%
52
Number of respondents
120
109
100
80
61
60
40
20
0
0 to 5 years
> 5 years
53
Absent
7.6%
92.4%
54
Number of respondents
80
69
70
60
50
47
42
40
30
20
12
10
0
Current Posting
55
10.6%
Absent
Present
89.4%
Figure 11. Infection control and emergency training of the respondents (n=170)
In this study, 10.6% (95% CI = 6 to 15%) of the respondents have got
infection control and emergency training and 89.4% havent got about training.
56
Frequency
Percent
TV
87
51.2
Radio
63
37.1
87
51.2
Internet news
144
84.7
14
8.2
Peer groups
77
45.3
In this study, ways for information was got about Ebola disease of the
respondents that 144 frequency (84.7%) via internet news accessed information about
Ebola, 87 frequency (51.2%) via television, 87 frequency (51.2%) via journals and
newspapers, 77 frequency (45.3%) from peer groups, 63 frequency (37.1%) via radio
and 14 frequency (8.2%) via posters and pamphlets. Most respondents had got
information access about Ebola disease from internet news.
57
Correct answer
Freq.
155
Influenza virus*
Humans species*
Incorrect answer
Freq.
91.2
15
8.8
36
21.2
134
78.8
116
68.2
54
31.8
93
54.7
77
45.3
80
47.1
90
52.9
118
69.4
52
30.6
Survive in freezers
47
27.6
123
72.4
Die in heating
39
22.6
131
77.1
Ebola virus
Vector animals*
* Negative statement (Data analysis statement about this study was showed that this
point (*) of the data distributions was displayed to negative question statement.)
Regarding causal agent 155 (91.2%) respondents answered correctly that
Ebola disease is caused by Ebola virus, 116 (68.2%) respondents answered correctly
that Ebola disease started from humans and 118 (69.4%) respondents answered
correctly that vector animals can cause Ebola disease, 93 (54.7%) respondents
answered correctly that Ebola virus was found in monkeys and chimpanzees and 80
(47.1%) respondents answered correctly that Ebola disease was found in pigs and fruit
bats. 134 (78.8%) respondents answered incorrectly that Ebola is one of the influenza
species, 123 (72.4%) respondents answered incorrectly that Ebola virus can survive in
freezers and refrigerators and 131 (77.1%) respondents answered incorrectly that
Ebola virus can die in heating 60 C in 60 minutes.
58
Correct answer
Freq.
Incorrect answer
Freq.
87
51.2
83
48.8
104
61.2
66
38.8
162
95.3
4.7
Contaminated objects
143
84.1
27
15.9
159
93.5
11
6.5
* Negative statement
Regarding mode of transmission that the respondents answered correctly were
87 (51.2%) by air borne, 104 (61.2%) by foods and water borne, 162 (95.3%) by
contact infected persons, 143 (84.1%) by contaminated objects and 159 (93.5%) by
blood and bodily secretions.
59
Correct answer
Incorrect answer
Freq.
131
77.1
39
22.9
149
87.6
21
12.4
146
85.9
24
14.1
97
57.1
73
42.9
Intense weakness
146
85.9
24
14.1
115
67.6
55
32.4
119
70.0
51
30.0
141
82.9
29
17.1
50
29.4
120
70.6
Constipation*
Fits*
Freq.
* Negative statement
Regarding signs and symptoms and complications that the respondents
answered correctly were 131 (77.1%) low grade fever, 149 (87.6%) headache and
sore throat, 146 (85.9%) muscle and joint pain, 97 (57.1%) constipation, 146 (85.9%)
intense weakness, 115 (67.6%) bloody vomiting and diarrhea, 119 (70.0%) impaired
kidneys and liver, 141 (82.9%) internal and external bleeding and 50 (29.4%) fits.
60
5.3.4 Knowledge about 90 % fatal syndromes and incubation period about Ebola
Table (6) Knowledge of the respondents on 90 % fatal syndrome and incubation
period about Ebola (n=170)
Correct answer
Knowledge about Ebola
Incorrect answer
Freq.
Freq.
167
98.2
1.8
Incubation period
118
69.4
52
30.6
Correct answer
Incorrect answer
Freq.
Detected by blood
144
84.7
26
15.3
Detected by urine*
62
36.5
108
63.5
Detected by tissues
51
30.0
119
70.0
112
65.9
58
34.1
Freq.
* Negative statement
Questionnaires about diagnostic measures that the respondents answered
correctly were 144 (84.7%) about Ebola detected by blood, 62 (36.5%) about Ebola
detected by urine, 51 (30.0%) about Ebola detected by tissues, and 112 (65.9%) about
Ebola detected by X ray and ultrasound.
61
Incorrect answer
Freq.
Freq.
Health personnel
164
98.2
1.8
Mortuary attendants
140
82.4
30
17.6
Questionnaires about high risk persons were answered 164 correctly (98.2%)
about health personnel and 140 correctly (82.4%) about mortuary attendants.
5.3.7 Knowledge about preventive measures
Table (9) Knowledge of the respondents on preventive measures about Ebola
(n=170)
Knowledge about preventive
measures
Correct answer
Incorrect answer
Freq.
Freq.
Hand washing
126
74.1
44
25.9
161
94.7
5.3
Vaccination*
129
75.9
41
24.1
Effective medications*
127
74.7
43
25.3
* Negative statement
Questionnaires about preventive measures that the respondents answered
correctly were 126 (84.7%) by hand washing, 161 (94.7%) by personal protective
equipments, 129 (75.9%) by vaccination, and 127 (74.7%) by effective medications.
62
Correct answer
Freq.
Incorrect answer
Freq.
87
51.2
83
48.8
Bleaching powders
110
64.7
60
35.3
167
98.2
1.8
167
98.2
1.8
19
11.2
151
88.8
Correct answer
Incorrect answer
Freq.
Freq.
150
88.2
20
11.8
156
91.8
14
8.2
* Negative statement
Questionnaires about waste management were answered 150 correctly
(88.2%) about Ebola patients can be buried as normal dead bodies and answered 156
correctly (91.8%) about burning all waste materials.
63
Frequency
Percentage
Correct answer
46
27.1
Incorrect answer
124
72.9
Total
170
100
Frequency
Percentage
93
54.7
77
45.3
Total
MeanSD = 28.515.144
170
100
Median=29.00
Mode=29.00
Min=7; Max= 40
Skewness= - 0.572
Kurtosis=0.944
64
Positive Perception
Everybody should aware the
life threatening about Ebola
disease.
Nurses should have a
systematic PPE (personal
protective equipments)
training.
Infection control and
systematic waste management
is important method to control
Ebola disease.
In continuing nursing
education program, the
selection topic towards
emerging disease like Ebola
should be presented and
discussed.
It would share and distribute to
family, friends and colleagues
about information on Ebola
disease.
Strongly
Agree
Freq. (%)
Agree
Freq.(%)
Disagree
Freq.(%)
Strongly
disagree
Freq.(%)
143(84.1%) 27(15.9%)
-
137(80.6%) 32(18.8%)
1(0.6%)
113(66.5%) 55(32.4%)
1(0.6%)
122(71.8%) 45(26.5%)
115(67.6%) 53(31.2%)
1(0.6%)
1(0.6%)
3(1.8%)
1(0.6%)
Table (14) expressed about the positive perception towards Ebola disease.
This study showed that more than 50% of the respondents described on strongly
agreed point regarding positive perception questionnaires. 84.1 % of the students
strongly agreed that everybody should aware the life threatening about Ebola disease,
80.6 % of them strongly agreed that nurses should have a systematic PPE (personal
protective equipments) training, 66.5 % of them strongly agreed that infection control
and systematic waste management is important method to control Ebola disease,
71.8 % of them strongly agreed that in continuing nursing education program, the
selection topic towards emerging disease like Ebola should be presented and
65
discussed and 67.6 % of them strongly agreed that It would share and distribute to
family, friends and colleagues about information on Ebola disease. In this study, the
positive perception statements about Ebola disease were described more strongly
agreed point than others in 4 levels Likert scale.
66
Negative Perception
All health personnel are not
important whose access
updated information about
Ebola disease.
Fever screening is done into
external travelers is not
important to control Ebola
disease.
It is not important that health
personnel have adequate
knowledge, experiences and
practices about emerging
disease like Ebola.
If have no desire to involve in
Ebola combating activities.
If do not induce to co-workers
for involvement in Ebola
combating activities.
If do not interest about Ebola
disease that has currently
caused in Myanmar.
Ebola that cannot reach in
Myanmar is recognized a
national surveillance disease.
Strongly
Agree
Freq.(%)
-
5(2.9%)
Freq.(%)
Strongly
disagree
Freq.(%)
1(0.6%)
29(17.1%)
140(82.4%)
7(4.1%)
52(30.6%)
106(62.4%)
29(17.1%)
140(82.4%)
Agree
Freq.(%)
Disagree
1(0.6%)
4(2.4%)
6(3.5%)
76(44.7%)
84(49.4%)
5(2.9%)
81(47.6%)
84(49.4%)
2(1.2%)
3(1.8%)
82(48.2%)
83(48.8%)
2(1.2%)
4(2.4%)
50(29.4%)
114(67.1%)
Table (15) expressed about the negative perception towards Ebola disease.
This study showed that about 50% of the respondents described on strongly disagreed
regarding negative perception questionnaires. 82.4 % of the students strongly
disagreed that all health personnel are
information about Ebola disease, 62.4 % of them strongly disagreed that fever
screening is done into external travelers is not important to control Ebola disease, 82.4
% of them strongly disagreed that it is not important that health personnel have
adequate knowledge, experiences and practices about emerging disease like Ebola,
49.4 % of them strongly disagreed that If have no desire to involve in Ebola
combating activities, 49.4 % of them strongly disagreed that If do not induce to co-
67
Frequency
Percentage
94
55.3
76
44.7
Total
MeanSD = 43.733.645
170
100
Median=44.00
Mode=48.00
Min=32; Max= 48
Skewness= - 0.588
Kurtosis= - 0.403
68
Mean
knowledge
score
t value
p value
First Year
102
26.91
-5.335
<0.001
Second Year
68
30.90
Academic year
69
Poor
Gender
Percent
Percent
Total
Male
100.0
0.0
Female
91
54.2
77
45.8
168
Table (19) Association between age group and knowledge on Ebola disease
(by one way ANOVA)
Age Group
Mean
knowledge
score
F value
p value
21 to 30
67
28.18
0.269
0.764
31 to 40
93
28.67
41 to 50
10
29.20
Total
170
28.51
70
Table (20) Association between marital status and knowledge on Ebola disease
Knowledge on Ebola disease
Good
Poor
Marital Status
Percent
Percent
Total
Single
74
56.5
57
43.5
131
Married
19
48.7
20
51.3
39
Table (21) Association between total years of service and knowledge on Ebola
disease (by independent sample t test)
N
Mean
knowledge
score
t value
p value
0-5 years
61
27.43
-2.067
0.040
> 5 years
109
29.11
Total years of
service
71
Mean
knowledge
score
t value
p value
Absent
13
26.92
-1.156
0.250
Present
157
28.64
Table (23) Association between current posting and knowledge on Ebola disease
Knowledge on Ebola disease
Good
Poor
Current posting
Percent
Percent
Total
Clinical (Hospitals)
85
53.8
73
46.2
158
Public Health
66.7
33.3
12
72
Table (24) Association between current posting and knowledge on Ebola disease
(by one way ANOVA)
Current posting
Mean
knowledge
score
F value
p value
Township/Station
hospital
47
28.57
0.177
0.912
District hospital
42
28.33
Regional/State
hospital
69
28.39
Health center
12
29.50
Total
170
28.51
73
Mean
knowledge
score
t value
p value
Absent
152
28.42
- 0.624
0.534
Present
18
29.22
Infection
control training
74
Mean
perception
score
t value
p value
First year
102
43.25
-.2.144
0.033
Second year
68
44.46
Academic year
were
more
(MeanSD
44.463.483)
than
first
year
Table (27) Association between gender and perception towards Ebola disease
Perception towards Ebola disease
Good
Poor
Gender
Percent
Percent
Male
50.0
50.0
Female
93
55.4
75
44.6
168
75
Total
Table (28) Association between age group and perception towards Ebola disease
(by one way ANOVA)
Age Group
Mean
perception
score
F value
p value
21 to 30
67
43.76
0.039
0.962
31 to 40
93
43.68
41 to 50
10
44.00
Total
170
43.73
Table (29) Association between marital status and perception towards Ebola
disease
Perception towards Ebola disease
Good
Poor
Marital Status
Percent
Percent
Total
Single
73
55.7
58
44.3
131
Married
21
53.8
18
46.2
39
76
Table (30) Association between total years of service and perception towards
Ebola disease (by independent sample t test)
Total years of
service
Mean
perception
score
t value
p value
0-5 years
61
43.20
-1.430
0.155
> 5 years
109
44.03
>5
years of service were more (MeanSD = 44.03 3.513) than 0 to 5 years of service
(MeanSD=43.20 3.842). There was no statistically significant association between
total years of service and perception towards Ebola disease t (df=168)
= -1.430,
p = 0.155.
Table (31) Association between other qualification and perception towards Ebola
disease (by independent sample t test)
Other
qualification
Mean
perception
score
t value
p value
Absent
13
44.54
0.832
0.407
Present
157
43.66
77
Table (32) Association between current posting and perception towards Ebola
disease
Perception towards Ebola disease
Good
Poor
Current posting
Percent
Percent
Total
Clinical (Hospitals)
88
55.7
70
44.3
158
Public Health
50.0
50.0
12
Table (33) Association between current posting and perception towards Ebola
disease (by one way ANOVA)
Current posting
Mean
perception
score
Township/Station
hospital
47
43.21
District hospital
42
44.10
Regional/State
hospital
69
43.91
Health center
12
43.42
Total
170
43.73
F value
p value
0.539
0.656
78
Table (34) Association between infection control training and perception towards
Ebola disease (by independent sample t test)
N
Mean
perception
score
t value
p value
Absent
152
43.83
1.035
0.302
Present
18
42.89
Infection
control training
Table (35) Association between knowledge and perception towards Ebola disease
Perception towards Ebola disease
Good
Poor
Knowledge level
Percent
Percent
Total
Good
59
63.5
34
36.5
93
Poor
35
45.5
42
54.5
77
79
CHAPTER 6
DISCUSSION
In this study, total 170 comprising 2 male and 168 female students from
nursing (Bridge) course students in University of Nursing, Yangon were chosen to
identify their knowledge and perception level about Ebola disease. Regarding to this
discussion, this study did not access and get the previous literature and studies
regarding knowledge and perception towards Ebola disease among health care
workers so the general discussion point only come from the reliable data collection
and analysis in this study population. The main objective of this study was to
determine the relationship between knowledge and perception towards Ebola disease
and the demographic characteristics of nursing students in University of Nursing,
Yangon, Myanmar. The hypotheses of this study were assumed that there were
associations between socio-demographic characteristics, knowledge level and
perceptions level toward Ebola disease of the study area. There were 4 discussion
parts in this chapter as follows;
1) Socio-demographic characteristics
2) Sources of information getting about Ebola disease
3) Knowledge level about Ebola disease
4) Perceptions level towards Ebola disease
socio-demographic
factors
are
the
personal
information
and
characteristics of the respondents that based on each respondent belong. These factors
can also associate with or relate to knowledge and perceptions levels toward Ebola
disease among respondents. With regards to the socio-demographic factors;
80
independent variables (gender, academic year, age, race and religion, marital status,
and total years of service in government servants, other qualification, current posting
and infection control training) were associated with dependent variables (knowledge
and perception levels towards Ebola disease). According to data analysis, knowledge
level was significantly association with academic year, total years of service and
perception level.
Gender - In this study, 2 male students (1.2%) and 168 female students
(98.8%) were participated in the study. Nursing students in Myanmar especially as
University of Nursing, Yangon was 1 male/10 female proportional recruitment and
enrollment so male students are usually fewer than female students. In this study, total
study population was 260 followed by 157 first year students as included one male
student and 103 second year students as included only one male student so the
participants were selected by simple random sampling method that 2 male participants
were included with lottery selection by chance. Two male participants are 1 from 1st
year and 1 from 2nd year Bridge course student in each and 101 female students from
1st year and 67 female students from 2 nd year Bridge course respectively. On female
dominated nursing profession in Myanmar, this study found out the relationship
between gender and knowledge level and perceptions level towards Ebola disease.
There was no statistically significant association between gender and knowledge level
p value = 0.298 and gender and perception level towards Ebola disease p value =
0.696. In this study, gender display was unequal; the knowledge and perception level
of the respondents cannot distinguish high and low level about Ebola disease.
Academic year - In this study, 102 first year students (60%) and 68 second
year students (40%) were participated in the study. This study found that there was
statistically significant association between academic year and knowledge level
towards Ebola disease p value <0.001. Data analysis showed when education level
was more and more; the knowledge level of the respondents was high level about
Ebola disease (Mean score=30.90). And then, there was statistically significant
association between academic year and perception level towards Ebola disease p
value =0.033. So, data analysis showed that education level was high, the perception
level of the respondents was increased about Ebola disease (Mean score=44.46).So,
the education level of the respondents is important and needed to be adequate
81
knowledge access during outbreak control and through it also needed to try and
promote absolutely for career preference as personal development regarding formal or
informal educational accessibility.
Age - In this study, age was purposively categorized as three groups of 21 to
30, 31 to 40 and 41 to 50 years to do data analysis among respondents in study area.
The youngest age of the respondent was 26 and the oldest was 49. Mean knowledge
scores among age group were increased from 21 to 30 years age group (Mean
= 28.18), to 31 to 40 years age group (Mean = 28.67), to 41 to 50 years age group
(Mean = 29.20). There was no statistically significant association between age groups
and knowledge level towards Ebola disease p value=0.764. Regarding the perception
score, mean perception score among age group were 21 to 30 years age group (Mean
= 43.76), 31 to 40 years age group (Mean = 43.68) and 41 to 50 years age group
(Mean = 44.00). There was no statistically significant association between age group
and perception level towards Ebola disease p value =0.962. However, this study found
out that the elder respondents were higher knowledge and perception score as they
have been longer service duration and longer life experiences than the younger one.
So, the younger age groups are needed to improve knowledge in various ways for
information access and increase perception level by their voluntary involvement,
participation and motivations during epidemic outbreak.
Race and religion In this study where majority of the respondents are
Bamar 122 (71.8%), ethnic groups 46 (27.0%) and others 2 (1.2%) included Hindu
and Indian. Ethnic groups included Kayin and Rakhine are most frequent than others.
Majorities were Buddhist 152 (89.4%) and others were Christian 16 (9.4%), Hinduism
1 (0.6%) and Islam 1 (0.6%) respectively. Most respondents were major identity in
Bamar race and Buddhist religion. This study did not find out the association between
race and religion and knowledge and perception level of the respondents because most
of the Bamar race and Buddhist religion were influencing prominently on others.
Marital status - Most of the respondents were single 131(77.0%) and other
respondents were married 39(23.0%). In this study, the marital status of the
respondents were unmarried 56 members in 21 to 30 years of age group,70 members
in 31 to 40 years of age group and 5 members in 41 to 50 years of age group so
nursing profession in Myanmar, nurses are prominently unmarried people in their
82
>5
years of service were more (Mean = 44.03) than 0 to 5 years of service (Mean
=43.20). There was no statistically significant association between total years of
service and perception level towards Ebola disease p = 0.155. The respondents with
> 5 years of service were longer duration of services as they may have enthusiastic
and relevant life experiences in infection control and epidemic outbreak control like
H1N1, Avian Influenza that this study was described the association between total
years of service and knowledge level. In this study, the longer duration of service of
the respondents have the higher knowledge and higher perception level according to
their willingness and life experiences.
Other qualifications - In this study, other qualification of the respondents
whose were present of another degree or graduations 92.4% (95% CI = 88 to 96%)
and 7.6% absent of another of degree respectively. 157 members of degree or
graduations of the respondents were contained 51 B.Sc graduated, 98 B.A graduated
and 4 L.L.B (Law) and 4 Diploma in ICU and ENT. The mean knowledge scores
indicate that the presence of other qualifications among respondents were more (Mean
= 28.64) than the absent (Mean =26.92). There was no statistically significant
association between other qualification and knowledge level towards Ebola disease p
=0.250. The mean perception scores indicate that the presence of other qualifications
among respondents were less (Mean =43.66) than the absent (Mean =44.54). There
83
posting and perception level, mean perception score in various posting of respondents
were township/station hospital posting (Mean = 43.21), district hospital posting
(Mean = 44.10), regional/state hospital posting (Mean = 43.91) and health centers
posting (Mean = 43.42). There was no statistically significant association between
current posting and perception level towards Ebola disease p =0.656. In this study,
although the health centers especially public health posting among respondents have
84
the slightly higher knowledge level than clinical posting sites as they have known the
disease process such as seriousness, fatality and infectious about Ebola disease that
leads to be lower perception level and showed their unwillingness involvement in
disease controlling activities. And then, other clinical posting sites were not much
different between high and low levels of knowledge and perception about Ebola
disease.
Infection control and emergency training - In this study, 10.6% (95% CI =
6 to 15%) of the respondents have got infection control and emergency training and
89.4% havent got about training. Thus, most of the respondents had not been about
infection control and emergency training towards epidemic outbreak control like
Ebola disease. Only 18 respondents had got about infection control and emergency
training; they are 7 respondents in regional/ state hospitals, 5 respondents in
township/station hospitals, 3 respondents in district hospitals and 3 respondents in
public health site. The mean knowledge scores indicate that the presence of infection
control training among respondents were more (Mean = 29.22) than the absent (Mean
=28.42). There was no statistically significant association between infection control
training and knowledge level towards Ebola disease p =0.534. Regarding mean
perception scores indicate that the presence of infection control training among
respondents were less (Mean = 42.89) than the absent (Mean =43.83). There was no
statistically significant association between infection control training and perception
level towards Ebola disease p =0.302. In this study, although the presence of infection
control training among respondents have the remarkable knowledge score as they
have known the disease process such as seriousness, fatality and infectious regarding
higher knowledge level about Ebola disease that leads to be lower perception level
and showed their unwillingness involvement in disease controlling activities. By data
analysis, only 18 members of the respondents had got the infection control and
emergency training as well as personal protective equipments training so the
respondents in respective posting sites are needed to get and access about those
trainings efficiently and relevantly. Therefore, these studies found out that the
presence of infection control training among the respondents have ethical issues for
involvement in Ebola combating activities.
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87
persons, 84.1 percent by contaminated objects and 93.5 percent by blood and bodily
secretions. This study showed that the knowledge level of the respondents about mode
of transmission was described favorable level indicated correctly answered up to 50%.
Initial signs and symptoms about Ebola are nonspecific and may include fever,
chills, myalgias, and malaise. Fever, anorexia, asthenia/weakness are the most
common signs and symptoms. Patients may develop a diffuse erythematous
maculopapular rash by day 5 to 7 (usually involving the face, neck, trunk, and arms)
that can desquamate (Casillas et al., 2003 & CDC, 2014). Other symptoms such as
chest pain, shortness of breath, headache or confusion, may also develop. Patients
often have conjunctival injection. Hiccups have been reported. Seizures may occur,
and cerebral edema has been reported. Bleeding is not universally present but can
manifest later in the course as petechiae, ecchymosis/bruising, or oozing from
venipuncture sites and mucosal hemorrhage. Frank hemorrhage is less common.
Pregnant women may experience spontaneous miscarriages. Patients with fatal
disease usually develop more severe clinical signs early during infection and die
typically between days 6 and 16 of complications including multi-organ failure and
septic shock (CDC, 2014).
Questionnaires were assessed on signs and symptoms and complications about
Ebola disease that the respondents answered correctly were 77.1 percent about low
grade fever, 87.6 percent about headache and sore throat, 85.9 percent about muscle
and joint pain, 57.1 percent about constipation, 85.9 percent about intense weakness,
67.6 percent about hematemesis and bloody diarrhea, 70.0 percent about impaired
kidneys and liver, 82.9 percent about internal and external bleeding and 29.4 percent
about fits. This study showed that the knowledge level of the respondents about signs
and symptoms and complications was described favorable level.
Ebola virus disease (EVD) is a severe, often fatal illness, with a death rate of
up to 90% (WHO, 2014). Questionnaires about Ebola disease is 90 percent fatal
syndrome was answered 98.2 percent correctly and 1.8 percent incorrectly. The
incubation period is 2 to 21 days (WHO, 2014). Questionnaires about incubation
period of Ebola disease was answered 69.4 percent correctly and 30.6 percent
incorrectly. This study showed that the knowledge level of the respondents about it
was described higher level indicated correctly answered nearly 70% and above.
88
The risks persons are people exposed to and handling wild animals; people
depending on wild animals such as bats as a food source; mortuary attendants; health
workers caring for Ebola patients; health workers in hospital settings (WHO, 2014).
In almost all outbreaks of Ebola Hemorrhagic Fever (EHF), the fatality rate among
health care workers with documented infections was higher than that of nonhealth
care workers (Adrian et al., 2011). Questionnaires about high risk persons were
answered correctly 98.2 percent in health personnel and 82.4 percent correctly in
mortuary attendants. This study showed that the knowledge level of the respondents
about it was described higher level indicated correctly answered up to 80%.
Antigen-capture enzyme-linked immunosorbent assay (ELISA) testing, IgM
ELISA, polymerase chain reaction (PCR), and virus isolation can be used to diagnose
a case of Ebola disease within a few days of the onset of symptoms. Persons tested
later in the course of the disease or after recovery can be tested for IgM and IgG
antibodies; the disease can also be diagnosed retrospectively in deceased patients by
using immunohistochemistry testing, virus isolation, or PCR (Casillas et al., 2003).
Diagnostic measures were assessed questionnaires that the respondents answered
correctly 84.7 percent about Ebola detected by blood, 36.5 percent about Ebola
detected by urine, 30.0 percent about Ebola detected by tissues, and 65.9 percent
about Ebola detected by X ray and ultrasound. This study showed that the knowledge
level of the respondents about diagnostic measures was described unfavorable level
indicated correctly answered <50%.
The occupation health staff (OHS) of the health care workers (HCWs) is the
primary consideration and reason for recommending personal protective equipments
(PPE) in the first place. The choice of respiratory protection is one facet of an array of
PPE for ensuring the OHS of health workers, including gowns, gloves, goggles and
protective suits. Suggesting HCWs use lesser protection because they could work 3 h
instead of 40 min is illogical, when the risk of working longer in lesser PPE may be
death (CDC, 2014).
Many HCWs have contracted Ebola despite wearing PPE, which in itself
supports the case for conservative recommendations (MacIntyre et al., 2011& 2013).
Standard precautions are recommended in the care and treatment of all patients
regardless of their perceived or confirmed infectious status. They include the basic
89
Knowledge questionnaires
regarding preventive measures about Ebola disease were assessed that the respondents
answered correctly 84.7 percent prevention by proper hand washing, 94.7 percent
prevention by personal protective equipments, 75.9 percent prevention by vaccination,
and 74.7 percent prevention by effective medications. Response to the current Ebola
virus outbreak based on traditional control measures has so far been insufficient to
prevent the virus from spreading rapidly. This has led to urgent discussions on the use
of experimental therapies and vaccines untested in humans and existing in limited
quantities, raising political, strategic, technical and ethical questions(Feldmann,
2014). This study showed that the knowledge level of the respondents about
preventive measures was described higher level indicated correctly answered nearly
75% and above.
Ebola virus is easily killed by soap, bleach, sunlight, or drying. Machine
washing clothes that have been contaminated with fluids will destroy Ebola virus.
Ebola virus survives only a short time on surfaces that are in the sun or have dried
(CDC, 2014). By reviewing CDC notes, questionnaires were assessed infection
control measures about Ebola disease that the respondents answered correctly 51.2
percent about washed by soap, 64.7 percent by bleaching powders, 98.2 percent about
care in normal inpatient units, and 98.2 percent about care in isolation unit and 11.2
percent about quarantine for 5 days. This study showed that the knowledge level of
the respondents about infection control measures was described slightly favorable
level indicated correctly answered average about 50%.
Communities affected by Ebola should inform the population about the nature
of the disease and about outbreak containment measures, including burial of the dead.
People who have died from Ebola should be promptly and safely buried. Burial
90
ceremonies in which mourners have direct contact with the body of the deceased
person can also play a role in the transmission of Ebola (CDC, 2014).
Waste management during outbreak was assessed by questionnaires that
answered 88.2 percent correctly about Ebola patients can be buried as normal dead
bodies and 91.8 percent correctly about burning all waste materials. This study
showed that the knowledge level of the respondents about waste management was
described higher level indicated correctly answered average nearly 90%.
Continuously, questionnaires was assessed about Ebola suspected patient can be
reported within 3 days that answered 27.1 percent correctly and 72.9 percent
incorrectly. This study showed that the knowledge level of the respondents about
reporting was described unfavorable level indicated correctly answered < 30%.
According to the knowledge questionnaires, total knowledge score about
Ebola disease given was 42 total scores that it was divided by good knowledge above
mean score and poor knowledge below mean score (mean score 28.51). The
distribution of the level of knowledge was that 93 respondents 54.7 percent had good
level of knowledge about Ebola disease and the poor level of knowledge was found in
77 respondents 45.3 percent. In this study, half and above of the respondents were
good knowledge level that described proper information access, relevant background
knowledge and life experiences to be interests, understanding
and alertness on
disease threats regarding current public health problem called Ebola disease.
However, above these finding results; most of the respondents needed to be adequate
knowledge regarding epidemiology of Ebola disease, understanding disease threats
and safe fulfillment in infection control activities about Ebola disease.
6.4 Perceptions level towards Ebola disease
The operation definitions of perceptions is the way of feeling or thinking so
the perceptions level towards Ebola disease do not the same feeling in each mind of
respondents. Questionnaires regarding perceptions level of the respondents about
Ebola disease were answered by four point Likert scale. This study showed that more
than 50% of the respondents described on strongly agreed point. Positive perceptions
questions were marked on strongly agreed point that showed 84.1 percent perceived
about life threatening Ebola disease, 67.6 percent perceived about information
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92
93
94
the research topic. Therefore, health education program should be done widely to get
adequate knowledge and to be awareness raising about Ebola disease among pubic in
disseminating preparedness messages and provides specific response strategies and
then capacity building program should be promoted such as infection control training
and personal protective equipments training and health talks, workshop, symposium
and seminar about emerging disease like Ebola among all health care workers.
Moreover, regarding the title of the study; Knowledge and perceptions
towards Ebola virus disease among nursing students in University of Nursing,
Yangon in the study population that was found out to their willingness, interests,
desires and conceptual knowledge and perception level leading to alertness,
preparedness, response, and control activities about Ebola disease. In Myanmar, there
are not previous studies and still needed to find out relevant research on current
outbreak Ebola virus disease. And then few literature reviews in other countries were
conducted and assessed about it. These findings will be useful and beneficial for
another study regarding Ebola virus disease and other outbreak control program and
health care and infectious disease control activities that will be relevant and reliable
data among nurses or health personnel about Ebola disease. Ministry of Health in
Myanmar has been many activities as health promotion, prevention and disease
control activities so this study was showed to emphasize and be absolutely highlights
and then effectively prepare and mange to 2014 epidemic Ebola outbreak as an
international public health emergency.
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CHAPTER 7
CONCLUSION
96
service. Moreover, level of knowledge was also high level that depended on longer
years of service, presence of other degree or graduation and infection control training.
Then, the knowledge level of the respondents was slightly higher in public health
posting site than clinical posting sites but also association was not found out.
In this study, regarding knowledge scores, more than half of the students
54.7% had good knowledge about Ebola disease and nearly half of the students 45.3%
had poor knowledge respectively. Minimum knowledge scores are 7 while maximum
one is 40 upon 42 given marks. In this study, regarding perception scores, more than
half of the students 55.3% had good perception and nearly half of the students 44.7%
had poor perception towards Ebola disease respectively. Minimum perception scores
are 32 while maximum one is 48 upon 48 given marks.
Through, most of the respondents heard information about Ebola disease from
social media and they mainly heard from television, radio, internet news, journals and
newspapers and friends. Most of the respondents heard more than one kind of social
media. It could conclude that health education program and media information
dissemination play an important role to achieve the better outcomes of disease
controlling and combating activities.
Study findings revealed that higher education level were significantly
associated with knowledge and perception level. Although respective with higher
education level has higher knowledge and higher perception level. This study also
found out that knowledge level was significantly associated with perception level.
In conclusion, the results of this study showed that knowledge level was
significantly associated with education level, total years of service, and perception
level after data analysis. It was concluded that although they had got life experience in
government employee life, their knowledge and perception levels were not much
different between high and low levels. There was some misconception on the
knowledge and perception towards Ebola disease. Therefore, health education about
emerging disease like Ebola should be provided not only in general population but
also in health care workers with correct and essential information to reduce incorrect
knowledge and encouraged the health care personnel to be good perception and
attitude in disease controlling activities with voluntary involvement.
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CHAPTER 8
RECOMMENDATIONS
In this study, that found out to the knowledge level of the respondents was
significantly associated with academic year, total years of service and perception level
of the respondents about Ebola disease these were the most important factors to
determine these study objectives. Based on the study finding, the following
recommendations are suggested for future outbreak control program.
8.1 Implementation
1) According to this study result, television and radio are proper channels and
effective means of information dissemination widely during disease outbreak. So,
health promotion and disease control programs especially for outbreak control are
recommended to disseminate health information through television and radio to
achieve the effective outcomes of disease control programs.
2) The academic year of the respondents was associated factor on knowledge and
perception towards Ebola disease. The findings from the respondents highlighted that
higher education level can access and understand current problems regarding health
knowledge, health care provision, outbreak and disease control activities. Beside that,
all health care workers such as nurses also need to be essential knowledge level that
based on the education level to combat epidemic outbreak. Also updating education
program and technical trainings and supervisory meetings between healthcare workers
and general population are recommended to do as a regular basis and more frequent.
3) The total years of service were also associated with good knowledge and good
perception in this study. Service years are one important fact to manage disease
control and epidemic outbreak so the health care workers with longer services
duration should be recruited and enrolled voluntary into outbreak control activities.
98
4) The support from elder age can increase the knowledge and perception level among
the respondents according to result of this study. The elder age among the respondents
is showed the higher knowledge level whose have been longer service duration and
life experiences about outbreak control so is recommended that elder age group than
younger age group should be emphasized to be recruitment and enrollment voluntary
with personalized consent into outbreak control activities like a crisis.
5) In this study, the support from presence of other degree or qualification can
increase the knowledge level among the respondents according to result of this study.
So, educational career preference among health care workers especially nurses is
recommended to expand, invite and be attended and learned by voluntary or
sequential enrollment that can get proper knowledge and awareness raising in
comprehensive health care services.
6) In this study area, the support from presence of infection control training can
increase the knowledge level among the respondents according to result of this study.
So this study is recommended that infection control training such as H1N1 or SARS
training should be trained to all health care workers alternatively and sequentially.
Therefore, a comprehensive outbreak control program which includes health
information and education sessions, and capacity building for service providers
(including health educators and health care workers) is recommended to design for
educational policy maker and advisors, government and international organizations.
Then, the continuous sessions for capacity building and trainings on Ebola disease are
recommended to conduct for both of nurses or healthcare workers and volunteer
workers. Consequently, the raising awareness and promoting knowledge and
motivating perception among health sectors will also support to be proper knowledge
and to change health workers attitude on outbreak control. Finally, successful disease
control programs among those study population like health care workers are needed to
encourage and engage with implementation and intervention by service providers,
focal persons and implementing organizations.
99
100
REFRENCES
Adrian, C.M, Sosa, A. & Wilder, C.L, Sands, H 2011. A Current Review of
Ebola Virus:Pathogenesis, Clinical Presentation, and Diagnostic Assessment.
The Journal of nfectious Disease November 1.
Anthony, M.C, Amul, G. H. 2014. Did SARS Prepare East Asia for Ebola? .
diplomat.
Africa, W. 2014 2014 Ebola Virus Disease (Evd) Outbreak in West Africa.
Asia, T. 2014. Vietnam, Myanmar Test Patients for Ebola. The Sunday times (sep 14).
Baize, S., Pannetier, D., Oestereich, L., Rieger, T., Koivogui, L., Magassouba,
N.,Soropogui, B., Sow, M.S., Keita, S., De Clerck, H., Tiffany, A.,
Dominguez, G., Loua, M., Traore, A., Kolie, M., Malano, E.R., Heleze, E.,
Bocquin, A., Mely, S., Raoul, H., Caro, V., Cadar, D., Gabriel, M., Pahlmann,
M., Tappe, D., Schmidt-Chanasit, J., Impouma, B., Diallo, A.K., Formenty, P.,
Van Herp, M., And Gunther, S. 2014. Emergence of Zaire Ebola virus disease
in Guinea preliminary report. . N. Engl. J. Med. 2014.
Barber, E. 2014. Learning From Past Viral Epidemics, Asia Readies for Possible
Ebola Outbreak.
Busico, K.M, Ksiazek, T.G, Roels, T.H, Fleerackers, Y, Feldmann, H, Khan, A.S &
Peters, C.J 1999. Prevalence of IgG Antibodies to Ebola Virus in Individuals
during an Ebola Outbreak, Democratic Republic of the Congo, 1995. JID,
179.
Bausch, D.G, Schwarz. L. 2014. Outbreak of ebola virus disease in Guinea: where
ecology meets economy. 3056.
Casillas A.M, Sosa, A, Cam L. Wilder, C.L & Sands, H. 2003. A Current Review of
Ebola Virus:Pathogenesis, Clinical Presentation,and Diagnostic Assessment.
Biological Research For Nursing, 4, No. 4.
CDC 2007. 2007 Guidelines for Isolation Precaution: Perceving Transmission of
Infections Agents in Healthcare.
CDC 2010. Ebola Hemorrhagic Fever Information Packet.
101
CDC 2014. Infection Prevention and Control Management Plan for Suspected Cases
of Viral Haemorrhagic Fever Caused by Filoviruses (Ebola and Marburg
Viruses). Infection Prevention and Control Service Version 6.
CDC August 1, 2014. Interim Guidance for Environmental Infection Control in
Hospitals for Ebola Virus.
CDC August 10, 2014. Ebola Virus Disease Information for Clinicians in U.S.
Healthcare Settings.
CDC 2014. What is Contact Tracing? Centers for Disease Control and Prevention.
accessed.
Del, R.C, Gm, L & Guarner, J 2014. Ebola Hemorrhagic Fever in 2014: the tale of an
evolving epidemic. Ann Intern Med
Donovan, G. K. 2014. Ebola, epidemics, and ethics - what we have learned. Donovan
Philosophy, Ethics, and Humanities in Medicine
Feldmann, H., Geisbert, T.W 2011. Ebola haemorrhagic fever. Vol 377
Formenty. P, Wyers. M, Steiner. C, Donati. F,Dind. F 1999. Ebola Virus Outbreak
among Wild Chimpanzees Living in a Rain Forest of Cote dIvoire,Francine
Walker, and Bernard Le Guenno. The Journal of Infectious Diseases.
Gostin, L. & Phelan. A, 2014. The Ebola Epidemic A Global Health
Emergency. JAMA.
Green, A. 2014. WHO and partners launch Ebola response plan. World Report, Vol
384 August 9, 2014.
Grolla, A. Dick, D. Strong. J. E & Feldmann. H 2005. Laboratory diagnosis of Ebola
and Marburg hemorrhagic fever. Bull Soc Pathol Exot, 98, 205-209.
Hewlett. B.L. 2005. Providing Care and Facing Death: Nursing During Ebola
Outbreaks in Central Africa. Journal of Transcultural Nursing, 16, No.4, 289297.
Jackson, C., Lowton, K. & Griffiths, P. 2014. Infection prevention as a show: a
qualitative study of nurses infection prevention behaviours. Int. J. Nurs. Stud.
2014, 51, 400408.
Jahrling P. B. , Geisbert, J. R. Swearengen, M. Bray, N. K. Jaax, J. W. Huggins,J. W.
Leduc, & Peters, C.J. 1999. Evaluation of Immune Globulin and Recombinant
Interferon-a2b for Treatment of Experimental Ebola Virus Infections. JID,
179.
102
Jarrett. A, 2014. Ebola: A Practice Summary for Nurse Practitioners. The Journal for
Nurse Practitioners - JNP.
Kabananukye, K. I. B. (2001). Denial, discrimination and stigmatization: The case of
Ebola epidemic in some districts. Kampala, Uganda: Makerere University.
Khine-Thant-Su 2014. Passengers Checked for Fever at Burmas Airports and Ebola
Fears. The Irrawaddy.
Kristina B.M, Ksiazek, T.G., Roels, T.H., Fleerackers, Y., Feldmann, H., Khan, A.S
& Peters, C.J. 1995. Prevalence of Igg Antibodies to Ebola Virus in
Individuals During an Ebola Outbreak, Democratic Republic of the Congo,
1995.
Lawrence G.O, J., For, O. N. I., Global, N. A., Health Law, University, G., Law
Center, Washington, D. D. L., Md,Mph, Of, D., And, M., Immunology,
University, G., Medical Center, Washington, D. A. P., Llm, B. L., For, O. N.
I., Global, N. A., Health Law, University, G., Law Center & Washington, D.
2014. The Ebola Epidemic a Global Health Emergency.
Leroy, E. M., Kumulungui, B., Pourrut, X., Rouquet, P., Hassanin, A., Yaba,
P.,Delicat, A., Paweska, J.T., Gonzalez, J.P., And Swanepoel, R. 2005. Fruit
bats as reservoirs of Ebola virus. Nature. 2005. 438, 575576.
Macintyre, C.R, Seale, H, Richards, G.A, Davidson, P.M 2014. Respiratory
protection for healthcare workers treating Ebola virus disease (EVD): Are
facemasks sufficient to meet occupational health and safety obligations?
PubMed.
Macintyre, C.R, Chughtai, A.A, Seale, H, Guy A. Richards,G.A, Patricia M,
Davidson D, 2014. Response to Martin-Moreno et al. (2014) Surgical mask or
no mask for health workers not a defensible position for Ebola. International
Journal of Nursing Studies, 2455.
Martnez Ga, R. R. C. 2014. Ebola: "A Fatal Syndrome". . [PubMed - indexed for
MEDLINE]
Martin-Moreno, J. M., Llins, G., Hernndez, J.M., Rodin, G., Sharpe, M., Walker, J.,
Hansen, C.H., Martin, P., Symeonides, S., And Gourley, C. 2014. Is
respiratory protection appropriate in the Ebola response?. . Lancet. 2014,
384: 856.
Mupere E, Kaducu O.F &Yoti Z. 2001. Ebola haemorrhagic fever among
hospitalised children and adolescents in nothern Uganda : Epidemiologic and
clinical observations. African Health Sciences, 1 No 2.
103
Nicho, S.T. 1998. Emerging Viral Diseases. 1998, American Society for
Microbiology. Yoshihiro Kawaoka
Okeke, I.N.. 2011. Divining without Seeds: the Case for Strengthening Laboratory
Medicine in Africa. Ithaca. Cornell University Press, 200.
Okware, S. I., Omaswa, F.G., Zaramba, S., Opio, A., Lutwama, J.J.,
Kamugisha, J.,Rwaguma, E.B., Kagwa, P., And Lamunu, M. 2002. An
outbreak of Ebola in Uganda. Trop. Med. Int. Health. 7, 10681075.
Oyewale .T, Rollin, P.E. etc1995. Serologic Survey among Hospital and Health
Center Workers During the Ebola Hemorrhagic Fever Outbreak in Kikwit,
Democratic Republic of the Congo,1995.
Pandey, A. 2014. South East Asia in Ebola (Ebola Scare in Southeast Asia as
Vietnam and Myanmar Test Suspected Patients). International Business
Times.
Richards, G. A., Murphy, S., Jobson, R., Mer, M., Zinman, C., Taylor,
R., Swanepoel, R., Duse, A., Sharp, G., And De La Rey, I.C. Crit. 2000.
Unexpected Ebola virus in a tertiary setting: clinical and epidemiologic
aspects. Care Med, 28, 240244.
Salaam-Blyther, T. 2014. The 2014 Ebola Outbreak: International and U.S.
Responses Congressional Research Service.
Schwartz, D. 2014. Worst-Ever Ebola Outbreak, by the Numbers 394 New Cases
in 5 Days: 'Exponential' Increase Will Require Exceptional Response, Un Says
CBC News
Scidev.Net 2014. Asia-Pacific Analysis: Is the region ready for Ebola? South-East
Asia & Pacific desk.
Tambo1, E & Ngogang, J.Y 2014. Need of surveillance response systems to combat
Ebola outbreaks and other emerging infectious diseases in African countries.
Tambo et al. Infectious Diseases of Poverty
104
Tomori . O, B. J., Rollin. P.E, Fleerackers. Y, Guimard. Y, Roo. A.D 1999. Serologic
Survey among Hospital and Health Center Workers during the Ebola
Hemorrhagic Fever Outbreak in Kikwit, Democratic Republic of the Congo,
1995. The Journal of Infectious Diseases, 179.
U.S., 2014. Ebola Hemorrhagic Fever Fact Sheet. Special Pathogens Branch
Division of High-Consequence Pathogens and Pathology National Center for
Emerging Zoonotic Infectious Diseases Centers for Disease Control and
Prevention U.S. .
WHO 2014. Case definition recommendations for Ebola or Marburg Virus Diseases.
WHO 2014. Global Alert and Response (GAR) Ebola virus disease update - west
Africa. Disease outbreak news.
WHO 2014. Ebola virus disease. Media centre, Fact sheet N103.
WHO 2014. West Africa - Ebola virus disease.
WHO 2014. Frequently asked questions on Ebola virus disease.
WHO 2014. WHO Statement on the Meeting of the International Health Regulations
Emergency Committee Regarding the 2014 Ebola Outbreak in West Africa.
WHO 2014.05 June, 2014. Interim Version 1.1 Ebola and Marburg Virus Disease
Epidemics: Preparedness, Alert, Control, and Evaluation.
WHO/HSE/PED/CED/2014.05 (June, 2014).
WHO 2014. Ebola and Marburg virus disease epidemics: preparedness, alert,
control,and evaluation. HSE/PED/CED.
WHO 05-Aug-2014 West Africa - Ebola Virus Disease. 2014 Ebola Virus Disease
(EVD) outbreak in West Africa Travel and transport risk assessment:
Recommendations for public health authorities and transport sector.
WHO 8 August 2014. Who Statement on the Meeting of the International Health
Regulations Emergency Committee Regarding the 2014 Ebola Outbreak in
West Africa.
WHO 2014 August. Personal Protective Equipment (Ppe) for Ebola Virus Disease
Frequently Asked Questions (Faqs) August 2014.
WHO 2014 August. Ebola and Marburg Virus Disease Epidemics:
Preparedness, Alert, Control, and Evaluation. ; 2014 (Available at:
http://www.who.int/csr/disease/ebola/manual_EVD/en/ (accessed 28.08.14.))
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ANNEXES
Annex (1) Variables and operational definitions
No.
Variable Names
Operational definitions
Measurement
scale
1.
Age
Ratio
2.
Gender
Nominal
3.
Race
Race of respondent
Nominal
4.
Academic year
5.
Marital status
6.
Total years of
service in
government
life
Other qualification
8.
Current posting
9.
Training
10.
Information
11.
Knowledge
Ordinal
Nominal
Ordinal
Nominal
Nominal
Nominal
Nominal
Ordinal
12.
Perception
107
Nominal
Name of Organization
Name of Proposal
in
Introduction
I am Min Htike Aung, and studying at University of Public Health. I am doing
research on Knowledge and perception towards Ebola virus disease among nursing
students in University of Nursing, Yangon. I am going to give you information and
invite you to be part of this research. Before you decide, you can talk to anyone you
feel comfortable with about the research. This consent form may contain words that
you do not understand. Pleases ask me to stop as we go through the information and I
will take time to explain. If you have questions later, you can ask me or another
researcher.
(2)
Ebola virus disease among nursing students in University of Nursing, Yangon. This
information might helpful in strengthening of the public health education program.
108
(3)
(4)
Participant selection
You are being invited to take part in this research because we feel that you had
(5)
Voluntary participation
Your participation in this research is entirely voluntary. It is your choice
whether to participate or not. If you choose not to participate in the study and nothing
will change. You may change your mind later and stop participating even if you
agreed earlier.
(6)
Procedures
We are inviting you to take part in this research. If you accept, you will be
(7)
that you may feel uncomfortable talking about some of the topics. However, we do
not wish for this to happen. You do not have to answer any questions or take part in
the survey if you feel the question(s) are too personal or if talking about them makes
you uncomfortable.
109
(8)
Benefits
There will be no direct benefit to you, but your participation is likely to help
us find out more about how to provide appropriate public health information and
services in line with the needs of knowledge and perception towards Ebola virus
disease.
.
(9)
Incentives
You will not be provided any incentives to take part in the research.
(10)
Confidentiality
The research being done in the community may draw attention and if you
participate you may be asked questions by other people in the community. We will
not be sharing information about you to anyone outside the research team. The
information that we collect from this research will be kept private. Any information
about you will have a number on it instead of your name. Only the researcher will
know what your number is and we will keep the number safely.
(11)
local health staff before it is made widely available to the public. We will publish the
results so that other interested people may learn from the research.
(12)
choosing not to participate will not affect your rights and advantages in any way. You
may stop participating in the answering the questions at any time that you wish
without being affected.
110
(13)
Who to contact
If you have any questions, you can ask them now or later. If you wish to ask
questions later, you may contact Min Htike Aung (Phone no - 0943004426),
University of Public Health, Yangon.
Name of participant
-------------------------
Signature of participant
-------------------------
Date
-------------------------
I have been read this consent form for participation and known about their
desire questioning and answering. I confirm about participants consent freely getting
it.
Name of researcher
-------------------------
Signature of researcher
-------------------------
Date
-------------------------
111
(Ebola)
(Ebola)
()
() /
(Ebola)
()
()
()
(Ebola)
112
()
() /
(Ebola)
(Ebola)
()
(Ebola)
()
(Ebola)
/
()
113
()
(Ebola)
(Ebola)
()
()
()
(Ebola)
()
()
114
()
()
()
()
()
-)
115
()
(Ebola)
()
()
------------------------------------------------------
/ -----------------------------------------------------
-----------------------------------------------------
------------------------------------------------------
------------------------------------------------------
------------------------------------------------------
116
(2) Female
2. Academic year
(1) First Year (B I)
------------- yrs
5. Religion
(1) Buddhist
(2) Christian
(3) Hinduism
(4) Islam
6. Marital Status
(1) Single
(4) Widow
(2) Married
(3) Divorced/Separated
(5) Others -------------------------- (Specify)
-------------------- yrs
117
Office Use
(1) Yes
(2) No
(b) Radio
(1) Yes
(2) No
(2) No
(1) Yes
(2) No
(e) Pamphlet/posters
(1) Yes
(2) No
(1) Yes
(2) No
(1) Yes
(2) No
(2) False
(2) False
(2) False
(2) False
(2) False
6. Ebola virus was also found in vector animals as mosquitoes and flies.
(1) True
(2) False
(2) False
118
Office Use
(2) False
(2) False
(2) False
11. Ebola virus can be transmitted by direct contact with infected patients.
(1) True
(2) False
(2) False
(2) False
(2) False
15. Headache and sore throat are early signs of Ebola disease.
(1) True
(2) False
16. Signs of Ebola disease include muscle pain and joint pain.
(1) True
(2) False
(2) False
119
(2) False
(2) False
(2) False
(2) False
(2) False
(2) False
(2) False
(2) False
(2) False
(2) False
(2) False
120
(2) False
(2) False
(2) False
(2) False
(2) False
(2) False
(2) False
(2) False
(2) False
(2) False
121
39. Ebola suspected patients should be kept quarantine for five days.
(1) True
(2) False
(2) False
41. All waste products touching with Ebola patients must be destroyed
by burning.
(1) True
(2) False
(2) False
122
Office Use
123
124
Office Use
11. In continuing nursing education program, the selection topic towards Office Use
emerging disease like Ebola should be presented and discussed.
(1) Strongly agree
(2) Agree
(3) Disagree
(4) Strongly disagree
12. I would share and distribute to my family, friends and colleagues
about information on Ebola disease.
(1) Strongly agree
(2) Agree
(3) Disagree
(4) Strongly disagree
125
(Ebola)
()
( - ( )
()
()
()
()
() ---------------------
()
() --------------------- ()
()
()
()
()
()
()
126
() /
()
()
() /
()
()
() ------------------------
/
() --------------------------------------------- ()
()
/
() /
()
() /
()
(Infection Control and Emergency Training)
() --------------------------------------- ()
()
127
()
( -
/
/
/
()
()
. ()
()
()
()
. Influenza
()
()
()
.
()
()
()
.
()
()
()
.
()
()
()
.
()
()
()
. /
()
()
()
128
.
()
()
()
.
()
()
()
.
()
()
()
.
()
()
()
.
()
()
()
()
()
()
.
()
()
()
.
()
()
()
.
()
()
()
.
()
()
()
.
()
()
()
129
()
()
()
.
()
()
()
()
()
()
.
()
()
()
.
()
()
()
.
()
()
()
.
()
()
()
.
()
()
()
. /
()
()
()
. X ray Ultrasound
()
()
()
.
()
()
()
130
.
()
()
()
.
()
()
()
()
()
.
()
()
()
.
()
()
()
. /
(Sterilization Methods)
()
()
()
. Bleaching powder
(Sterilization Methods)
()
()
()
.
()
()
()
.
()
()
()
.
()
()
()
.
()
()
()
.
()
()
()
()
()
()
131
()
()
()
()
()
()
()
()
()
(Fever Screening)
()
()
()
()
PPE (Personal protective equipments)
()
()
()
()
132
()
()
()
()
()
()
()
()
()
()
()
()
133
()
()
()
()
()
()
()
()
(Emerging diseases)
()
()
()
()
()
()
()
()
134
True
False Don't
know
1.
2.
3.
4.
5.
6.
8.
9.
10.
11.
infected patients.
12.
13.
Ebola
virus
can
be
transmitted
by
touching
15.
disease.
16.
17.
18.
135
False Don't
know
Ebola disease.
20.
21.
Ebola disease.
22.
23.
24.
25.
26.
27.
28.
29.
30.
disease.
31.
32.
33.
34.
disease.
35.
136
False Don't
know
38.
39.
40.
41.
42.
0 - 28 scores
137
4.
Positive statements
Score
(2) Agree
(3) Disagree
5.
(2) Agree
(3) Disagree
11.
(2) Agree
(3) Disagree
(2) Agree
(3) Disagree
138
No.
Positive statements
Score
12.
No.
2.
(2) Agree
(3) Disagree
Negative statements
Score
3.
(2) Agree
(3) Disagree
6.
(2) Agree
(3) Disagree
(2) Agree
(3) Disagree
139
No.
7.
8.
Negative statements
Score
(2) Agree
(3) Disagree
9.
(2) Agree
(3) Disagree
10.
(2) Agree
(3) Disagree
(2) Agree
(3) Disagree
Good perception
Poor perception
12 - 43 scores
140
Month
Days(From---to--)
Protocol
preparation
Protocol defense
Data collection
Data Entry and
Analysis
Thesis
preparation
Submission of
thesis(draft)
Distribution of
draft to readers
Thesis defense
Submission of
Thesis
September
1
19
22
October
24
25
10
13
November
31
21
24
28
December
4
12
15
19
22
31
2. Date of Birth
8-7-1986
3. Place of Birth
4. Nationality
Mon/Bamar
5. Religion
Buddhist
6. Education
B.N.Sc
University of Nursing, Yangon
7. Year of Qualification
January, 2007
Tutor
8. Current function
1-12-2014 up to now
Trained Nurse
Yangon Children Hospital
1-4-2011 to 30-11-2014
Instructor
Community Health Nursing
Department,
University of Nursing, Yangon