According to the World health organization (2007) “Health is a state of complete physical, mental and social well-being , not merely the absence of disease and infirmity”. From this definition we surmise three main aspects and they always stroll side by side. This definition has both psychiatric and medicine field which insist us for holistic care. If one of the aspect will be ignored then it will difficult to achieve the complete state of well being. The health care professional should take care of physical problems while treating their mental health (Sturgeon, 2007). Mental health set ups are not only to treat the mental disorders, but the physical health issues too. On the other hand, “ the physical health of patients with mental illness is neglected which leads to high premature mortality rates” (brown, 2012).

Writing on this topic will help in understanding the importance of holistic care in mental health care setting. Neglecting physical health is a serious issue. Health care providers can prevent thousands of premature deaths by simple interventions, like the care of minor physical instabilities. With the socio-cultural context, stigma and stereotyping are the major barrier of physical health in mental health. In our culture, people easily stigmatize the patient without thinking the consequences. “Unluckily stigmatizing attitudes toward mental illnesses are present within the mental health professions themselves. The staff usually stigmatizes the patients and treats them unfairly. Instead of paying attention they just ignore the symptoms reported by the patients and label them as symptoms of mental health. Such symptoms may further worsen the condition”. (Cooper 2010)

Thornicroft 2011 conducted a study which shows that only 13% mentally ill patients are getting the proper physical health treatments, 48% are getting poorer attention, the rest 30% are not getting any physical attention and 80% population is dying because of this issue which is the main factor of increasing mortality rate. Two main reasons are unnatural deaths and poorer physical health care.

However, It shows the high mortality rate in mentally ill patients due to ignorance of physical health. It is very important to address this issue and take important steps to improve their health. During my mental health clinical, I found the enormous ignorance of physical health. A 25 years old female was facing extreme stomachache and she was complaining continuously. On the first day, Everybody was ignoring the patient by saying she is depressed rather listen her complain. Staff even didn’t perform any assessment or notice the facial expressions of the patient. On the second day when I went to the patient she reported her complain and I shared her concern to the doctor she said that just ignore these patients otherwise they will start complaining all the time. On the third day when I attend the clinical, staff told me that patient was very sick at night so she is admitted in hospital for physical checkup. Contemplating the scenario its perturbing that staff is ignoring those mentally ill patients who are very vulnerable to other threatening problems and other unexpected outcomes.

“Mentally ill patients are more prone to physical illness than the general population because of many reasons such as lack of exercise, high rates of

smoking

and poorer diet all contributes to diseases like hypertension, high cholesterol and respiratory illness etc” (Chacón, 2011). Some researchers show a strong genetic relationship between some psychological and physiological illness such as the people with diabetes have the tendency to get schizophrenia. Patient with mental illness can’t pay attention to their physical health so it is our responsibility to take care of their health. Further, somatic pain is also a reason, referring to the scenario my patient had pain, but nobody was listening to her concern because they were assuming that she have somatic delusions. These perceptions lead to serious illnesses in mentally ill patients. Thornicroft (2011) states that “there are many barriers which contribute to physical illness. He gives the concept of “diagnostic overshadowing” that people with mental illness receive worse treatment for physical disorders”. If a patient is admitted in emergency with co-morbid of mental illness and diabetes, staff will less likely to concentrate on diabetes. Furthermore, workload and shortage of trained staff are the contributing factors. Else, negligence in daily assessment is a major issue. Referring to my scenario, the patient was showing facial expressions but they didn’t notice it. Brown (2012) says that “health disparities experienced by these people is due to problems in accessing health assessment or lack of resources like equipment to assess the physical symptoms”. They should have access to all the facilities such as BP apparatus, to check their BP like in other diseases. Moreover, these patients are unable to explore their symptoms because of altered thought process and the side effects of antipsychotic drugs. These factors lead to serious physical problems in those mentally ill patients.

According to Maslow’s Hierarchy, physical needs and health are the most important to be fulfilled. He says that physiological needs are deficiency needs, meaning that these needs are important in order to avoid unpleasant consequences like pain . So, from this model we can infer that physical health and needs are important in order to maintain a healthy life.

Now, it’s our responsibility to aware the client about reducing the cause of physical illness. Moreover, to fulfill these responsibilities we should plan some strategies. At the individual level, we can only achieve the improvement, when the health care providers are trained in the skills like therapeutic communication, proper physical assessment, and other psychomotor skills. Staff should be sincere with their patients and have a keen eye on their patient’s assessment. (Brown, 2012) states that “ mental health nurses and clinicians play an active role in health promotion, primary prevention and the early detection of physical health problems”.

At the community level, management of health care organization should arrange trainings for providing the latest and reliable information that will help staff to give holistic care, to refresh their knowledge with new researches and the ongoing evaluation and analysis of training sessions. Thus the improvement in all these aspects will help caregivers to provide holistic care to mentally ill patients and complete state of wellbeing. Furthermore, at this level we can give knowledge to the families that their consciousness will be helpful for the patient and their early detection.

At the international level, we need a multidimensional strategy to reduce disparities in the physical health of mentally ill patients (Tsay, 2007). Integration of mental and physical health is very important, like in my scenario patient was getting only medical attention and the staff was ignoring her verbal pain and facial expressions. These organizations which are handling mentally ill patients should take care of physical health to provide them holistic care and enough resources for the health care professionals to manage their health with all the three aspects.

In conclusion, the physical health of mentally ill patients should be part of the field of action of psychiatric practitioners. Health consists of physical, mental, and social aspects consideration of all three aspects are very essential; a change in one aspect will lead to distortion of health. There for it is the duty of health care providers and organizations to prevent illness and restore health by screening, diagnosis and treat physical illness of mentally ill patients. Here my suggestion is that as a health care professional, we have to consider all three aspects of health and provide holistic care to the patients to achieve a complete state of health.

REFERENCES

Thornicroft, G. (2011).

physical health disparities and mental

. The British Journal of Psychiatry Retrieved from

http://bjp.rcpsych.org/content/199/6/441.full.pdf

Buhagiar, K. (2011

). physical health behaviors and health locus of control in people with schizophrenia-spectrum disorder and bipolar disorder: a cross-sectional comparative study with people with nonpsychotic mental illness

. BMC Psychiatry Retrieved from

http://www.springerlink.com/content/2628t51807u8p131/fulltext.pdf

Tsay, J. (2007).

disparities in appendicitis rupture rate among mentally ill patients

. Retrieved from

http://www.springerlink.com/content/a6v7309617l52m76/fulltext.pdf

Chacón, F. (2011).

Efficacy of lifestyle interventions in physical

. Annals of General Psychiatry Retrieved from

http://www.springerlink.com/content/d4ku137132654624/fulltext.pdf

Brown, B. (2012).

improving the physical health of people with severe mental illness

. No mental health without physical health Retrieved from

http://docs.health.vic.gov.au/docs/doc/20C06D82E2C17401CA2578B700253D49/

$FILE/improving-the-physical-health-of-people-with-severe-mental-illness-no-mental-health-without-physical-health.pdf

Cherry, K(nd)

. Hierarchy of needs

. The Five Levels of Maslow’s Hierarchy of Needs Retrieved from

http://psychology.about.com/od/theoriesofpersonality/a/hierarchyneeds.htm

Sturgeon, S. (2007).

Promoting mental health as an essential aspect of health promotion

.Oxford University Press. Retrieved from

http://heapro.oxfordjournals.org/content/21/suppl_1/36.abstrac

(1948).

Who definition of health

. Retrieved from

http://www.who.int/about/definition/en/print.html

Meldrum, D. (2011).

the physical health of people living

. Retrieved from

http://www.mifa.org.au/sites/www.mifa.org.au/files/documents/Physical

health Lit review FINAL June 2012.pdf

(2012

). Physical health conditions among

. Retrieved from

http://www.samhsa.gov/data/2k12/NSDUH103/SR103AdultsAMI2012.pdf

This assignment is a critical analysis and reflection of my continuing personal and

professional development

(CPPD) needs in practice. This account will identify practical needs that I must improve with supportive evidence based research, and evaluate the impact of this need for my personal development as a future qualified nurse. My learning need was with assertiveness in communication when working with a staff nurse during admission. To meet the need and demonstrate the ability to engage in advancing my care,

Gibbs (1988) framework model of reflection

will be used. To maintain confidentiality as emphasised by the Nursing and Midwifery Council (NMC 2008), a pseudonym Tommy will be used to protect the patient’s anonymity. In addition, I will be using the post-registration education and practice (PREP) guidelines (NMC 2011) to maintain up to date knowledge and skills as well as empowering a lifelong learning in my nursing career. (NMC 2012)

My skills in communication have improved in all contact and this has been acknowledged in every practice. However, I thought of this learning need, when I recognised my weakness was with assertiveness in communication when working with a staff nurse, faced with a difficult patient during admission. I took part in this learning activity in November, 2014 during my placement in hospital. I identified this need during the second week of placement, as I was able to perform patient admissions under the supervision of my mentor. The need to improve this skill was established from my mentor’s feedback and I agreed that it must be developed in order to help avoiding errors in future practice, improving my decision-making skills and professional satisfaction. I have spent a good amount of time to research and critically analyse this learning need However I felt this could be an ongoing process of improvement as Webb (2011) identified, supported by the Department of Health’s (2013) ongoing process of improvement in the NHS to be more efficient and less bureaucratic. I again felt this was important for me to work on because it had an impact on the patient and me as a future qualified nurse (Fowler, 2008).

Tommy is a 50 year old who suffers from right leg cellulitis and lives alone with his cat. I felt my first meeting with Tommy was challenging as I found it difficult to present myself as a self-assured, assertive and empathetic student nurse due to the impression that the situation was out of my comfort zone. I observed from the beginning of the visit that this gentleman was unable to cope; however I felt that I could not make a direct statement without coming across as patronising or a dominant student nurse. On the positive side, I chose to improve this learning need so that I would learn to be prepared with the knowledge and set of skills I must have in managing complex patient care in future placements (Fowler, 2008).

Having encountered patients who have refused requests from other student nurses and staff nurses alike by expressing their dislikes, disagreements and sometimes even anger when offered treatment, I have observed that patients sense how the student nurses present themselves and could base their decision on the student nurses’ abilities to communicate assertively (Fowler, 2008). This also made me think about my self-awareness and empathetic skills. As I listened to Tommy’s emotional concerns, he opened up about being terrified of not having anyone in his house to feed his cat while he was in hospital because he had no close relatives. I responded calmly and confidently, using clear language that my intention was to obtain his permission to allow health professionals offer long term support to him (Fischhoff et al, 2011).

As student nurses, our main role involves patient interaction and several studies have indicated that student nurses lack assertive skills evidenced by Bekkum and Hilton (2013) McCabe and Timmins (2005) qualitative study in two schools (n=30). It highlighted that most student nurses were assertive but chose not to display this skill to maintain positive interpersonal relations and avoid conflict. However, quantitative study (n=72) by Almost (2006) deemed it important to measure nursing students’ level of assertiveness prior to, and near completion of their pre-registration programme and to offer help throughout their programme to develop their assertiveness. Almost also considered the conflicts mainly developed from the multi-professional roles that student nurses have and that the basic nursing functions of caring and controlling can result in tension.

Many researchers have challenged these such as Iglesias and Vallejo (2012) qualitative study identified that work have established that conflict resolution techniques can be achieved through compromise and collaboration which the nurses can use for their specific work environments. However all the previously mentioned approaches suffered from serious limitations as Tommy’s safety could have been compromised when nurses failed to speak up or be heard, identified by Page’s (2004) qualitative study. I found Almost (2013) very appropriate when giving personal care because this technique would have enhanced my learning need earlier in my nursing programme to improve patient care. Bekkum & Hilton, (2013) qualitative study support and acknowledgement on these account findings imply that, education programs ought to be taken into account. The perceptions of the participant’s risks involved in not being assertive and the focal point must be on changing these perceptions rather than attempting to change student nurses’ values or focusing solely on specific assertive behaviours to improve student emotional intelligence. Based on the findings, I realised that my practice was out of date therefore would cost the National Health Service (NHS) and impact negatively on patients’ care.

As identified by Smith’s (2012) phenomenological study, 75 per cent (n=20) of student nurses felt unable to verbally express their concerns when working with qualified nurses. Yet Jones’ (2013) qualitative study identified that 60 per cent (n=30) of student nurses felt confident by the end of their training. However, there is little consensus in the research available although I feel my experience reflects Smith’s (2013) findings. My inability to be assertive during patient admission was because I was working with an experienced qualified nurse and hiding behind my mentor limited my development in skill. This impacted on my clinical ability when I failed to be an assertive student nurse. It also shows in these research studies I was not using up to date practice.

White’s (2009) phenomenological study identified that 75 per cent (n=28) nursing students in clinical placements suffer from self-doubt, have anxiety about their clinical performance and do not possess the characteristics of strong self-confidence. A qualitative study conducted for student nurses by Jones, Mccoy and Pitt (2013) have indicated that majority of student and staff relationships highlight that a sense of belonging was central for student nurses for a good clinical experience. A students’ sense of belonging and feeling a part of the team were essential before students could learn. This is reflected in Lathlean and Levett-Jones’ (2009) quantitative study (n=200) of student findings on third year student nurses who participated in the study as they had been on a number of clinical placements. This explanation, however, seemed to overlook the fact that many students feel compelled to work hard in order to fit in the nursing team rather than become motivated to learn. This has made me realise that although being in a good nursing team, I would still prioritise looking after my patients by paying more attention to the patient needs and expectations. A qualitative study conducted by Lyndon (2006) mentioned that student nurses’ ability to make a clinical decision could be influenced by patient situation, availability of resources and interpersonal relationships. Student nurses, however, on a variety of situations, can experience moral distress as Ganske, Iseminger, Lachman and Murray (2012) have identified in their phenomenological study. These two articles revealed that the ability to communicate with patients should not cause moral distress as student nurses would neither be aggressive nor patronising, nonetheless the interaction would achieve the patient’s best interest.

This is reinforced by Grumbach and Bodenheimer, (2004) qualitative study which identified (n=18) of student nurse, who noted that greater disability may be as a result of anxiety in some cases and loss of self-confidence. However, Begley (2010) phenomenological study (n=20) identified and argues, little has been investigated to explain the reasons why assertive behaviour occurs in one situation and not in another. Results suggest that, student nurses’ standard measures of assertiveness and of anxiety are irrespective of their scores p=00.1 chances. One should consider the consequences of student practitioners being assertive, while making a decision regarding how to behave I felt this was helpful in reminding me how important self- confident skills can aid improved patient care. Although, their underlying theories of subjectivity are very different, there are some important affinities between the researches that correlate which I believe would help me care better in future placement.

In addition, Begley’s (2010) qualitative study established that patients were to be considered as partners in their health care delivery. Trust does not come easily for people and I have since learnt from past experiences that patients need to be included and actively involved in the planning and evaluation of their care. By learning to ask open questions helped promote and encouraged patient expression and enabled patients to enhance trust in a relationship as I have shown my interest and investment in the patient’s care and treatment. This study has an impact in addressing my need and offered help on how to be assertive when dealing with difficult patients.

As highlighted by White (2014) qualitative study, majority of student nurse depend on their mentors to be assertive and sometimes adopt it as coping strategies. Even though, this is a small number of student nurses, (n=30) to base a judgement on, it provides statistically relevant data and allows an insight into practical experiences. I also felt this research was significant for me to work on my assertiveness, because it had an effect towards the patient and me as a future qualified nurse. I solely depended on my mentors for assertiveness as a coping strategy.

Conversely, these poor coping strategies I adopted were highlighted in a qualitative study by Fischhoff et al, (2011) where common coping strategies utilised by student nurses being assertive in clinical settings are explored. Although this is a small sample size (n=18) which does not provide statistically relevant data, it is qualitative design allows an insight into the student nurses experience of assertiveness coping strategies (Parahoo, 2006). I found these results of the thematic critical analysis linked to my own clinical experience, including the poor coping assertiveness strategy I adopted. This was due to underestimating my capacity from the onset of being self-assured and self-confident without being aggressive (REF). I found that these researches gave me insight into how unethical and limiting avoidance practices are when dealing with patients, which was seen in a small number of participants in this study (n=3) (Morris & Turnball, 2006). I felt this was helpful in reminding me how important assertiveness skills can improve patient care (Morris & Turnbull, 2006).

Besides, Fischhoff et al, (2011), descriptive study postulates assertiveness in student nurses who become attached to their mentors remain as consistent helpers for weeks in their placement during the period from the first till the third year, and it is suggested that this is due to the students underestimating their capacity from the onset of being self-assured. Although this is a small sample size (n=207) which does provide statistically significant relevant data, 60 percent (n=127) were more positive compared to 40 percent (n=83). Its quantitative design allows an insight into the student nurses’ experience of assertiveness skills (Begley, 2010).

Nonetheless, Phillips and Simmonds (2012) phenomenological study supported this descriptive study and further on said this is a key concern for some student nurses within practice setting. The concept of assertiveness and understanding concept as student nurses will enable them to consider that the patient’s aggressiveness might be about other issues rather than their care. In a phenomenological study of (n=50) nursing students in London, Monsu (2014) identified that greater disability may be as a result of anxiety and loss of self-confidence dealing with a difficult patient. Findings of these researches do not seek to be generalised but were reliable to me due to the appropriateness of the methodology and the thematic analysis being correctly applied. This will aid me in caring for my patients in future practice.

In a questionnaire survey of (n=200) student nurses in London, Smith (2013) identified that 70 per cent (n=49) of university students preferred mentors to do all the assertiveness communication for them due to underestimating their ability. Only 20 per cent (n=4) of students responded and of those who did respond, many of them did not fully complete the questionnaire. The data suggested that 70 per cent of students who preferred a mentor to do all the assertiveness communication do not constitute very strong evidence. Yet Monsu (2013) argues that from his own experience as a student in placement, there was a strong attachment with mentors being assertive in all him / her communication which did help with the assertiveness skills needed for future practice. This cannot be generalised as Monsu (2013) is not referring to a piece of empirical research but to his own experience. Having identified the context of Monsu’s (2013) own experience argument, I found it very relevant to me and it topped my hierarchy of evidence, but does not appear to have been undertaken in a thorough manner to help my caring for patients in future due to their lack of a soundly-based qualitative theory compared to Smith (2013).

Having discussed with my mentor what happened during the admission; it felt good to have attempted the interaction with the patient and recognised some of his needs. Even though the patient seemed reluctant, I demonstrated the ability to remain calm although I did struggle with my approach when I spoke to him about offering more support. Instead, I focused to help the client respond to my questions and identify what his concerns were. I believe during that incident, I showed assertive behaviour because I maintained my duty of care to the patient. I have reflected that this would have an effect on my clinical ability if I had failed to be the patient’s advocate. With the DOH (2009) updated work on providing guidelines on consent to treatment and putting these principles of consent into practice, my actions caused me to consider my practice whether obtaining informed consent would be an issue. Tommy fully realised that he should comply with the nurse as she understood the consequences if his pains were not treated (Cole, 2012). According to Baldwin, Duffield, Fry and Merrick (2011) the interaction between the decision-making, skill development opportunities, social support and identity comes with the nursing role so as to be prepared for the upcoming nurse population to meet new challenges.

When this type of situation happens again, I believe I have the skill to show my assertiveness skills by using compromise as well as recognising the boundaries of my actions. Using clinical decision skills and asking open questions, which I can gain from meeting other patients would enable me to show that I am a self- assured, reliable and trustworthy student nurse. I need to try and achieve leadership skills that could be essential for patient satisfaction and to achieve this, I have learnt to engage in leadership activities such as handovers and undertaking tasks on behalf of my mentor. I recognised that once I fitted into the clinical environment, I needed to be more actively involved in challenging clinical situations such as detecting unpredictable patient deterioration and learning to make quick clinical decisions. Cook & Leathard (2004) suggested that good student nursing leadership and good quality nursing care will be effective if nurses go through leadership training programmes during the early stages of their career. This can help me in preparation to become more aware of how I feel, think and act in front of my patients. Reflecting and learning to be assertive can increase my confidence and self-esteem through appreciating what I have done well and maturely, accepting the improvements I must make to become a better nurse in the future.

Having said that, I was satisfied that I had the opportunity to practice nursing handover, as it is one of the vital roles of a qualified nurse and one aspect of nursing care that is required of me when I am qualified.Loseby, Hudson & Lyon (2013) wrote, handovers are information that can influence the delivery of care. In the process of this learning experience I felt well supported by my mentor giving me several opportunities to practice my handover until I felt more confident and less anxious because she created quality time for me and necessary feedback that helped my learning need as well as other aspects ofnursing. McCloughen, O’Brien & Jackson (2010) defines a mentor as someone that helps others grow by teaching them, encouraging them and being interested in their success. This is also further supported byHamric, B.A., Hanson, M.C., Tracy, F.M., & O’Grady, T.E.,(2013) who indicated that a good mentor is one who spends quality time to foster growth, committed to the development of their learning need, willing to share and feedback on any rough spot in their career development.

In conclusion, I have critically analysed and reflected on clinical learning needs, which are essential for my continuing professional development. As a student, critical analysis and reflection helped to facilitate good learning outcomes so that I can relate and apply concepts to clinically orientated situations as well as explore and evaluate evidence. Also my clinical learning need was acknowledged through mentor feedback by showing assertive skills in communication with difficult patients. This need is an on-going process of development for me. However; I recognised that attempting interactions with patients and collaborating with nursing staff will help in my development to be a more self-assured nurse. Participating and engaging in leadership activities such as handovers and task delegation would be beneficial at this stage of my learning. Through the reflection and recognition of these learning needs, I could only move forward and continue to develop my learning proficiency as a student nurse towards professional competency as a qualified nurse.

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Introduction

Ebola virus is one of the most virulent and lethal pathogens known to human. Ebola virus epidemics have emerged from time to time since it was first discovered in 1976 from the Democratic Republic of Congo, formerly known as Zaire, but the largest known Ebola virus outbreak up to date is ongoing at the time of writing this article, in West Africa. Approximately 550 000 cases are estimated to be reported from Sierra Leone and Liberia by the 20

^th

of January 2015. The transmission of the infection to a number of countries including Guinea, Liberia, Sierra Leone, Nigeria and occasional cases being reported from USA, Canada, Netherland and India reveal the potential of the infection to get spread worldwide. Despite this disease being highly contagious, life-threatening, and no specific treatment being found, it can be prevented with the use of proper infection prevention and control measures. The study of the Ebola virus disease is important as that knowledge will pave the way for the reduction of victims, the invention of an effective drug and will also be useful in the management of a similar epidemic.

Virology

Ebola virus is a member of the family Filoviridae. As the name implies the virus is filamentous in shape. Marburg virus and Ebolavirus are the two main genera of the viral family which are medically important. Viruses of these two genera are studied and presented together due to their many similarities in the life cycle, the primary reservoirs, ways of transmission, clinical presentation, treatment and prevention measures. The only noted difference is that the Marburgvirus is spread by bat species adapted to open forests such as savannah whereas Ebolavirus is spread by bat species adapted to deep rain forests(1).

Five subtypes of Ebolavirus namely,

Ebolavirus zaire, Ebolavirus sudan,


Ebolavirus reston, Ebolavirus cote d’ Ivore,

and

Ebolavirus bundibugyo

have been identified and named after the area in which they were first discovered(1). Of these

E. Zaire

was the first to be isolated and studied(1) and it is responsible for the most number of outbreaks(1) including the latest outbreak in 2014 before which

E. sudan

accounted for ¼ of all Ebolavirus deaths(1). Except for the slight lower fatality rate,

E. sudan

is more or less similar to

E. zaire.

The case fatality rate of E. sudan is reported as 40-60% and that of E. zaire as 60-90% (3).

Transmission

Ebola is initially transmitted to human as a zoonosis. Various species of fruit bats found throughout central and sub Saharan Africa as hosts (2),( 4). Contact with bats through bites and scratches or exposure to their secretions and excretions through broken skin or mucous membranes can cause the infection in humans (2), (4). The infection can also be transmitted through other end hosts. Those recorded from Africa are forest antelopes, porcupines, chimpanzees, gorillas, monkeys and other non-human primates. Attacks during hunting these animals or handling infected animal carcasses have resulted in the introduction of the virus to the human population from the wild (1).The outbreak of the epidemic begins with the subsequent transmission of the infection from the index case to secondary individuals. An outbreak often begins from a single introduction to a human from the wild, which involves virus variants of little genetic diversity. Records reveal that outbreaks stemmed from multiple introductions lead to distinct chains of human to human transmission with a greater diversity in the virus variants(5).

EVD is highly contagious. The infection may spread in the community and in the hospital environment through direct contact with infected body fluids such as blood, secretions and excretions or tissue of an acute patient or through direct contact with contaminated materials like clothes and bed linen(1). One major reason for the rapid spread of the epidemic is the traditional funeral rituals, which include cleansing of the cadaver, removal of hair finger nails, toe nails and clothing. People taking care of infected people including health care staff also have a high risk of contracting the disease. Moreover semen of male survivors is said to remain infectious for up to 82 days after the onset of the symptoms. As long as the virus remains in the body fluids the person remains infectious. Airborne transmission of Ebola virus is strongly suspected but is not yet experimentally proven.

Clinical Presentation

EVD caused by different strains of Ebola virus bring about different clinical features. Incubation period of Ebola virus is generally considered as 2 – 21 days. (21, 3) Ebola virus disease shows various acutely developing constitutional prodromal symptoms which lead to a wide range of differential diagnosis including not only other viral haemorrhagic fevers, but also malaria (3), typhoid (3), cholera (1), other bacterial rickettsial and even non-infectious causes of haemorrhage.

The evolution of the disease resembles that of a severe haemorrhagic fever. Patients present with high fever, temperatures being as high as 39-40

⁰

C (3, 6), body aches and fatigue (3).Subsequently gastrointestinal symptoms such as epigastric pain nausea, vomits and /or diarrhoea without blood appear if fever persists until day 3 – 5 (6).

After 4 – 5 days of illness (4) a macular rash may appear but it may not be clearly noticeable on dark skin (1). After this stage haemorrhage from different sites begin. Bleeding from both upper and lower digestive tract, respiratory tract, urinary tract, vagina in females can be observed (21, 3). Further petechiae on the buccal mucosa, skin and conjunctivae develop. Recurrent episodes of vomiting which prevents any oral intake of fluids and large amounts of watery diarrhoea (5 or more liters per day) (6) contributes to a massive fluid loss leading to dehydration. If fluid replacement is inadequate, prostration, severe lethargy and ultimately hypovolaemic shock follows.

Hypovolaemic shock has been reported in 60% of the cases (6). Despite the high body temperatures, patients acquire cold extremities due to peripheral vasoconstriction. Rapid and thready pulses, tachypnea, oliguria or anuria can be observed (6). Simultaneously features such as asthenia chest and abdominal pains, pains in muscles and joints and headaches develop. Although in some cases cough and dyspnea occur due to pulmonary haemorrhages, other respiratory symptoms except for hiccups are uncommon (6). Conjunctival injection is a common clinical feature. Neurologic symptoms that are usually seen are hypoactive and hyperactive delirium characterized by slowed cognitive functions, confusion, agitation and rarely seizures (6). As the disease evolves internal bleeding can also start but generally by this time patients are already in a state of coma (1).

It is reported that only 5% of the patients present with haemorrhage from gastro intestinal tract before death. Most of the reported deaths have occurred due to shock during the 7

^th

to 12

^th

day of illness. Symptoms of 40% of the patients have improved around the 10

^th

day though symptoms like oral ulcers and thrush have developed. Most of the patients who survived up to the 13

^th

day have shown a higher chance of ultimately getting recovered. Some patients who showed initial improvement of symptoms have developed neck rigidity and lowered levels of consciousness which are associated with late mortality.

Pathology

Examination of autopsies and post-mortem biopsies is extremely useful in the study of the pathology of the ebola virus disease. Due to the biosafety risk to the autopsy personnel when handling specimens, pathological descriptions of only a limited number of cases are available (7).

A common finding of Haematoxilin and eosine stained tissue sections is oval shaped or filamentous eosinophilic intracellular inclusions which are formed by the aggregation of nucleocapsids of the virus. These inclusions can be detected in macrophages, hepatocytes, endothelial cells, connective tissue fibroblasts etc. Immunohistochemical stains reveal viral antigens in cells of various infected tissues including macrophages, dendritic cells, epithelial cells of sweat and sebaceous glands, interstitial and tubular cells of the kidney, seminiferous tubules, endothelial cells and endocardial cells. In addition necrotic cells and cell debris contain antigens in large quantities. Electron microscopy exhibits abundant free virus particles in alveolar spaces, liver sinusoids, and interstitial cells of the testis and in dermal collagen. Karyorrhexis and apoptosis are seen in the cells of the portal triads, macrophages of the red pulp of the spleen and in the tubular epithelial cells of the kidney (7).

Liver tissue shows the most symptomatic histopathological features including focal or widespread necrosis of hepatocytes and mild steatosis. Although usually inflammation is minimal, hyperplasia of kupfer cells and infiltration of mononuclear inflammatory cells is seen. Infected lung shows congestion, haemorrhage and intra-alveolar oedema but inflammation is not significant. Mild focal infiltrates of mononuclear inflammatory cells are known to occur in the lamina propria of the stomach small intestine and the colon. Skin biopsies reveal dermal oedema, focal haemorrhages, petechiae, ecchymoses, and macular rashes. The spleen and lymph nodes exhibit widespread lymphoid depletion due to apoptosis and necrosis. Inflammation of the kidney is not evident although acute tubular necrosis is a usual finding. Even though the endocardium of the heart contains viral antigens, the myocardium does not show any significant damage. Brain histology shows panencephalitis and perivascular infiltration of lymphocytes (7).

Prevention

World Health organization (WHO) has recommended a set of infection prevention and control measures for health-care workers that include precautions that should be taken at different stages of managing EVD patients

Standard precautions

Regardless of the diagnosis it is recommended for health-care workers to take standard precautions when handling all patients, as it is difficult to identify EVD patients during early stages of the disease. These are,

• Performing hand hygiene
• Using disposable gloves before touching materials probable of being contaminated with virus
• Wearing eye protection and gown before involving in procedures which have a possibility of body fluids being projected.

Hand hygiene

Hand hygiene must be performed using soap and water or alcohol-based hand rub solution, following WHO recommended technique,

• before wearing gloves and personal protective equipment (PPE)
• after an exposure to a patient’s body fluids
• after a contact with a contaminated surface or equipment
• after removing PPE.
• if hands are visibly soiled

Personal Protective Equipment (PPE)

PPE should be worn before entering EVD patients’ care areas according to the recommended order by WHO and removed before leaving the care area. Contact of a used PPE with any part of the face or non-intact skin should be avoided. The PPE includes,

• Non-sterile gloves of the correct size
• Impermeable and disposable gown with long sleeves
• Face shield
• Puncture resistant and impermeable closed shoes

Patient placement and management

Suspected or confirmed EVD patients should be isolated and if possible kept in single rooms. If not they must be placed in beds with at least 1m gap in between. Visitors must be restricted except for those who are needed for the well-being of the patient such as a child’s parent.

Management of used equipment and other materials

It is recommended that equipment like stethoscopes should be decontaminated and sterilized before reuse, if separate equipment is not available. Parenteral medication equipment, surgical blades, syringes and needles should never be reused. They should be disposed in puncture resistant bins. All non-sharp solid waste should be disposed in to leak-proof bags or bins.

Used linen should be collected in leak-proof bags kept at the place of use. They should be washed with water and detergent, rinsed, soaked in 0.05% chlorine for 30 minutes and then dried.

All bins must always remain upright and should be sealed when ¾ full. Before being taken out of the wards the outer surfaces of these containers must be disinfected using 0.5% chlorine.

Environmental cleaning

Cleaners should wear heavy-duty rubber gloves, and impermeable, puncture proof boots in addition to the PPE. Water and detergent must be used to clean the work surfaces and floors of the hospital. This should be practiced at least once a day. Other contaminated surfaces and objects must be cleaned and disinfected using 0.5% chlorine.

Handling of biological material

Performing autopsies,

post-mortem

biopsies and other laboratory tests of tissue samples of EVD confirmed or suspected patients should be minimized and should only be performed by trained personnel. Full PPE must be worn during handling specimens. All specimens should be delivered in clearly labeled, leak-proof, non-breakable, containers with disinfected outer surfaces.

Dead bodies must never be washed or embalmed. They should be sealed in double bags, disinfected with 0.5% chlorine and buried promptly. Some cultural and religious rituals can be adapted if needed, but handling of the body must be kept to a minimum and full PPE must be worn at all times.

In case of exposure to infected body fluids

All current tasks must be safely and immediately stopped and PPE must be removed safely. Affected skin should be washed with soap and water and any affected mucous membranes like conjunctiva should be washed off with a plenty of running water. The person should be checked for fever and other symptoms for 21 days.

Pathogenesis

Pathogenesis of Ebola virus shows a similarity to that of most of the other filoviruses which involves immunosuppression, increased vascular permeability and coagulopathy (7, 18). Ebola virus enters the host though abrasions of the skin, though mucous membranes or though injection by accident. The virus enters monocytes, macrophages and dendritic cells and gets carried away via lymphatics to the circulation. It then spreads to the liver and spleen infecting tissue macrophages and fibroblastic reticular cells. The main cellular targets of the virus are macrophages, dendritic cells and kupfer cells. Ebola virus shows interaction between varieties of cellular proteins which is why the infection is characterized by broad tissue and organ tropism.

Immunopathology

In most of the viral infections immune system plays a major role in containing the infection from spreading. However the tissues and organs of fatal EVD cases show minimal inflammation, suggesting of impairment in the immune responses.

It has been found that structural proteins of filoviruses

e.g.

VP24 (Virion protein) and VP35 inhibit interferon responses and thus evade the host innate immunity. As previously mentioned, apoptosis of natural killer cells and T lymphocytes is revealed in histopathology which explains the suppression of the adaptive immune responses.

As in many severe infections, Ebola virus infection also causes a massive release of pro-inflammatory mediators and vasoactive substances. Even though the pro-inflammatory mediators promote inflammation and coagulation, the systemic spread of the infection is not effectively controlled. This is probably due to the vasodilation mediated by the vasoactive substances.

Endothelial dysfunction and coagulopathy

The virus invades endothelial cells and endocardial cells and causes injury (18). This results in internal haemorrhage, fluid and electrolyte imbalance and cardiovascular failure. Endothelial damage results in the platelet aggregation and consumption. The increased level of pro-inflammatory factors and the increased production of surface tissue factor protein in infected monocytes and macrophages promote the coagulation cascade. Due to the hepatocellular damage the production of coagulation factors, fibrinogen, protein C and S are also decreased .Collectively this results in disseminated intravascular coagulation.

Other socio-economic problems related to Ebola virus epidemics

When considering the current outbreak, in addition to the huge number of lives that has been succumbed to the disease, it has created many other critical problems not only in Ebola hit countries, but in other African countries as well.

Agriculture has the biggest contribution to the African economy. As many farmers have died of the epidemic and many have abandoned their farmlands in the fear of catching the disease, there is a huge labour shortage in these countries and a fall of food production. An emergence of a food scarcity in the near future is predicted by experts.

Chocolate producing companies and many other industries are greatly affected by labour shortage. Nigeria and Ivory Coast are major cacao producing countries but most of the workers are migrants from Liberia and Guinea. International companies like Nestle and Mars have launched education and fundraising programmes to prevent the spread of the infection among cacao workers.

Many schools have been closed owing to the deadly infection surging through the country. Besides the impact on education, the feeding programme carried on by the governments for children has come to a standstill as a consequence.

Tourism is another sector hit by the epidemic. Even though Africa is a large continent bigger than Europe, USA and China combined; tourists tend to see it as a single country since the Ebola epidemic has emerged. For instance, Tanzania, a famous wild life destination is an East African country, more than 6000 miles away from an Ebola hit land. It is reported that hotels of Tanzania have lost 50% of bookings for 2015 (21).

Many African countries refuse to host international events and conferences due to the risk of the Ebola epidemic being introduced. For example, Morocco, the host of African Cup of Nations, which is scheduled to January 2015, requests a postponement. The government says, “There is no way we can be lenient with the health and safety of the Moroccan citizens” (24).