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Assessment of the Knowledge, Attitude and Practice of Pygmies towards the Transmission of Ebola Viral Disease in the Congo Basin: A Descriptive and Analytic Cross-Sectional Study

Author(s): Frankline Sevidzem Wirsiy, Jane-Francis Akoachere, Alphonse Um Boock, Dickson Shey Nsagha, Emmanuel Nji Kah, Adolf Tah Yoah, Eugene Vernyuy Yeika

Article Information

Untitled Document

Frankline Sevidzem Wirsiy1*, Jane-Francis Akoachere2, Alphonse Um Boock3, Dickson Shey Nsagha1, Emmanuel Nji Kah1, Adolf Tah Yoah1, Eugene Vernyuy Yeika4

1Department of Public Health and Hygiene, University of Buea, Cameroon
2Department of Microbiology and Parasitology, University of Buea, Cameroon
3FAIR MED Technical Adviser for Africa, Sri Lanka and India
4Bangangte District Hospital, Bangangte, Cameroon, Clinical Research Education Networking and Consultancy, Douala, Cameroon

*Corresponding Author: Frankline Sevidzem Wirsiy, Faculty of Health Sciences, Department of Public Health and Hygiene, University of Buea, Cameroon

Received: 08 November 2018; Accepted: 14 November 2018; Published: 21 November 2018

Abstract

Background: Ebola virus disease (EVD) or Ebola haemorrhagic fever is a fatal illness in humans and non-human primates caused by the Ebola virus. Several outbreaks of the EVD have occurred in sub-Saharan Africa, especially in the Congo Basin. We therefore sought to assess the Knowledge, Attitude and Practice of Pygmies towards the Transmission of Ebola Viral Disease in the Congo Basin of Eastern Cameroon.

Methods: A cross-sectional community based study was conducted from August to September 2016. Multi-stage cluster sampling was used to select 13 villages from the Abong-Mbang Health District in the Baka community of South Eastern Cameroon. A total of 510 inhabitants were selected using systematic random sampling technique. Data was collected using structured interviewer-administered questionnaire and analysed using SPSS version 20. Descriptive statistics were conducted and results presented using tables.

Results: Of the 510 participants included in this study with a female predominance of 257 (50.4%). The main occupations of the inhabitants were hunting 160 (31.4%) and farming 152 (29.8%). Although 425 (83.3%) of the inhabitants were aware of EVD, most did not know how what caused it: 76 (14.9%) thought it is caused by a witchcraft, 87 (17.1%) by a curse and 72 (14.1%) by dead animals. Based on the participants’ opinion, the modes of transmission of EVD included: waterborne 75 (14.8%), airborne 89 (17.5%), witchcraft 195 (38.2%), smoking 50 (9.8%) and consuming bush meat 101 (19.7%). Common practices carried out by participants included: consumption of dead animals picked up in the bush 113 (22.2%), consumption of fresh uncooked meat 73 (14.4%), exposing and touching dead bodies 396 (87.6%), scarification 357 (70.0%) and seeking primary health care from a traditional healer when sick 187 (36.7%). Respondent with secondary and tertiary education had better practices on the prevention of EVD compared to those with primary or no formal education (37.5% versus 25.3%).

Conclusion: Though majority of pygmies were aware of the existence of EVD, many had a poor knowledge on its cause and transmission, and equally showed a negative attitude towards the disease. Only educational level and tribe were significantly associated with good attitude towards the transmission and prevention of EVD. We suggest sensitization and surveillance of communities for EVD in the Congo Basin as a means to prevent subsequent potential outbreaks of an Ebola epidemic.

Keywords

Knowledge, Attitude, Practice, Ebola Viral Disease, Congo Basin

Article Details

Untitled Document

Abbreviations: EVD-Ebola viral disease; SSA-Sub Saharan Africa; WHO-World Health Organization

1. Introduction
Ebola virus disease (EVD) or Ebola haemorrhagic fever (EHF) is a fatal illness affecting humans and nonhuman primates caused by the Ebola virus [1, 2]. Ebola virus largely circulates in sub-Saharan Africa causing dreadful epidemics of EVD [3]. This virus was discovered during simultaneous outbreaks of febrile illness with shock and haemorrhage in Sudan and former Zaire in 1976 [4]. There are presently 5 known species of Ebola virus: Zaire Ebola virus, Sudan virus, Ivory Coast virus, Bundibugyo virus (discovered in an outbreak in Uganda) and Ebola Reston (not pathogenic to humans) [1]. Since 1976, over 25 outbreaks have been reported and most outbreaks occurring in the Congo Basin and the largest and deadliest outbreak ever registered was the 2014 epidemic in West Africa [5, 6]. Spread of EVD occurs through mucous membrane or percutaneous contact with body fluids (blood, urine, faeces or saliva) of an infected human [6]. Skin and skin structures appear to be heavily infected after death and may transmit infection during burial practices [7]. Body fluids that may contain Ebola viruses include saliva, mucous, vomit, faeces, sweat, tears, breast milk, urine and semen [5]. Semen or breast milk of a person after recovery from EVD may carry the virus for several weeks to months [7]. Symptoms of EVD are non-specific and typically occur 8-10 days after exposure and can last as long as 16-17 days [1]. Common symptoms include fever, headache, joint and muscle aches, body weakness, followed by diarrhoea, vomiting, abdominal pain, and red eyes [1]. Haemorrhagic symptoms usually occurs late and resulting late diagnosis of Ebola virus [1, 2]. Common laboratory complications of EVD include elevated aminotransferases levels, marked lymphocytopenia, and thrombocytopenia [8].

Many factors increase the risk of acquiring and transmitting the Ebola virus [9]. Prevention of EVD is largely through avoidance of risky activities particularly those which expose an individual to contact with body fluids of the animal suspected to be the reservoirs to Ebola virus [2]. These activities include consuming animals known to be reservoirs, consuming dead animals picked from the forest, consuming raw animals and practicing hunting as a major occupation [2]. EVD has high mortality and no specific treatment or vaccine [1-3, 6]. Treatment is mainly supportive in nature [6]. Lack of proper knowledge, attitude and good practices toward the acquisition, development and transmission of the EVD is a great risk factor that exposes communities to EVD epidemics. Forest-dwelling hunter-gathering activities can expose the indigenous population to the risk of Ebola virus infections as they can easily get in contact with reservoirs and consequently develop an epidemic. On 8 May 2018, WHO was notified by the Ministry of Health of the Democratic Republic of the Congo (DRC) of two confirmed cases of Ebola virus disease occurring in Bikoro health zone, Equateur province [10]. This is the ninth time Ebola has been recorded in Congo. The question remains: What are the determinants of EVD transmission among inhabitants of the Congo Basin? We therefore sought in this study to assess the knowledge, attitude and practice of pygmies towards the Transmission of Ebola Viral Disease Transmission among pygmies in the Congo Basin of South Eastern Cameroon.

2. Methods
2.1 Study design and setting
We carried out a community based cross-sectional descriptive study from August to September 2015 to assess the knowledge, attitude and practice of pygmies towards the transmission of Ebola viral disease transmission among Pygmies in the Abong Mbang Health district situated in the Congo Basin. The Abong Mbang health district population as of 2014 was estimated at 28,904 inhabitants and covered an area of about 15,000 km2 [11]. It is made up of 8 health areas namely; Mindourou, Nkouak, Mbomba, Angossas, Ankoung, Atok, Abong Mbang North and Abong Mbang South as shown in Figure 1 and this health district has 25 public and private health facilities [11].

image

Figure 1: Level of Good Knowledge, Attitude and Practice on EVD.

The Congo Basin has a total surface area of 3.7 million square kilometers cutting across many countries including the South-Eastern rainforest of Cameroon. This Basin is populated mainly by Pygmies (Bantus and Bakas) and has numerous and diverse species of animals including monkeys, fruit bats, gorillas and chimpanzees which are known reservoirs to the Ebola virus. This Congo Basin was the seat of the first Ebola outbreak in 1976 and following that, several outbreaks of EVD have been reported from this region.

2.2 Definition of terms
2.2.1 Risk: The chance of becoming infected if exposed to an infectious agent by its specific transmission mechanism.

2.2.2 Determinant: A determinant is any factor or variable that can affect the frequency of a disease or health outcome in a specific population. Determinants can be classified as either intrinsic or extrinsic.

2.2.3 Exposure: Refers to the proximity and/or contact with a source of a disease agent in such a manner that effective transmission of the agent or harmful effects of the agent may occur.

2.2.4 Primary transmission: This is when the infection is acquired directly from the host

2.2.5 Secondary transmission: This is when the infection is acquired from another infected person.

2.2.6 Risk of exposure of participants to developing the EVD: This was defined based on the number of reservoirs to Ebola consumed by the participants. Very high exposure to developing EVD was defined as those who consumed all the 6 animals known to be Ebola reservoirs (fruit bats, chimpanzees, gorillas, buffalo, monkeys, antelope and porcupines), high exposure were those who consumed 4-5 of these animals, moderate exposure were those who consumed 2-3 animals, and low exposure were those consumed none or just one of the animals.

2.2.7 Knowledge on transmission of EVD: Those who were considered to have a good knowledge on the transmission of EVD were those who thought EV could be transmitted through direct contact with infected persons or by consuming contaminated animals. Fair knowledge was for those who thought transmission was through sexual contact or sharing cloths. Poor knowledge was defined as those who thought that EV was transmitted by witchcraft, smoking and by flies or that EVD was a curse or those who or had no idea on the mode of transmission.

2.2.8 Bush meat: Animals hunted from the forest and consumed by the community.

2.3 Sample size determination
The minimum sample size was estimated using a single population proportion formula, image Since there was no similar study in SSA, the following assumptions were made: 95% (Z=1.96) confidence interval, 50% proportion
and 5% margin error. Therefore image

2.4 Data collection and analysis
Multi-stage cluster sampling was used to select 13 villages from the Abong-Mbang Health District namely Dympam, Nobamkele, Cyrie, Diassa, Mbang, Mbiatoh, Elandjoh, Sombou, Kendjo, Bitsoman, Mayos, Mballam and Djibot in the South-Eastern Rainforest of Cameroon and 510 participants were further selected using systematic random sampling from households. Data was collected using a structured interviewer administered questionnaire. Data was entered into Epi-Info version 3.5.3 and analyzed using Statistical Package for Social Scientists version 20. Descriptive statistics were used to summarize the independent variables of interest and presented as tables.

2.5 Ethical considerations
Ethical approval was obtained from the Centre Regional Ethics Committee for Human Health Research (No: CE031/CRERSHC) of the Ministry of Public Health Cameroon and administrative approval was also obtained from the Regional Delegation of Public Health for the East Region of Cameroon. Informed consent was taken from every participant prior to collection of data and interviews were conducted in private.

3. Results
3.1 Socio-demographic characteristics and determinants of good knowledge, attitude and practice on the transmission of EVD
Five hundred and ten (510) participants were recruited in this study selected from 13 villages. There was a slight female predominance of 257 (50.4%) and over 306 (60%) of the participants were below the age of 35. Over 102 (20%) of participants had no education and 320 (62.7%) having only a primary level of education. The main occupations were hunting 160 (31.4%) and farming 152 (29.8%) (Table 1).

Characteristic

Number

Percentage (%)

Gender

Male

253

49.6

Female

257

50.4

Age

18-25

164

32.2

26-35

147

28.8

36-45

70

13.7

46-55

63

12.4

55

66

12.9

Level of education

No education

102

20.0

Primary

320

62.7

Secondary

80

15.7

Tertiary

8

1.6

Marital status

Single

102

20.0

Married

375

73.5

Widowed

33

6.5

Occupation

Hunter

160

31.4

Farmer

152

29.8

Both (Hunter and farmer)

99

19.8

Traditional healers

19

3.7

Others

80

15.7

Table 1: Socio-demographic characteristics of study participants.

3.2 Knowledge of respondents on EVD
Over 425 (83.3%) of participants were aware of Ebola virus. The main sources of information were sensitization meetings among communities 304 (59.6%), radio 60 (11.8%), television 54 (10.6%) and from health facilities 92 (18%). Among the participants aware of EVD, 235 (46.1%) did not know what causes EVD: 76 (14.9%) thought it is caused by witchcraft, 87 (17.1%) by a curse and 72 (14.1%) by dead animals. Only 236 (46.8%) of participants agreed that EVD could be transmitted through contact with infected persons, while 184 (36.1%) had no idea on the mode of transmission. Base on the participants’ opinion, the modes of transmission of EVD included waterborne 75 (14.8%), airborne 89 (17.5%), witchcraft 195 (38.2%), smoking 50 (9.8%) and consuming bush meat 101 (19.7%) (Table 2).

Variable

Frequency

Percentage (%)

Have you ever heard of Ebola viral disease?

Yes

425

83.3

No

85

16.7

Source of information about EVD

Radio

60

11.8

Television

54

10.6

Sensitization meetings

304

59.6

Health facility

92

18.0

Cause EVD

Witchcraft

76

14.9

Curse

87

17.1

Virus

123

24.1

Dead animals

72

14.1

Don’t know

152

29.8

Which of the following animals serve as a reservoir for EVD?

Bat

22

4.3

Monkey/Chimpanzee

437

85.7

Antelope

51

10.0

Signs and symptoms of EVD

Fever

119

23.3

Haemorrhage

209

41.0

Severe headache

49

9.6

Muscle pain

41

8.0

Vomiting

92

18.1

Do you believe EVD can be transmitted by contact with an infected person?

Yes

236

46.8

No

87

17.1

Don’t know

184

36.1

Do you think EVD can be transmitted by touching or manipulating dead animals or humans?

Yes

264

51.8

No

147

28.8

Don’t know

99

19.4

Do you think EVD can be treated?

Yes

164

32.1

No

160

31.4

Don’t know

186

36.5

Do you think Hunters are most at risk of contracting EVD?

Yes

308

60.4

No

130

25.5

Don’t know

72

14.1

Table 2: Knowledge of study participants towards EVD (n=510).

3.3 Attitude of the respondents toward EVD
Majority 206 (40.7%) agreed they consumed all 6 animals (Table 4) known to be reservoirs to Ebola virus: 151 (29.6%) consumed 4-5 of these animals, 127 (24.9%) consumed 2-3 of these animals and 24 (4.7%) none or only one of these animals. 276 (54.1%) participants sought health care in a health facility when perceived they were sick, whereas 187 (36.7%) and 47 (9.2%) consulted traditional healers and self-care respectively (Table 3).

Variable

 

Frequency

Percentage (%)

What is the state of meat you prefer to eat?

Fresh cooked
Dry cooked
Fresh uncooked
Dry uncooked

197
162
73
80

38.7
31.8
14.4
15.7

Source of meat consumed

Hunting
Bought
Picked dead

291
106
112

57.1
20.8
22.1

Number of reservoirs to Ebola consumed

6 reservoirs
4-5 reservoirs
2-3 reservoirs
1 reservoir

206
151
127
24

40.7
29.6
24.9
4.7

Health seeking behaviors

Traditional healer
Medical Centre
Self-care

187
276
50

36.7
54.1
9.2

Table 3: Attitude of study participants towards EVD (n = 510).

3.4 Practices exposing respondents toward developing EVD
Common practices carried out by participants included: consumption of dead animals picked up in the bush 113 (22.2%), consumption of fresh uncooked meat 73 (14.4%), exposure to dead bodies and touching of these dead bodies 396 (87.6%), scarification 357 (70.0%) and seeking primary health care from a traditional healer when sick 187 (36.7%) (Table 4).


Variable

 

Frequency

Percentage (%)

Do you eat bush meat?

Yes
No

505
5

99.0
1.0

Do you practice any form of hunting?

Yes
No

391
119

76.7
23.3

If you hunt, do you pick dead animals in the bush?

Yes
No

149
242

38.2
61.8

Do you consume dead animals recovered from the forest?

Yes
No

113
397

22.2
77.8

Have you ever been scarified by a traditional healer?

Yes
No

357
153

70.0
30.0

Do you seek care in a heal facility when you perceive sickness?

Yes
No

279
231

54.7
45.3

Do you expose the corpse of someone who dies prior to burial

Yes
No

396
114

87.6
22.4

 

Table 4: Practice of study participants towards EVD (n = 510).

3.5 Socio-demographic determinants of good knowledge, attitude and practices
Gender, age, educational level and tribe were significantly associated with good knowledge. Male were more knowledgeable than females (88.7% versus 60.5%) on EVD. Older respondents had a better knowledge compared to younger respondents (79.8% versus 69.4%). Respondents with secondary and tertiary education were more knowledgeable than those with primary and no formal education (90.4% versus 58.8%). The Bantu respondents had a better knowledge on EVD compared to the Baka (85.1% versus 64.1%). Respondent with secondary and tertiary education had better practices on the prevention of EVD compared to those with primary or no formal education (37.5% versus 25.3%) (Table 5).

Variables

Categories

Good Knowledge

Good Attitude

Good Practice

Gender

Male

224 (88.7%)

117 (46.3%)

85 (33.7%)

Female

156 (60.5%)

105 (40.7%)

75 (29.1%)

P value (chi-sq. value)

<0.001 (50.56)

0.25 (1.29)

0.33 (0.95)

Age category

? 35 years

216 (69.4%)

140 (45.0%)

100 (32.0%)

>35 years

159 (79.8%)

84 (42.0%)

61 (30.8%)

P value (chi-sq. value)

0.012 (6.27)

0.54 (0.372)

0.64 (0.215)

Educational Level

No formal/Primary

248 (58.8%)

136 (32.2%)

107 (25.3%)

Secondary/Tertiary

80 (90.4%)

48 (54.8%)

33 (37.5%)

P value (chi-sq. value)

<0.001 (16.15)

<0.001 (14.77)

0.028 (4.80)

Occupation

Farming

113 (74.1%)

66 (43.3%)

49 (32.1%)

Hunter

126 (78.7%)

72 (45.2%)

54 (33.6%)

Herbalist/others

141 (71.0%)

83 (42.0%)

56 (28.5%)

P value (chi-sq. value)

0.744 (0.25)

0.88 (0.33)

0.88 (0.547)

Marital status

Single

81 (79.1%)

47 (46.1%)

34 (33.1%)

Married

369 (71.6%)

166 (44.2%)

109 (29.2%)

Widow(er)

24 (73.1%)

13 (40.2%)

11 (31.9%)

P value (chi-sq. value)

0.069 (5.66)

0.06 (4.01)

0.087 (4.32)

Residence type

Permanent

328 (78.2%)

169 (46.7%)

118 (32.8%)

Temporal

106 (71.0%)

60 (40.3%)

45 (30.0%)

P value (chi-sq. value)

<0.001 (30.79)

0.20 (1.57)

0.65 (0.197)

Tribe

Baka

268 (64.1%)

155 (37.0%)

124 (29.6%)

Bantu

78 (85.1%)

46 (50.0%)

31 (33.2%)

P value (chi-sq. value)

0.001 (13.83)

0.029 (4.74)

0.524 (0.04)

Table 5: Socio-demographic determinants of good knowledge, attitude and practices among respondents on the transmission of EVD.

4. Discussion
EVD outbreaks constitute a major public health issue in sub-Saharan Africa [6, 10]. Many outbreaks of EVD have occurred in the Congo Basin since the first epidemic of Ebola that was reported in 1976, World Health Organization (WHO) has reported 25 outbreaks with most outbreaks reported in the Congo Basin [6]. The recent Ebola outbreak occurring still in DRC found in the Congo basin is the ninth time Ebola has been recorded in Congo [10]. To minimize the chances of another outbreak in the Congo Basin, knowledge on its prevention is very important [12]. Prevention can only be successful following an understanding of the potential risk factors as this will be useful to develop educational messages targeting communities at risk. WHO aims to prevent Ebola outbreaks by maintaining surveillance for EVD and supporting at-risk countries to develop preparedness plan. We investigated potential factors that could increase the risk of exposure to Ebola infection in the Congo Basin. This was done by studying their feeding and health seeking behaviors and also assessing their knowledge on various aspects of the disease. Studies have shown some ethnic backgrounds to be an important risk factor influencing exposure to Ebola virus in many communities [13]. The cultural beliefs, behaviors, knowledge and attitudes of a tribe like the Pygmies (Baka and Bantu people) of the Congo Basin could increase their risk of infection with the Ebola virus. In the same light, one of the main causes of persistence of Ebola infection during the 2014 outbreak was the continuation of high risk beliefs and behaviors that led to endless sources of opportunities to exploit, blunting the power of prevention and control measures [9, 14-15]. Therefore, an investigation of the risk of exposure of the Congo Basin inhabitants to Ebola virus infection is very important to formulate prevention strategies against EVD thereby contributing to the response system of preventing any Ebola outbreaks in the Congo Basin and other regions in SSA at risk. Health seeking behaviors were investigated to highlight its role on the acquisition and spread of the Ebola Virus.

Our findings showed that the risk of primary transmission is high in the study area as many of their main activities increases exposure. WHO in 2014, stipulated hunter-gatherer activities in rainforest areas to be high risk factors in the acquisition of an Ebola infection through primary transmission [7]. Most Ebola epidemics reported by WHO, originated from situations where a group of hunters killed an infected animal or recovered an infected animal carcass [7, 16]. Hunting especially in the tropical rainforest is an activity that has been associated to a high risk of exposure to infection with the Ebola virus [9]. Majority of participants in this study were seen to carry out these activities that highly exposes them to the risk of an Ebola viral infection; 31.3% of the study participants were hunters and 19.4% both hunters and farmers. Hunting and consumption of bush meat has been observed to be a common practice in the Congo Basin. Picking animals found dead in the forest is a risk factor of primary transmission of Ebola virus and other zoonotic infections which have been observed in this study. Outbreaks of Ebola including the deadliest 2014/2015 West African outbreak which killed more than 11,313 people have been thought to have originated likely from consuming an infected bush meat [9, 17]. This outbreak was caused by the Zaire Ebola virus which is the most virulent of all Ebola virus strains [18]. There is accumulating molecular and serological evidence that fruit bats are reservoirs and that human infection is acquired through contact with their body fluids [19].

Many studies have indicated serological evidence of Ebola amongst the inhabitants of the Congo Basin. Bouree et al. reported serological evidence of Ebola virus in the East region of Cameroon which is part of the Congo Basin [20]. In their study, antibodies to Ebola virus were identified in 1,517 apparently healthy persons from Eastern region of Cameroon. A positive rate of 9.7% was found, confirming that the virus circulated in Cameroon in the absence of clinical cases [20]. Highest rates were found among pygmies, young adults, and rainforest farmers [20]. Equally, WHO clearly showed the geographical distribution of Ebola and Marburg outbreaks in Africa (1967-2014) and countries with serological evidence of Ebola [21]. Paix et al. and Gonzalez et al. had earlier reported serological evidences of Ebola virus in Cameroon with seropositive rates of 2% and 7.7% respectively [22, 23]. In the same light, Johnson et al. reported sero-positivity for Ebola among pygmies inhabiting the tropical forest of Central Africa, part of which is the Congo Basin [13]. Studies by Dieudonne et al. (2011) showed that the South-eastern equatorial rain forest harbors apes and fruit bats which are known reservoirs to the Ebola virus [15]. Leroy et al. (2004) had shown an Ebola sero-positivity among pygmies of Central Africa due to their hunting gathering activities [24]. The presence of sero-positivity in the absence of EVD could be because a less virulent strain of Ebola virus is circulating in the Congo Basin or from acquired immunity by the indigenous population given that many outbreaks of EVD have been reported from this region. It is in this light that World Health organization suggested that with such an epidemic of bloody diarrhoea as well as their exposure status to zoonotic infections, the Ebola virus could have been circulating in the absence of clinical evidence [25]. All these prior studies indicating the serological evidence of EVD in the Congo Basin solidifies the high chances of future outbreaks of EVD in this region.

Knowledge on the cause, manifestation and transmission of EVD was observed to be poor. We generally observed a high level of misconceptions on transmission mechanisms as participants mentioned water, contaminated food, cigarette smoking, and witchcraft as modes of transmission. This high level of ignorance shows the need for rigorous sensitization campaigns in the Congo Basin. Poverty, health care inaccessibility and unavailability are the major contributory factors to the inability of most participants to seek primary health care in health facilities. Informal discussions in a community with low level of education as observed amongst the Pygmies which could have far reaching consequences as wrong information will be circulated during the event of an outbreak of EVD. Proper education of Pygmies through health talk is therefore very important as these talks can be given by health personnel who are well informed about EVD. Education is a means of social change and helps in changing ones perception about the occurrence of a phenomenon.

The health seeking behavior was investigated to highlight its role in the secondary transmission of the infection. We investigated the factors that could affect their health care decision and thus promote or reduce the possibility of spread of infection. Sociocultural and service related factors influenced their health seeking behavior. Invasive treatment by traditional healers such as scarification practiced by the Pygmies has been identified to be a high risk factor to secondary transmission of an Ebola infection in rainforest areas [7]. Most inhabitants of the Congo Basin still rely exclusively on traditional health care involving procedures like scarification [26]. Scarification is performed for treatment of medical conditions, spiritual protection and for enhancing beauty. In case of an outbreak, practices like scarification will play a major role in secondary transmission and rapid spread of EVD. World Health organization has responded to the current Ebola outbreak in the Democratic Republic of the Congo by deploying rapid Response Teams to investigate cases and deaths reported in Bikoro health zone in the Equateur province [10], provided technical and operations support to the Ministry of Health and Partners in the activation of multi-partner multi-agency Emergency Operations Centre to coordinate the response at all levels, shared risk communication materials in French and Lingala with the WHO country offices [10], initiate active surveillance activities, provided financial support together with Wellcome Trust needed for critical research to support the operational response [10]. In case of a future Ebola outbreak in any community of the South Eastern equatorial forest of the Congo basin made up of many pygmies, an emergency public health response will be the key. Also in addition to active surveillance, passive surveillance of the Ebola viral disease needs to be mandatory in high risk areas.

5. Limitations
This study shares the limitation of all cross-sectional study designs; it was not supplemented by many qualitative data. This study also incurred an undesirable limitation on the setting as South-Eastern Rainforest of Cameroon was used to represent the entire Congo Basin; however this region is inhabited entirely by the pygmies who are the main indigenes of the Congo Basin.

6. Conclusion
We conclude that majority of pygmies were aware of the existence of EVD, though many had a poor knowledge on its cause and transmission, and showed a negative attitude toward the disease. Although great improvement has been achieved over the past decade in controlling outbreaks of EVD, better surveillance and prevention of the risk of acquiring an outbreak is preferable, because an outbreak of EVD anywhere poses a risk everywhere in the world.
Based on the findings from this study, we recommend rigorous sensitization and surveillance of communities for EVD in the Congo Basin as a means to empower inhabitants with knowledge on disease prevention and hence preventing or identifying potential outbreaks of an Ebola epidemic in the future. In the same light, screening populations for antibodies to EVD is a prospective study of utmost importance.

Ethics approval and consent to participate
All the principles of a good ethical research were respected. Ethical approval was obtained from the Centre Regional Ethics Committee for Human Health Research of the Ministry of Public Health Cameroon.

Competing interests
The authors declare that they have no competing interests.

Funding
FAIRMED Africa

Authors’ contributions
FSW and AUB developed the study conception and design, contributed in acquisition, analysis and interpretation of data. JFA, EVY and DSN contributed in the conception of the work and critical revision of the intellectual content of the manuscript. ENK and ATY contributed in the analysis and interpretation of the data. All the authors read and approved the final manuscript.
Acknowledgments
The authors acknowledge FAIRMED Africa for providing sponsorship to this study.

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Citation: Frankline Sevidzem Wirsiy, Jane-Francis Akoachere, Alphonse Um Boock, Dickson Shey Nsagha, Emmanuel Nji Kah, Adolf Tah Yoah, Eugene Vernyuy Yeika. Assessment of the Knowledge, Attitude and Practice of Pygmies towards the Transmission of Ebola Viral Disease in the Congo Basin: A Descriptive and Analytic Cross-Sectional Study. Journal of Environmental Science and Public Health 2 (2018): 196-209.

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