Journal of Environmental Science and Public Health

doi: 10.26502/jesph.96120039

Volume 2, Issue 4 Research Article

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

1
Department of Public Health and Hygiene, University of Buea, Cameroon
2
Department of Microbiology and Parasitology, University of Buea, Cameroon
3
FAIR MED Technical Adviser for Africa, Sri Lanka and India
4
Bangangte 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.

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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

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

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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].

100%
25.4% Poor
80% Good
56.5%
68.6%
60%

40% 74.6%
20% 43.5%
31.4%
0%
Knowledge Attitude Practice

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

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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

Z2 P(1−P)
The minimum sample size was estimated using a single population proportion formula, n= . Since there was
d2

no similar study in SSA, the following assumptions were made: 95% (Z=1.96) confidence interval, 50% proportion

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 (1.96)(1.96)×0.5(1−0.5)
and 5% margin error. Therefore n= (0.05)(0.05)
= 384.

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

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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 Yes 425 83.3
disease? 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 Bat 22 4.3
reservoir for EVD? Monkey/Chimpanzee 437 85.7
Antelope 51 10.0

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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 Yes 236 46.8
contact with an infected person? No 87 17.1
Don’t know 184 36.1
Do you think EVD can be transmitted by Yes 264 51.8
touching or manipulating dead animals or No 147 28.8
humans? 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 Yes 308 60.4
contracting EVD? 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 197 38.7
Dry cooked 162 31.8
Fresh uncooked 73 14.4
Dry uncooked 80 15.7
Source of meat consumed Hunting 291 57.1
Bought 106 20.8
Picked dead 112 22.1
Number of reservoirs to Ebola consumed 6 reservoirs 206 40.7
4-5 reservoirs 151 29.6

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 2-3 reservoirs 127 24.9
1 reservoir 24 4.7
Health seeking behaviors Traditional healer 187 36.7
Medical Centre 276 54.1
Self-care 50 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 505 99.0
No 5 1.0
Do you practice any form of hunting? Yes 391 76.7
No 119 23.3
If you hunt, do you pick dead animals in the Yes 149 38.2
bush? No 242 61.8
Do you consume dead animals recovered from Yes 113 22.2
the forest? No 397 77.8
Have you ever been scarified by a traditional Yes 357 70.0
healer? No 153 30.0
Do you seek care in a heal facility when you Yes 279 54.7
perceive sickness? No 231 45.3
Do you expose the corpse of someone who dies Yes 396 87.6
prior to burial No 114 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

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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 No formal/Primary 248 (58.8%) 136 (32.2%) 107 (25.3%)
Level 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

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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].

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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

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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.

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Acknowledgments
The authors acknowledge FAIRMED Africa for providing sponsorship to this study.

References
1. Bannister B. Viral haemorrhagic fevers imported into non-endemic countries: Risk assessment and
management. Medicine Bulletin 95 (2010): 193-225.
2. Feldmann H, Geisbert T. Ebola haemorrhagic fever. Lancet 377 (2011): 849-862.
3. Bausch DG, Towner JS, Dowell SF, et al. Assessment of the risk of Ebola virus transmission from bodily
fluids and fomites. Journal of Infectious Diseases 15 (2007): 142-147.
4. Bres P. The epidemic of Ebola haemorrhagic fever in Sudan and Zaire, 1976 (introductory note). Bull
World Health Organ 56 (1978): 245.
5. CDC urges all US residents to avoid nonessential travel to Liberia, Guinea and Sierra Leone because of an
unprecedented outbreak of Ebola. CDC (2014).
6. Mustafa M, Yusof IM, Kassim M, et al. Ebola Virus Disease, Management and Prevention. IOSR J Dent
Med Sci 15 (2016): 142-148.
7. Ebola virus disease Fact sheet No. 103. World Health Organization (2014).
8. Moghadam SRJ, Omidi N, Bayrami S, et al. Ebola viral disease: A review literature. Asian Pac J Trop
Biomed 5 (2015): 260-267.
9. World Health Organization. One year into the Ebola epidemic: A deadly, tenacious and unforgiving virus.
WHO Ebola Report (2015).
10. World Health Organization. Emergencies preparedness, response: Ebola virus disease outbreak-Democratic
Republic of the Congo. WHO Report (2018).
11. Joseph N. Abong Mbang Health District Service: First Semester activity report (2014).
12. Muyembe J, Mulangu S, Masumu J, et al. Ebola virus outbreaks in Africa: past and present. Onderstepoort
Journal 79 (2012): 451.
13. Johnson ED, Gonzalez JP, Alain G. Filovirus activity among selected ethnic groups inhabiting the tropical
forest of equatorial Africa. Transactions of the Royal Society of Tropical Medicine and Hygiene 87 (1994):
536-538.
14. Gatherer D. The 2014 Ebola virus disease Outbreak in West Africa. Journal of Genomic Virology 95
(2014): 1619-1624.
15. Gire SK, Goba A, Andersen KG. Genomic surveillance elucidates Ebola virus origin and transmission
during the 2014 outbreak. Science Journal 345 (2014): 1369-1372.
16. Dieudonne N, Cindy P, Pierre B, et al. Risk Factors for Zaire Ebola virus-Specific IgG in Rural Gabonese
Populations. Journal of Infectious Disease 204 (2011): 775.
17. Gary W, Gary P. Backs against the Wall: Novel and Existing Strategies Used during the 2014-2015 Ebola
Virus Outbreak. Clinical Microbiology Reviews 28 (2015): 593-598.

J Environ Sci Public Health 2018; 2 [4]: 196-209 208

 18. Baize S, Pannetier D, Oestereich L. Emergence of Zaire Ebola Virus Disease in Guinea-Preliminary
Report. New England Journal of Medicine 371 (2014): 1418-1425.
19. Francesconi P, Yoti Z, Declich S. Ebola hemorrhagic fever transmission and risk factors of contacts,
Uganda. Emerging Infectious Diseases 9 (2003):1430-1437.
20. Bauree P, Bergmann JF. Ebola virus infection in man: A serological and epidemiological survey in the
Cameroon. American Journal of Tropical Medicine and Hygiene 32 (1983): 1465-1466.
21. World Health Organization Ebola and Marburg virus disease epidemics: preparedness, alert, control, and
evaluation. Geneva-Switzerland INTERIM version 1.2 (2018).
22. Paix Ma, Poveda Jd, Malvy D, et al. Serological study of the virus responsible for hemorrhagic fever in an
urban population of Cameroon. Bull Soc P athol Exot Filiales 81 (1988): 679-682.
23. Gonzalez Jp, Josse R, Johnson Ed, et al. Antibody prevalence against hemorrhagic fever viruses in
randomized representative Central African populations. Research in Virology (Annales de l’Institut
Pasteur) 140 (1989): 319-331.
24. Leroy EM, Telfer P, Yaba P. A serological survey of Ebola virus infection in central African nonhuman
primates. Journal of Infectious Diseases 190 (2004): 1895-1899.
25. Zaki SR, Shieh WJ, Greer PW, et al. Commission de Lutte contre les Epidemies a Kikwit, A Novel
Immunohistochemical Assay for the Detection of Ebola Virus in Skin: Implications for Diagnosis, Spread,
and Surveillance of Ebola Hemorrhagic: Journal of Infectious Diseases 179 (1999): 36-47.
26. Aili P. What future for the Baka? Indigenous peoples’ rights and livelihood opportunities in South-East
Cameroon; Report 13-International Work Group for Indigenous Affairs (IWGIA); Copenhagen-Denmark,
Plan Finland and Plan Cameroon (2012): 14-38.

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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