Study Guide-Video-Outbreak!

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Teacher Notes
https://www.pbs.org/wgbh/frontline/film/outbreak

This 54:16 minute PBS documentary details the 2014 Ebola epidemic in West Africa. The video describes how it may have started, what caused it to spread through several West African countries, and how the mishandling of key epidemiological practices resulted in thousands of deaths.

Please be aware that this video is at some points difficult to watch. It shows people who have contracted Ebola and it presents desperate conditions in medical camps built to deal with Ebola cases. Interviews with healthcare volunteer nurses and doctors are achingly poignant; the day-to-day work involved in caring for hundreds of sick and dying people in over-crowded camps with less than adequate resources is a profoundly moving experience for these hero-volunteers.

Why would you want to show this video to your students?  The video profiles many of the epidemiological steps necessary for investigating an outbreak that did not happen in the Ebola outbreak investigation—with tragic results. If you have discussed the steps of an epidemiological investigation with your students or had your students read the article on how epidemiologists conduct an outbreak investigation, they will recognize that these steps were not followed for the 2014-2015 Ebola outbreak.  They will also see the consequences.  The steps become much more than an outline to read; they become real-life scientifically-based strategies that allow an outbreak to be resolved more quickly—which saves lives. Students see epidemiology in action in a real-world situation that occurred not long ago and which will likely occur again.

The accompanying study guide presents questions that reinforce epidemiological investigation understanding.  By finding out how the steps were and were not followed—and why—students more fully understand the key processes behind the investigative method and learn how cultural factors and political considerations can affect epidemics and healthcare.

It is recommended that you watch the video before showing it to your classes.  In class, you can always fast-forward through some parts if you know where they fall in the video.  Record the times as you preview the video so you know when you want to pause and fast-forward.

You may also want to pause periodically for questions from students, to discuss a point more fully, or to allow your students to answer the study guide questions in more detail. You may also have questions of your own to add to the study guide. The study guide emphasizes the epidemiological investigation, but also includes questions concerning cultural, political, and social influences.

Direct your students to keep a running list of events or policies that went wrong in the Ebola outbreak response. They will be finding out about multiple events and policies throughout the video.

 Outbreak Study Guide

  1. List events or policies that contributed to the severity of the Ebola outbreak. These include not following steps to proper epidemiological investigation, cultural practices, social factors, economic reasons, political considerations, and mistakes made by government departments of health and international organizations. Describe these factors for the countries in which the outbreak occurred. (You will be finding out about events and policies throughout the video.)
  • No contact tracing was performed.
  • The disease was not correctly identified for over 3 months.
  • WHO (World Health Organization) did not want to declare an international alert.
  • Guinea government officials (the Ministry of Health) allowed only confirmed cases to be included in the mortality rates.
  • Guinea government officials (the Ministry of Health) allowed only confirmed cases to be followed up for contact tracing. This greatly reduced the number of contacts identified and led to more infection spread.
  • Guinea officials did not want to report numbers of cases accurately because it would frighten away the business community from investing.
  • Cultural practices of preparing for burials spread the disease.
  • People did not understand how disease spreads.
  • People believed curses brought the illness.
  • Doctors Without Borders said more officials were added to the administration all the time and there were many meetings, but they were all “just useless” to actually helping in the control of the outbreak or helping treat the many cases in health camps.
  • People rioted and looted shelters set up for Ebola victims. More disease was spread when they took bloody mattresses and transferred infected blood from the shelters into the general population.
  1. How do they think this outbreak started? (December 2013)

Children from Melandou, a village in Guinea, west Africa, discovered a large hollow tree in the jungle with hundreds of bats living in it. They did not know that bats can carry deadly diseases.  They hit the bats, killed quite a few, filled bags with the bats, and took them back to the village to eat them.

This is probably how the outbreak started although it is impossible to be sure. What is certain is that people began to get sick shortly after.

3a. For three months, the outbreak disease spread hundreds of miles, but was mistaken for what two diseases?

malaria and cholera

  1. What does this say about the importance of the epidemiological step of correctly identifying the disease? How can incorrectly identifying the disease impact the control of an outbreak?

One of the steps of the epidemiological process is correctly identifying the pathogen causing the outbreak. This step is extremely important in controlling and minimizing the effects of the outbreak.  If the disease is incorrectly identified, as in the Ebola outbreak, control measures and medical interventions for the wrong disease would not work to treat, contain, or control the disease spread.

4a. From previous Ebola outbreaks, what three steps had been shown to be key to controlling the outbreak?

1) isolate the sick

2) monitor anyone who had contact with the sick

3) safely bury the dead

b. Where these key steps followed in the Ebola outbreak? If not, explain.

No.

1) Isolate the sick.  It was extremely difficult to isolate the sick. People moved freely over borders to neighboring countries and spread the disease. Attempts at quarantining the sick were met with resistance from the public to the point of rioting. Shelters that were set up by the governments or departments of health had deplorable conditions which aided in the spread of the virus and offered no medical care. People, understandably, did not want to go to one of these shelters.

2) Monitor contacts of sick people. Contact monitoring was not done by the Ministries of Health of several countries involved in the Ebola outbreak. This meant that the virus spread with no containment measures being in place.

3) Safely bury the dead. Cultural practices involved washing the dead and preparing them for burial.  As the Ebola virus is spread through contact with body fluids, anyone coming into contact with the body was most likely infected. (More detail in question 6a)

5a. At one point, the Guinea Ministry of Health ordered healthcare teams in the field to include only confirmed cases of Ebola in death counts. What would this do to the morbidity (disease occurrence) rates reported and what other effects might this have on how the outbreak was perceived and handled?

The numbers of Ebola cases reported to the world would be much lower than actual numbers of cases. The outbreak would not be perceived to be as serious as it was and restrictions on travel would not occur. International business with affected countries would continue which was the Ministry of Health’s goal regardless of the spread of Ebola.

Acquiring the resources (healthcare workers, volunteers, construction materials, medicine, protective gear, etc.) was greatly delayed because the situation was not regarded as serious as it was due to denials by public officials, inexperience in interpreting the situation by some organizations, and by policies which deliberately misrepresented the severity of the outbreak.

Unfortunately, underestimating the seriousness of the situation put thousands of people at risk for disease and death.

b. The Ministry of Health also stopped investigating contacts of cases that were not confirmed Ebola cases but not yet dead. What important epidemiological step is omitted by this policy and how does it affect the control and containment of the outbreak?

The epidemiological process includes investigating contacts of known infected persons in order to limit spread. If you don’t follow-up on contacts, you cannot isolate people who may be contagious; the virus can continue to spread.

c. Why did the Ministry of Health make the decisions mentioned above (questions 5a and 5b)?

Public health officials wanted to underestimate the outbreak so that international business would be less affected.

6a. How did traditional cultural burial practices play a major role in the spread of Ebola?

An Ebola victim’s body is highly contagious. Cultural practices involve washing the body, dressing the body in clean clothes, braiding hair, and cutting nails in preparation for burial. Multiple family members participate in preparing the body. Everyone in contact with the body is vulnerable to infection and in the case of Ebola (highly infectious), most people become infected with the virus if they participate in this custom.

b. Who was Mendinor? How was her funeral a “catastrophe”?

Mendinor was a highly respected village healer. She was well-known in surrounding villages that were distributed over a large distance. When Mendinor died of Ebola, many people from several villages attended her funeral. This set off a chain reaction of infections that led to thousands of deaths. The resulting infections killed entire families and spread the disease to yet another country—Liberia.

At this point, the outbreak was out of control and no one even knew it.

  1. What eventually led to the decline in numbers of Ebola cases and containment of the outbreak? (Name two factors and explain.)

1) Changed behavior.

Eventually people understood that Ebola was real and they finally understood the mechanics of the viral disease. They understood the critical importance of dealing with the infection in a logical and correct manner.  They began safe burial practices and did not spread the disease as much in the community.

2) Massive world efforts.

Many countries donated materials, volunteers, medicine, and troops to the efforts of containing the outbreak.

8. How has watching this video changed your understanding of containing a dangerous infectious disease?

Answers will vary.