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Knowledge, Attitudes, and Practices Related to Ebola Virus Disease at the End of a National Epidemic--Guinea, August 2015.

Health communication and social mobilization efforts to improve the public's knowledge, attitudes, and practices (KAP) regarding Ebola virus disease (Ebola) were important in controlling the 2014-2016 Ebola epidemic in Guinea (1), which resulted in 3,814 reported Ebola cases and 2,544 deaths. * Most Ebola cases in Guinea resulted from the washing and touching of persons and corpses infected with Ebola without adequate infection control precautions at home, at funerals, and in health facilities (2,3). As the 18-month epidemic waned in August 2015, Ebola KAP were assessed in a survey among residents of Guinea recruited through multistage cluster sampling procedures in the nation's eight administrative regions (Boke, Conakry, Faranah, Kankan, Kindia, Labe, Mamou, and Nzerekore). Nearly all participants (92%) were aware of Ebola prevention measures, but 27% believed that Ebola could be transmitted by ambient air, and 49% believed they could protect themselves from Ebola by avoiding mosquito bites. Of the participants, 95% reported taking actions to avoid getting Ebola, especially more frequent handwashing (93%). Nearly all participants (91%) indicated they would send relatives with suspected Ebola to Ebola treatment centers, and 89% said they would engage special Ebola burial teams to remove corpses with suspected Ebola from homes. Of the participants, 66% said they would prefer to observe an Ebola-affected corpse from a safe distance at burials rather than practice traditional funeral rites involving corpse contact. The findings were used to guide the ongoing epidemic response and recovery efforts, including health communication, social mobilization, and planning, to prevent and respond to future outbreaks or sporadic cases of Ebola.

Ebola-related KAP assessments were conducted in Sierra Leone (4), Liberia (5), Nigeria (6), and in one region in Guinea (7) during Ebola epidemics in 2014-2015. To learn more about Ebola-related KAP in Guinea as the nation's epidemic waned following more than a year of Ebola education and prevention activities, several organizations conducted an Ebola KAP assessment across all administrative regions in August 2015. At that time, cumulative case counts varied substantially across the four natural regions of Guinea (Forest Guinea, Maritime Guinea, Middle Guinea, and Upper Guinea) (Figure); previously intense transmission had been controlled in the Forest Guinea region, but transmission persisted in the Maritime Guinea region (8). Various control measures were implemented, including case investigation and contact tracing, health communication about prevention practices, and specialized treatment units and burial teams to manage persons and corpses affected by Ebola.

The assessment employed a cross-sectional design using a multistage cluster sampling procedure. The 2014 Guinea Census List of Enumeration Areas served as the sampling frame for the random selection of 150 clusters across all eight administrative regions, which were grouped by the four natural regions of Guinea. Within each administrative region, prefectures were randomly sampled from among two strata defined by high ([greater than or equal to]95) or low (<95) cumulative counts of confirmed cases that had been reported to the national Ebola surveillance system by May 2015. The sample was further stratified to include both urban and rural subprefectures. Districts within each subprefecture were randomly selected, and 20 households were selected from each cluster using a form of systematic random sampling known as the random walk method. ([dagger]) In each selected household, two interviews were conducted; the first was with the head of household, and the second was with a randomly selected woman aged [greater than or equal to] 25 years or a person of either sex aged 15-24 years. Interviews were conducted by locally trained data collectors using a free open-source set of tools to manage mobile data collection (https://opendatakit.org), installed on mobile devices. Data were analyzed using statistical software. For each record, weighted estimates adjusted for the probability of participant selection were calculated by applying a factor based on population size of the participant's administrative region; 95% confidence intervals were generated for overall and regional data.

Data collection teams approached 6,699 persons, 6,273 (94%) of whom (from 3,137 households) consented to initiate the assessment. Among these, 5,733 (91%) persons who reported that they had heard of Ebola before the survey were asked questions for up to 60 minutes about Ebola through individual interviews that included closed- and open-ended questions in local languages, and rarely, in French. These respondents were considered to have completed the survey and were included in the analysis (Table 1). Overall, socio-demographic characteristics did not vary substantially by region, except that participants from Forest Guinea were more likely than other participants to report some formal education and Christian religious affiliations.

Participants from the most heavily Ebola-affected regions (Forest Guinea and Martime Guinea) were more likely to have encountered Ebola response teams (61% and 72%, respectively), than were respondents from Middle Guinea (37%) and Upper Guinea (47%) (Table 2). Overall, 15% of participants perceived a high risk for acquiring Ebola; in Maritime Guinea, 25% of participants perceived a high risk. Most participants knew that Ebola is transmitted by contact with body fluids of infected persons (92%) or corpses (87%). However, the misconception that Ebola is transmitted by mosquito bites was reported by 49%, and this belief was reported by 66% of participants in Upper Guinea. Nearly all participants reported taking actions to avoid Ebola (95%), including more frequent handwashing (93%), avoiding contact with persons with suspected Ebola (44%), or avoiding crowds (22%).

The majority of participants across all regions (91%) indicated they would send relatives with suspected Ebola to Ebola treatment centers. Most (72%) participants knew that one could survive and recover from Ebola, but such knowledge varied by region, and was lowest in Upper Guinea (58%) and highest in Maritime Guinea (81%). A minority of participants (17%) reported that survivors could infect others through casual contact such as hugging and shaking hands, that they would not buy fresh vegetables from shopkeepers who survived Ebola (28%), and that they would not welcome survivors into their communities (19%). Overall, 44% of participants expressed at least one of those three attitudes toward survivors, and these attitudes were more common in the less-affected regions (Middle Guinea [58%] and Upper Guinea [55%]) than in heavily affected regions (Maritime Guinea [35%] and Forest Guinea [30%]). In contrast, 91% of all participants expressed the opinion that Ebola survivors could contribute to Ebola control, such as through educating community members about Ebola prevention (62%) or caring for Ebola patients (37%) (Table 2).

When asked about intended burial preparations for family members suspected to have died from Ebola at home, only 3% of participants reported that they would wash or touch the body, and most stated that they would accept special Ebola burial teams (89%). Overall, 66% said they would prefer to observe corpses of family members who had died from Ebola from a safe distance at burials, but this attitude varied widely by region (Forest Guinea [90%]; Upper Guinea [83%]; Maritime Guinea [65%]; and Middle Guinea [38%]). Attitudes about other alternatives to touching Ebola-affected corpses also varied by region. When asked about intended burial preparations for family members who died of any cause at home, the majority of participants (72%) indicated they would accept alternatives that did not involve corpse contact, but this attitude was least common among respondents in Forest Guinea (57%). Among 1,082 (20%) participants who had recently attended burials of persons who had died from any cause, a minority reported washing (6%), touching (4%), or crying over the corpse without touching it (27%), but 26% reported touching other burial attendees. Participants from Forest Guinea were more likely to report recently washing (16%) or touching (19%) corpses than were participants from other regions (Table 2).

Discussion

Eighteen months after the start of a devastating Ebola epidemic, most participants in this geographically diverse sample understood principal aspects of Ebola transmission and prevention, reported taking actions to reduce their risk for acquiring Ebola, and indicated they would use safer case management and burial practices for relatives with suspected Ebola. However, a substantial percentage of participants harbored misconceptions about Ebola transmission or expressed reticence about close proximity to Ebola survivors, including persons certified by the government to be cured of the disease. Although the World Health Organization declared Guinea to be Ebola-free by late 2015, clusters of Ebola cases occurred in 2016, partly through sexual transmission from survivors with persistence of Ebola virus in semen (9). These data underscore the value of ongoing health promotion efforts to prevent sporadic transmission or future outbreaks, including messaging that aims to reverse misconceptions about Ebola transmission and prevention, to clarify duration and modes of transmission from survivors, and to address stigma that survivors might face as they recover, rebuild their lives, and reintegrate into communities. Regional variations in the epidemic and related response activities might have resulted in the regional differences in attitudes and suggest that targeting health communication by region might be more effective than a uniform, national approach. Underlying differences in customs and traditions across different ethnic populations might have contributed to regional variation in attitudes and behaviors, especially regarding burials.

The assessment was the first national-level quantitative evaluation of Ebola-related burial practices among persons who attended a burial in West Africa during a period of ongoing Ebola transmission. It revealed that most participants would forsake traditional burial preparations involving washing or touching Ebola-affected corpses and would adopt safer practices without corpse contact. Compared with residents of other regions, residents of Forest Guinea were far more likely to indicate a preference for keeping a safe distance from Ebola-affected corpses. However, among the subset of persons who had recently attended burials for deaths from any cause, Forest Guinea residents were substantially more likely to have washed or touched corpses than were residents of other regions. The Forest Guinea region was the first region in the country to report Ebola cases and, unlike other regions, had contained its outbreak several months before the survey. This might explain why Forest participants reported a lower perceived risk for Ebola and might have reverted to traditional, high-contact burial practices for persons dying from causes other than Ebola. These findings underscore the observation that changes in cultural practices to combat highly infectious diseases such as Ebola might be transient, and that in-depth community engagement or new resources, such as cadres of professional body washers, might help prevent future transmission of infectious diseases related to corpse contact (10).

The findings in this report are subject to at least four limitations. First, because of the need to conduct the survey during the ongoing epidemic, interviewers did not validate the comprehension of some survey questions in French or other languages. Second, some participants might have provided socially desirable responses aligned to government recommendations rather than their actual opinions. For instance, government messages to encourage social distancing from Ebola-affected persons during the epidemic might have explained the reticence about close contact with Ebola survivors that some interviewers observed. Third, this analysis did not examine the relation between attitudes and exposure to health promotion interventions or messages. Finally, the sample was not nationally representative because of the partial randomization needed to intentionally oversample heavily affected areas, and the need to seek consent from heads of households, who were usually older men.

Despite their limitations, the mobile data collection tools permitted generation of preliminary findings that were shared with several organizations in Guinea within a few days of the interviews; this information was used to guide the ongoing response and health communication efforts, which contributed to eventual control of the epidemic. Such rapid KAP surveys, conducted during an outbreak, can provide important information for health communications efforts that can contribute to controlling an outbreak at its source, and thereby enhance global health security.

Summary

What is already known about this topic? Assessments of knowledge, attitudes, and practices (KAP) in countries affected by the Ebola virus disease (Ebola) epidemic during 2014-2015 found that although most participants understood many aspects of Ebola transmission and prevention, misconceptions about the disease and transmission modes persisted. In Guinea, health officials suspected that traditional burial preparations and funeral rites involving corpse contact promoted transmission, but they lacked national-level data about these practices.

What is added by this report?

As the Ebola epidemic waned in Guinea, a KAP survey found that most participants understood Ebola causes, transmission, and prevention, but nearly half believed that Ebola could be transmitted by mosquitoes or ambient air. The majority of participants reported more frequent handwashing and avoiding physical contact with persons suspected of having Ebola. Nearly all participants reported they would seek specialized treatment for family members with suspected Ebola and would engage special burial teams if someone died from Ebola in their homes. More than half would observe Ebola-affected corpses from a safe distance that would avoid corpse contact, but there was considerable regional variation in that finding.

What are the implications for public health practice?

KAP information collected during an epidemic can yield data to guide response and recovery efforts, health education, and social mobilization. Future activities should aim to reverse misconceptions about Ebola transmission and prevention, clarify duration and modes of transmission from survivors, prevent stigmatization of Ebola survivors, and foster safer case management and burial practices.

Acknowledgments

From Conakry, Guinea: 75 sampling specialists and interviewers who recruited or interviewed participants; approximately 6,000 Guinean residents and district leaders who participated in some aspect of the survey; Sakoba Kei'ta, Ministry of Health; Kadijah Bah, Sante Plus; Barry Ibrahima Kholo, Institute of Nutrition and Health; Paul Sengeh, FOCUS 1000; Mohamed Ag Ayoya, Guy Yogo, Jean-Baptiste Sene, Esther Braud, UNICEF-Guinea. From the United States: Alison Amoroso, Benjamin Dahl, Stephanie I. Davis, Rana Hajjeh, Amy Lang, Judy Lipshutz, Amanda MacGurn, Craig Manning, Sharmila Shetty, Kerri Simone, Frank Strona, Brittany Sunshine, Leigh Willis, Mary Claire Worrell, CDC; Sean Southey, PCI Media Impact, New York, New York.

Conflict of Interest

No conflicts of interest were reported.

Corresponding author: Mohamed F. Jalloh, yum8@cdc.gov, 404-401-2773.

References

(1.) Bedrosian SR, Young CE, Smith LA, et al. Lessons of risk communication and health promotion--West Africa and United States. MMWR Suppl 2016;65(Suppl 3):68-74.

(2.) Agua-Agum J, Ariyarajah A, Aylward B, et al.; International Ebola Response Team. Exposure patterns driving Ebola transmission in West Africa: a retrospective observational study. PLoS Med 2016;13:e1002170. https://doi.org/10.1371/journal.pmed.1002170

(3.) Toure A, Traore FA, Sako FB, et al. Knowledge, attitudes, and practices of health care workers on Ebola virus disease in Conakry, Guinea: a cross-sectional study. J Public Health Epidemiol 2016;8:12-6. https://doi.org/10.5897/JPHE2015.0752

(4.) Li W, Jalloh MF, Bunnell R, et al. Public confidence in the health care system 1 year after the start of the Ebola outbreak--Sierra Leone, July 2015. MMWR Morb Mortal Wkly Rep 2016;65:538-42. https://doi.org/10.15585/mmwr.mm6521a3

(5.) Kobayashi M, Beer KD, Bjork A, et al. Community knowledge, attitudes, and practices regarding Ebola virus disease--five counties, Liberia, September-October, 2014. MMWR Morb Mortal Wkly Rep 2015;64:714-8.

(6.) Iliyasu G, Ogoina D, Otu AA, et al. A multi-site knowledge attitude and practice survey of Ebola virus disease in Nigeria. PLoS One 2015;10:e0135955. https://doi.org/10.1371/journal.pone.0135955

(7.) Buli BG, Mayigane LN, Oketta JF, et al. Misconceptions about Ebola seriously affect the prevention efforts: KAP related to Ebola prevention and treatment in Kouroussa Prefecture, Guinea. Pan Afr Med J 2015;22(Suppl 1):11.

(8.) World Health Organization. Ebola situation report--July 29, 2015. Geneva, Switzerland: World Health Organization; 2015. http://apps.who.int/ebola/current-situation/ebola-situation-report-29-july-2015

(9.) CDC. Flare-ups of Ebola since the control of the initial outbreak. Atlanta, GA: US Department of Health and Human Services, CDC; 2016. https://www.cdc.gov/vhf/ebola/pdf/cdcs-ongoing-work.pdf

(10.) Fairhead J. Understanding social resistance to Ebola response in Guinea. Ebola Response Anthropology Platform; 2015. http://www.ebolaanthropology.net/wp-content/uploads/2015/04/Fairhead-EbolaASRFinalSubmissionWeb.pdf

Mohamed F. Jalloh, MPH [1]; Susan J. Robinson, PhD [2]; Jamaica Corker, PhD [3]; Wenshu Li, PhD [1]; Kathleen Irwin, MD [4]; Alpha M. Barry, MD, PhD [5]; Pauly ne Ngalame Ntuba, MPH [1]; Alpha A. Diallo, MD [6]; Mohammad B. Jalloh, MPH7; James Nyuma [7]; Musa Sellu [7]; Amanda VanSteelandt, PhD [1]; Megan Ramsden, MPH [1]; LaRee Tracy, PhD [3,8]; Pratima L. Raghunathan, PhD [1]; John T. Redd, MD [1]; Lise Martel, PhD [1]; Barbara Marston, MD [1]; Rebecca Bunnell, PhD [1]

[1] Division of Global Health Protection, Center for Global Health, CDC; [2] National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, CDC; [3] International Ebola Taskforce, CDC; [4] Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, CDC; [5] Sante Plus, Conakry, Guinea; [6] Guinea Ministry of Health, Conakry, Guinea; [7] FOCUS 1000, Freetown, Sierra Leone; [8] Center for Drug Evaluation and Research, Food and Drug Administration.

* https://www.cdc.gov/vhf/ebola/outbreaks/2014-west-africa/case-counts.html.

([dagger]) A form of systematic random sampling that helps minimize survey administration cost and time by avoiding prior listing of all households in the enumeration area by beginning the process at a certain geographic point and following a specified path to select households to interview. https://unstats.un.org/unsd/demographic/meerings/egm/Sampling_1203/docs/no_2.pdf.

Caption: FIGURE. Cumulative confirmed cases of Ebola virus disease, by natural region * and administrative prefecture*--Guinea, August 7, 2015
TABLE 1. Selected characteristics of respondents to a survey on
Ebola virus disease knowledge, attitudes, and practices--Guinea,
August 2015

Characteristic        Initiated survey   Completed survey
                       (N = 6,273) *        (N = 5,733)
                          No. (%)           ([dagger])
                                              No. (%)

Administrative
region
Conakry                      920 (15)            915 (16)
Boke                         664 (11)            581 (10)
Kindia                     1,062 (17)          1,042 (18)
Mamou                         400 (6)             366 (6)
Labe                          579 (9)            560 (10)
Faranah                       526 (8)             392 (7)
Kankan                     1,142 (18)          1,050 (18)
Nzerekore                    980 (16)            827 (15)

Sex
Male                       3,164 (50)          2,937 (51)
Female                     3,109 (50)          2,796 (49)

Age group (yrs)
15-24                      1,117 (18)          1,032 (18)
[greater than or           5,156 (82)          4,701 (82)
equal to]25

Education
None                       3,117 (53)          2,712 (50)
Some primary               1,224 (21)          1,155 (21)
education
Some secondary             1,600 (26)          1,560 (29)
education or
higher

Religion
Muslim                     5,357 (86)          4,949 (87)
Christian                    788 (13)            689 (12)
Other/None                     93 (1)              68 (1)

Occupation
Government/Office             364 (6)             358 (6)
worker
Trader/Merchant            1,216 (20)          1,132 (20)
Farmer/Breeder             1,860 (30)          1,667 (29)
Police/Military/               37 (1)              34 (1)
Guards
Student                      629 (10)            600 (11)
Spiritual/                     45 (1)              38 (1)
Traditional healer
Skilled laborer               282 (5)             264 (5)
Other                      1,230 (18)          1,120 (19)
Unemployed                    554 (9)             478 (8)
Heard of Ebola             5,733 (93)         5,733 (100)
before interview

                         % completed survey, natural
                                    region

Characteristic        Maritime Guinea   Middle Guinea
                        (n = 2,538)       (n = 926)

Administrative
region
Conakry                     36               --
Boke                        23               --
Kindia                      41               --
Mamou                       --               40
Labe                        --               60
Faranah                     --               --
Kankan                      --               --
Nzerekore                   --               --

Sex
Male                        52               44
Female                      48               56

Age group (yrs)
15-24                       19               18
[greater than or            81               82
equal to]25

Education
None                        43               60
Some primary                21               18
education
Some secondary              36               22
education or
higher

Religion
Muslim                      97               98
Christian                    3                2
Other/None                   0                0

Occupation
Government/Office            8                5
worker
Trader/Merchant             22               21
Farmer/Breeder              22               30
Police/Military/             1                0
Guards
Student                     12               12
Spiritual/                   1                0
Traditional healer
Skilled laborer              7                1
Other                       18               23
Unemployed                   9                8
Heard of Ebola              100              100
before interview

                       % completed survey, natural
                                  region

Characteristic        Upper Guinea   Forest Guinea
                      (n = 1,442)      (n = 827)

Administrative
region
Conakry                    --             --
Boke                       --             --
Kindia                     --             --
Mamou                      --             --
Labe                       --             --
Faranah                    27             --
Kankan                     73             --
Nzerekore                  --             100

Sex
Male                       53             54
Female                     47             46

Age group (yrs)
15-24                      15             21
[greater than or           85             79
equal to]25

Education
None                       64             35
Some primary               15             35
education
Some secondary             21             30
education or
higher

Religion
Muslim                     92             32
Christian                  8              60
Other/None                 0               8

Occupation
Government/Office          5               4
worker
Trader/Merchant            19             16
Farmer/Breeder             41             29
Police/Military/           0               1
Guards
Student                    6              12
Spiritual/                 1               1
Traditional healer
Skilled laborer            3               5
Other                      17             25
Unemployed                 8               7
Heard of Ebola            100             100
before interview

* Denominator varied for those who initiated the survey with regard
to education (N = 5,941), religion (N = 6,238), and occupation (N =
6,217).

([dagger]) Denominator varied for those who completed the survey
with regard to education (N = 5,427), religion (N = 5,706), and
occupation (N = 5,691).

TABLE 2. Knowledge, attitudes, and practices related
to Ebola virus disease--Guinea, August 2015

                                                        Overall *
                                          Response
Indicator                                 format        No.     %

Encountered Ebola response teams          Yes/No/DK     5,681   57
   in the past

Perceptions of personal risk for becoming infected with Ebola

No risk                                   Yes/No/DK     5,601   44
Low risk                                                        27
High risk                                                       15
Don't know/Not sure                                             14

Knowledge and perceptions about Ebola prevention and treatment

Preventable by avoiding contact with      Yes/No/DK     5,715   92
   body fluids of infected persons
Preventable by avoiding contact                         5,708   87
  with corpse of persons who died
   from Ebola
Immediate treatment in health facility                  5,704   86
   increases chance of survival
Immediate treatment in health facility                  5,698   88
   reduces chance of Ebola spread
Male survivors should use condoms                       5,237   46
   for at least 3 months to prevent
   sexual transmission ([dagger])
   ([dagger])

Misconceptions about Ebola transmission, prevention, and treatment

Transmissible by ambient air              Yes/No/DK     5,695   27
Can protect self from Ebola by                          5,705   49
   avoiding mosquito bites
Preventable by bathing with salt and                    5,695   22
   hot water
Can be successfully treated by                          5,693   5
   spiritual or traditional healers

Prevention practices used after learning about Ebola

Took some action to avoid Ebola           Yes/No/DK     5,537   95
   infection
Washed hands with soap and water          Open-ended,   5,240   93
   more often                             unprompted
Avoided all physical contact with                       5,240   44
   those suspected of having Ebola
Avoided crowded places                                  5,240   22

Intentions if family member suspected of having Ebola

Would send family member to an            Yes/No/DK     5,733   91
   Ebola treatment center
Would hide the family member from                       5,520   4
   neighbors and health authorities

Attitudes toward Ebola survivors ([section][section])

Survivors certified to be cured of        Yes/No/DK     4,637   17
   Ebola could infect others through
   casual contact (e.g., hugging or
   shaking hands)
Would not buy fresh vegetables from                     5,417   28
   survivor certified by government to
   be cured of Ebola
Would not welcome survivor                              5,468   19
   declared to be cured of Ebola back
   into community
Expressed one or more of the above        Composite     5,029   44
   attitudes toward Ebola survivors
   ([paragraph]) ([paragraph])
Possible to survive and recover           Yes/No/DK     5,703   72
   from Ebola
Survivors could contribute to Ebola                     4,957   91
   containment efforts
Survivors could educate community         Open-ended,   4,516   62
   members about Ebola prevention         unprompted
Survivors could help care for persons                   4,516   37
   suspected of having Ebola

Intentions if family member died at home

Would wash or touch body if family        Yes/No/DK     5,460   8
   member died
Would wash or touch body if family                      5,512   3
   member died of suspected Ebola
Would accept burial team if family                      5,344   89
   member died of suspected Ebola
Would accept alternatives to                            4,897   72
   traditional burials that do not
   involve physical contact with corpse
   if family member died of any cause
Observe burial from safe distance         Open-ended,   3,509   66
Have religious leader say a               unprompted    3,509   54
   final prayer
Know the location of the burial site                    3,509   22
Provide a name plate at the                             3,509   8
   burial site

Self-reported burial practices within past month of interview
(for persons dying of any cause)

Participated in any burial ceremony       Yes/No        5,532   20
   in the past month:
Washed the corpse                         Open-ended,   1,082   6
Touched the corpse                        unprompted    1,082   4
Touched others at the burial                            1,082   26
   ceremony (e.g., hug, handshake)
Cried over the corpse but did not                       1,082   27
   touch it

                                          Maritime Guinea
                                          ([double dagger])

Indicator                                 No.       % (95% CI)

Encountered Ebola response teams          2,509     72 (69.8-73.3)
   in the past

Perceptions of personal risk for becoming infected with Ebola

No risk                                   2,476     40 (38.4-42.3)
Low risk                                  2,476     23 (21.7-25.0)
High risk                                 2,476     25 (23.4-26.9)
Don't know/Not sure                       2,476     11 (10.1-12.6)

Knowledge and perceptions about Ebola prevention and treatment

Preventable by avoiding contact with      2,526     91 (89.8-92.0)
   body fluids of infected persons
Preventable by avoiding contact           2,524     86 (84.2-87.0)
  with corpse of persons who died
   from Ebola
Immediate treatment in health facility    2,526     89 (87.6-90.0)
   increases chance of survival
Immediate treatment in health facility    2,518     90 (88.4-90.8)
   reduces chance of Ebola spread
Male survivors should use condoms         2,396     44 (42.4-46.4)
   for at least 3 months to prevent
   sexual transmission ([dagger])
   ([dagger])

Misconceptions about Ebola transmission, prevention, and treatment

Transmissible by ambient air              2,514     24 (22.6-26.0)
Can protect self from Ebola by            2,523     44 (42.3-46.1)
   avoiding mosquito bites
Preventable by bathing with salt and      2,522     18 (16.6-19.6)
   hot water
Can be successfully treated by            2,517     3 (2.7-4.1)
   spiritual or traditional healers

Prevention practices used after learning about Ebola

Took some action to avoid Ebola           2,452     97 (96.0-97.4)
   infection
Washed hands with soap and water          2,370     94 (92.9-94.9)
   more often
Avoided all physical contact with         2,370     48 (46.1-50.1)
   those suspected of having Ebola
Avoided crowded places                    2,370     24 (22.0-25.4)

Intentions if family member suspected of having Ebola

Would send family member to an            2,538     93 (92.1-94.1)
   Ebola treatment center
Would hide the family member from         2,426     3 (2.5-3.9)
   neighbors and health authorities

Attitudes toward Ebola survivors ([section][section])

Survivors certified to be cured of        2,093     13 (11.1-13.9)
   Ebola could infect others through
   casual contact (e.g., hugging or
   shaking hands)
Would not buy fresh vegetables from       2,367     21 (18.9-22.1)
   survivor certified by government to
   be cured of Ebola
Would not welcome survivor                2,402     14 (12.9-15.7)
   declared to be cured of Ebola back
   into community
Expressed one or more of the above        2,203     35 (32.5-36.5)
   attitudes toward Ebola survivors
   ([paragraph]) ([paragraph])
Possible to survive and recover           2,523     81 (79.8-82.8)
   from Ebola
Survivors could contribute to Ebola       2,167     93 (92.2-94.4)
   containment efforts
Survivors could educate community         2,022     58 (55.8-60.2)
   members about Ebola prevention
Survivors could help care for persons     2,022     46 (44.0-48.4)
   suspected of having Ebola

Intentions if family member died at home

Would wash or touch body if family        2,416     5 (4.0-5.8)
   member died
Would wash or touch body if family        2,437     3 (2.7-4.1)
   member died of suspected Ebola
Would accept burial team if family        2,346     89 (88.0-90.6)
   member died of suspected Ebola
Would accept alternatives to              2,106     76 (74.4-78.0)
   traditional burials that do not
   involve physical contact with corpse
   if family member died of any cause
Observe burial from safe distance         1,605     65 (62.8-67.4)
Have religious leader say a               1,605     67 (64.9-69.5)
   final prayer
Know the location of the burial site      1,605     21 (18.6-22.6)
Provide a name plate at the               1,605     4 (3.0-5.0)
   burial site

Self-reported burial practices within past month of interview
(for persons dying of any cause)

Participated in any burial ceremony       2457      18 (16.0-19.0)
   in the past month:
Washed the corpse                         431       1 (0.3-2.5)
Touched the corpse                        431       4 (1.8-5.2)
Touched others at the burial              431       13 (9.4-15.6)
   ceremony (e.g., hug, handshake)
Cried over the corpse but did not         431       17 (13.2-20.2)
   touch it

                                               Natural regions

                                          Middle Guinea ([section])

Indicator                                 No.     % (95% CI)

Encountered Ebola response teams          923     37 (33.6-39.9)
   in the past

Perceptions of personal risk for becoming infected with Ebola

No risk                                   884     42 (39.2-45.8)
Low risk                                  884     30 (24.1-30.0)
High risk                                 884     9 (7.2-11.1)
Don't know/Not sure                       884     22 (19.1-24.6)

Knowledge and perceptions about Ebola prevention and treatment

Preventable by avoiding contact with      925     94 (92.0-95.2)
   body fluids of infected persons
Preventable by avoiding contact           922     93 (90.1-94.4)
  with corpse of persons who died
   from Ebola
Immediate treatment in health facility    923     88 (85.5-89.7)
   increases chance of survival
Immediate treatment in health facility    925     92 (89.7-93.3)
   reduces chance of Ebola spread
Male survivors should use condoms         746     39 (35.4-42.4)
   for at least 3 months to prevent
   sexual transmission ([dagger])
   ([dagger])

Misconceptions about Ebola transmission, prevention, and treatment

Transmissible by ambient air              924     31 (27.6-33.6)
Can protect self from Ebola by            925     42 (39.0-45.4)
   avoiding mosquito bites
Preventable by bathing with salt and      924     25 (22.1-27.7)
   hot water
Can be successfully treated by            924     6 (4.6-7.8)
   spiritual or traditional healers

Prevention practices used after learning about Ebola

Took some action to avoid Ebola           900     93 (91.7-94.9)
   infection
Washed hands with soap and water          840     91 (88.8-92.8)
   more often
Avoided all physical contact with         840     41 (37.4-44.0)
   those suspected of having Ebola
Avoided crowded places                    840     16 (13.8-18.8)

Intentions if family member suspected of having Ebola

Would send family member to an            926     94 (92.2-95.4)
   Ebola treatment center
Would hide the family member from         909     3 (2.1-4.5)
   neighbors and health authorities

Attitudes toward Ebola survivors ([section][section])

Survivors certified to be cured of        768     25 (22.2-28.4)
   Ebola could infect others through
   casual contact (e.g., hugging or
   shaking hands)
Would not buy fresh vegetables from       903     40 (36.3-42.7)
   survivor certified by government to
   be cured of Ebola
Would not welcome survivor                911     26 (22.8-28.4)
   declared to be cured of Ebola back
   into community
Expressed one or more of the above        871     58 (54.3-60.9)
   attitudes toward Ebola survivors
   ([paragraph]) ([paragraph])
Possible to survive and recover           925     74 (70.7-76.3)
   from Ebola
Survivors could contribute to Ebola       820     92 (90.5-94.1)
   containment efforts
Survivors could educate community         757     60 (56.1-63.1)
   members about Ebola prevention
Survivors could help care for persons     757     35 (31.1-37.9)
   suspected of having Ebola

Intentions if family member died at home

Would wash or touch body if family        870     11 (8.7-12.9)
   member died
Would wash or touch body if family        889     3 (2.0-4.2)
   member died of suspected Ebola
Would accept burial team if family        878     92 (90.6-94.2)
   member died of suspected Ebola
Would accept alternatives to              800     84 (81.4-86.4)
   traditional burials that do not
   involve physical contact with corpse
   if family member died of any cause
Observe burial from safe distance         671     38 (34.3-41.7)
Have religious leader say a               671     54 (50.0-57.6)
   final prayer
Know the location of the burial site      671     11 (8.4-13.0)
Provide a name plate at the               671     3 (1.6-4.0)
   burial site

Self-reported burial practices within past month of interview
(for persons dying of any cause)

Participated in any burial ceremony       897     31 (27.5-33.5)
   in the past month:
Washed the corpse                         274     3 (0.9-4.9)
Touched the corpse                        274     5 (2.5-7.7)
Touched others at the burial              274     44 (38.3-50.1)
   ceremony (e.g., hug, handshake)
Cried over the corpse but did not         274     30 (24.9-35.7)
   touch it

                                          Upper Guinea
                                          ([paragraph])

Indicator                                 No.     % (95% CI)

Encountered Ebola response teams          1,438   47 (44.1-49.3)
   in the past

Perceptions of personal risk for becoming infected with Ebola

No risk                                   1,433   50 (47.6-52.8)
Low risk                                  1,433   28 (25.6-30.3)
High risk                                 1,433   8 (7.0-9.9)
Don't know/Not sure                       1,433   14 (11.8-15.5)

Knowledge and perceptions about Ebola prevention and treatment

Preventable by avoiding contact with      1,440   94 (92.9-95.3)
   body fluids of infected persons
Preventable by avoiding contact           1,440   87 (85.1-88.5)
  with corpse of persons who died
   from Ebola
Immediate treatment in health facility    1,438   84 (82.0-85.8)
   increases chance of survival
Immediate treatment in health facility    1,439   86 (84.4-88.0)
   reduces chance of Ebola spread
Male survivors should use condoms         1,341   49 (45.8-51.2)
   for at least 3 months to prevent
   sexual transmission ([dagger])
   ([dagger])

Misconceptions about Ebola transmission, prevention, and treatment

Transmissible by ambient air              1,438   34 (31.5-36.3)
Can protect self from Ebola by            1,439   66 (63.8-68.6)
   avoiding mosquito bites
Preventable by bathing with salt and      1,437   29 (26.6-31.2)
   hot water
Can be successfully treated by            1,439   5 (3.9-6.1)
   spiritual or traditional healers

Prevention practices used after learning about Ebola

Took some action to avoid Ebola           1,407   92 (90.0-93.0)
   infection
Washed hands with soap and water          1,288   94 (92.5-95.1)
   more often
Avoided all physical contact with         1,288   40 (36.8-42.2)
   those suspected of having Ebola
Avoided crowded places                    1,288   27 (25.0-29.8)

Intentions if family member suspected of having Ebola

Would send family member to an            1,442   88 (86.2-89.6)
   Ebola treatment center
Would hide the family member from         1,404   5 (3.6-5.8)
   neighbors and health authorities

Attitudes toward Ebola survivors ([section][section])

Survivors certified to be cured of        1,135   21 (18.2-22.8)
   Ebola could infect others through
   casual contact (e.g., hugging or
   shaking hands)
Would not buy fresh vegetables from       1,372   36 (33.5-38.5)
   survivor certified by government to
   be cured of Ebola
Would not welcome survivor                1,365   28 (25.1-29.9)
   declared to be cured of Ebola back
   into community
Expressed one or more of the above        1,283   55 (52.6-58.0)
   attitudes toward Ebola survivors
   ([paragraph]) ([paragraph])
Possible to survive and recover           1,437   58 (55.0-60.2)
   from Ebola
Survivors could contribute to Ebola       1,225   84 (81.9-86.1)
   containment efforts
Survivors could educate community         1,029   63 (59.8-65.8)
   members about Ebola prevention
Survivors could help care for persons     1,029   39 (36.2-42.2)
   suspected of having Ebola

Intentions if family member died at home

Would wash or touch body if family        1,403   8 (6.7-9.5)
   member died
Would wash or touch body if family        1,406   4 (2.5-4.5)
   member died of suspected Ebola
Would accept burial team if family        1,371   83 (81.0-85.0)
   member died of suspected Ebola
Would accept alternatives to              1,297   65 (61.9-67.1)
   traditional burials that do not
   involve physical contact with corpse
   if family member died of any cause
Observe burial from safe distance         837     83 (80.5-85.5)
Have religious leader say a               837     34 (30.6-37.0)
   final prayer
Know the location of the burial site      837     18 (15.7-20.9)
Provide a name plate at the               837     11 (8.5-12.7)
   burial site

Self-reported burial practices within past month of interview
(for persons dying of any cause)

Participated in any burial ceremony       1,411   17 (14.8-18.8)
   in the past month:
Washed the corpse                         237     5 (2.3-7.9)
Touched the corpse                        237     5 (2.3-7.9)
Touched others at the burial              237     21 (15.5-25.9)
   ceremony (e.g., hug, handshake)
Cried over the corpse but did not         237     42 (35.9-48.5)
   touch it

                                          Forest Guinea **

Indicator                                 No.   % (95% CI)

Encountered Ebola response teams          811   61 (57.5-64.3)
   in the past

Perceptions of personal risk for becoming infected with Ebola

No risk                                   808   51 (47.4-54.4)
Low risk                                  808   35 (32.0-38.7)
High risk                                 808   5 (3.9-7.2)
Don't know/Not sure                       808   9 (6.8-10.7)

Knowledge and perceptions about Ebola prevention and treatment

Preventable by avoiding contact with      824   89 (86.6-91.0)
   body fluids of infected persons
Preventable by avoiding contact           822   83 (80.2-85.4)
  with corpse of persons who died
   from Ebola
Immediate treatment in health facility    817   78 (75.4-81.0)
   increases chance of survival
Immediate treatment in health facility    816   79 (76.1-81.7)
   reduces chance of Ebola spread
Male survivors should use condoms         754   57 (53.1-60.1)
   for at least 3 months to prevent
   sexual transmission ([dagger])
   ([dagger])

Misconceptions about Ebola transmission, prevention, and treatment

Transmissible by ambient air              819   17 (14.1-19.1)
Can protect self from Ebola by            818   38 (35.1-41.7)
   avoiding mosquito bites
Preventable by bathing with salt and      812   12 (9.5-13.9)
   hot water
Can be successfully treated by            813   7 (5.1-8.5)
   spiritual or traditional healers

Prevention practices used after learning about Ebola

Took some action to avoid Ebola           778   95 (93.9-96.9)
   infection
Washed hands with soap and water          742   95 (93.4-96.6)
   more often
Avoided all physical contact with         742   46 (42.2-49.4)
   those suspected of having Ebola
Avoided crowded places                    742   13 (10.9-15.7)

Intentions if family member suspected of having Ebola

Would send family member to an            827   87 (84.6-89.2)
   Ebola treatment center
Would hide the family member from         781   2 (1.3-3.5)
   neighbors and health authorities

Attitudes toward Ebola survivors ([section][section])

Survivors certified to be cured of        641   12 (9.2-14.2)
   Ebola could infect others through
   casual contact (e.g., hugging or
   shaking hands)
Would not buy fresh vegetables from       775   16 (13.5-18.7)
   survivor certified by government to
   be cured of Ebola
Would not welcome survivor                790   6 (4.5-7.9)
   declared to be cured of Ebola back
   into community
Expressed one or more of the above        672   30 (26.4-33.4)
   attitudes toward Ebola survivors
   ([paragraph]) ([paragraph])
Possible to survive and recover           818   69 (65.3-71.7)
   from Ebola
Survivors could contribute to Ebola       736   96 (94.8-97.6)
   containment efforts
Survivors could educate community         708   71 (67.5-74.1)
   members about Ebola prevention
Survivors could help care for persons     708   18 (15.4-21.0)
   suspected of having Ebola

Intentions if family member died at home

Would wash or touch body if family        771   10 (7.5-11.7)
   member died
Would wash or touch body if family        780   3 (2.0-4.6)
   member died of suspected Ebola
Would accept burial team if family        749   91 (88.8-93.0)
   member died of suspected Ebola
Would accept alternatives to              694   57 (53.4-60.8)
   traditional burials that do not
   involve physical contact with corpse
   if family member died of any cause
Observe burial from safe distance         396   90 (87.5-93.3)
Have religious leader say a               396   58 (53.2-63.0)
   final prayer
Know the location of the burial site      396   66 (61.0-70.4)
Provide a name plate at the               396   28 (23.1-31.9)
   burial site

Self-reported burial practices within past month of interview
(for persons dying of any cause)

Participated in any burial ceremony       767   18 (15.6-21.0)
   in the past month:
Washed the corpse                         140   16 (9.7-21.7)
Touched the corpse                        140   19 (12.2-25.0)
Touched others at the burial              140   33 (25.1-40.7)
   ceremony (e.g., hug, handshake)
Cried over the corpse but did not         140   22 (15.2-29.0)
   touch it

Abbreviations: CI = confidence interval; DK = don't know.

* Weighted percentages based on poststratification adjustments
with probability proportional to population size of the
participant's administrative region.

([dagger]) As of August 2015, Maritime Guinea reported the total
highest number of Ebola cases; all of its prefectures had reported
cases, and it was the only natural region with active
transmission (in Conakry and Forecariah prefectures) at the
time of data collection.

([section]) As of August 2015, Middle Guinea was the region least
affected by Ebola, and six of the 10 prefectures had never
reported Ebola cases.

([paragraph]) As of August 2015, Upper Guinea had experienced
low numbers of Ebola cases, and two of the eight prefectures
had never reported Ebola cases.

** As of August 2015, Forest Guinea had no active transmission.
However, it reported the first Ebola cases of the epidemic and
eventually reported cases in all six prefectures.

([dagger])([dagger]) Proportions of eligible participants who
did not respond or replied "don't know" were as high as 51.2%
in Middle Guinea, 44.5% in Maritime Guinea, 41.4% in Guinea
Upper, and 38.2% in Forest Guinea. These participants were not
excluded from denominators when calculating percentages.

([section])([section]) Ebola survivors were defined as persons
previously infected with Ebola who had been discharged from an
Ebola Treatment Center and certified by government health
officials to have been cured of the disease.

([paragraph])([paragraph]) Expressed one or more of the
following attitudes about Ebola survivors: 1) survivors
certified to be cured of Ebola could infect others through
casual contact, 2) would not buy fresh vegetables from survivor
certified by government to be cured of Ebola, and 3) would
not welcome back into community a survivor declared
to be cured of Ebola.
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Article Details
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Author:Jalloh, Mohamed F.; Robinson, Susan J.; Corker, Jamaica; Li, Wenshu; Irwin, Kathleen; Barry, Alpha M
Publication:Morbidity and Mortality Weekly Report
Article Type:Statistical table
Geographic Code:6GUIN
Date:Oct 20, 2017
Words:6898
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