Assessment of the epidemic preparedness and response capacity in Sierra Leone

Mohamed Vandi¹, Delia Akosua Bandoh^2,&, Kofi Mensah Nyarko³, Tete Amouh¹, Virgil Kuassi Lokossou⁴, Simon Antara⁵, Ernest Kenu²

 

¹Public Health Emergency Operation Center, Ministry of Health and Sanitation, Freetown, Sierra Leone, ²Ghana Field Epidemiology and Laboratory Training Programme, School of Public Health, University of Ghana, Legon, Accra, ³African Field Epidemiology Network, Freetown, Sierra Leone, ⁴ECOWAS Regional Center for Disease Surveillance and Control, Abuja, Nigeria, ⁵African Field Epidemiology Network, Kampala, Uganda (AFENET)

 

 

^&Corresponding author
Delia Akosua Bandoh, Ghana Field Epidemiology and Laboratory Training Programme, School of Public Health, University of Ghana, P.O Box LG 13, Legon, Accra. deliabandoh@st.ug.edu.gh

 

 

 

 

Public health emergencies are on the rise globally. In recent times, natural disasters and disease outbreaks have struck various countries increasing morbidity and mortality rates [1]. Most of these have disease outbreaks and natural disasters occur with little or no warning. The effects of these epidemics have heavily impacted the livelihood of affected societies [2]. These public health emergencies have become global challenges which require the response of joint efforts from health and other departments in order to be solved [3].

 

The African continent has been equally affected by these public health emergencies over the past few years. The 2014 Ebola Virus Disease outbreak claimed about 11,000 lives between 2014 and 2016 [4]. This epidemic left the health structure of the epicenters completely shattered and unable to support the needs of the countries. Most of these emergencies, if not contained can lead to devastating consequences.

 

Public health emergencies are of importance globally because they are a threat to global security [1]. Annually, populations which suffer public health emergencies are always affected in diverse ways by the events. The health, and socio-economic impact of emergencies continue to worsen leaving the community affected worse than before [2].

 

As one of the three West African countries that was hit greatly by the 2014 Ebola outbreak in addition to Liberia and Guinea, Sierra Leone was not adequately prepared for Ebola Virus Disease. The consequence of this pandemic has been the worse reported in the history of the country. More than 80% of the over 13,000 EVD infected persons lost their lives. Again, over 5% of the people involved in economic activities had a reduction in the amount of revenue they generated [5].

 

Though a lot has been done over the past decades to health issues, a sustainable approach to managing and developing public health capacity is needed to strengthen public health systems in low-resources countries. Preparedness towards emergencies is a process and always require continuous effort to face emerging public health issues [6]. Assessing the system to be able to know what is missing and fill the gaps is a way to improve preparedness of countries.

 

As parts of efforts to improve preparedness and response to public health in West Africa, The Economic Community of West African States (ECOWAS) had adopted approaches such as strengthening of their disease surveillance systems through capacity development and implementing the International Health Regulations, 2005. This was done to develop the core capacities of member states to detect, assess, and report public health events [7]. We assessed the epidemic preparedness and response capacity of Sierra Leone three years after the Ebola Virus Disease Outbreak.

 

 

Study site

 

Sierra Leone is bordered by Guinea to the northeast, Liberia to the southeast and the Atlantic Ocean to the southwest. It has a tropical climate, with a diverse environment ranging from savanna to rainforests. The country has a total area of 71,740 km2 (27,699 sq. mi) and a population of 7,075,641 as of the 2015 census. The country's capital and largest city is Freetown (population 1,050,301). Sierra Leone is made up of five administrative regions: the Northern Province, North West Province, Eastern Province, Southern Province and the Western Area. These regions are subdivided into sixteen (16) districts, which are further divided into 190 chiefdoms.

 

Sierra Leone had a weak health system which was further worsened by conflict and recent Ebola epidemic in 2014. In spite of the introduction of Free Healthcare Initiative launched in 2010 improved access to health care for all pregnant and lactating women, children under five, and other select at-risk groups, access to care is still poor. After the Ebola crisis, the country has made considerable improvement in capacity to detect, notify and respond to major infectious diseases of public health concern and continues to strengthen its capacity to respond to viral hemorrhagic fevers such as Ebola and Lassa fever.

 

The MoHS is the lead agency in the health sector in the country. The country has a public health emergency operation centre (PHNEOC) which facilitates coordination of a goal-oriented response to public health issues including emergencies. Key divisions and units which operate under the ministry of health include Directorate of health securities & emergency, surveillance department and the national public health reference laboratory (NPHRL) and environmental health and sanitation. The collection, collation, analysis and interpretation of health data is also a function of the districts which results in reporting through the integrated disease surveillance and response (IDSR) system and other means to the PHNEOC.

 

Study design and population

 

We carried out a qualitative cross-sectional study in Sierra Leone. We interviewed stakeholders and triangulated the findings with records reviewed in the country. We conducted interviews with various representatives of the major stakeholders involved in the emergency preparedness and response in Sierra Leone from April to July 2018. Interviews were done using the interview guide prepared by experts and validated by WAHO.

 

Data collection tools

 

A data review tool, a structured questionnaire and interview guide were developed based on the WHO IHR core capacities under sixteen (16) major areas.

 

-Coordination, Policy and Plans

 

-Structure and Function of Disease Surveillance Institute and Epidemic Response and Recovery

 

-Cross-Border Response

 

-Laboratory

 

-Public Health Emergency Communication/Risk communication

 

-Logistics

 

-Rapid Response Capacity, IPC, Clinical Case Management

 

-Medical Countermeasures and Personnel Deployment

 

-Vector Control

 

-Availability of Epidemiology/ Surveillance and Related Capacity (Institutional Capacity)

 

-Health Sector Workforce Development Plan

 

-International Health Regulation (IHR) and Joint External Evaluation (JEE)

 

-Stakeholder Engagement

 

-One Health Approach

 

-Resource Mobilization and Sustainability

 

-Monitoring and Evaluation and Research

 

These tools were tested and validated by the West African Health Organizations and Ministers of Health in West Africa.

 

Data collection

 

Data collection was in two phases. The first phase was the desk review of the country´s IHR capacity scores, JEE report and actions implemented after JEE. Desk review of the national surveillance and response documents (policies, systems, plans, structures, coordination mechanisms, documents on simulation exercises, responsibilities and procedure, guidelines including available assessment reports) at the regional and country level was carried out.

 

In the second phase we conducted interviews using a structured questionnaire based on the IHR core capacities with representative within the Ministries of Health and other relevant stakeholders on the status of the country´s surveillance and response capacity and their respective roles in health emergency preparedness and response. All relevant data on the polices, plans, guidelines and relevant literature available were verified during data collection.

 

Data analysis

 

Data from key informant interviews was transcribed, transcripts were manually coded and themes developed under the sixteen (16) major areas of the WHO IHR core capacity areas. Data from reviews was also analysed and grouped under the sixteen (16) major areas. The findings from the interviews and review findings were triangulated.

 

Ethical considerations

 

Approval was obtained from Ministries of Health of all West African countries in ECOWAS through WAHO. In the countries, permission was sought from the head of National Coordinating Institutes. The purpose of the assessment was explained to participants who were interviewed and their approval was obtained before interviews were conducted. Participants and countries were free to opt out of the assessment at any point they liked and they were assured it would not affect them in any way as a nation.

 

 

A total of 14 stakeholders in health were interviewed from seven institutions in the country. Notable of these institutions were Ministry of Health and Sanitation, National Public Health Reference Laboratory, Office of national security Table 1.

 

Summary of Key Findings under 16 IHR Core competencies Sections

 

Coordination, Policy and Plans

 

The country has developed the All Hazards Plan and Concept Of Operations (CONOPS) that details coordination mechanism. The directorate of Health Security and emergencies under the Public health directorate of the ministry of health provides overall coordination of public health emergency preparedness and response in the country. There are other developed policies in place that guide its coordination mechanisms. These include: National Environmental Health And Sanitation Strategy (2016-2020), Integrated Pest Management Plan, Draft Emergency Preparedness Plan, Draft Public Health Agency Strategy and the National Health Sector Strategy (2017-2021).

 

Structure and Function of Disease Surveillance unit and Epidemic Response and Recovery

 

The country has an established Emergency Operation Center (EOC) at the national level that facilitates coordination of public health emergency response. A National Public Health Agency is however in its developmental stages. This agency would be charged with the constitutional mandate of addressing all public health issues in Sierra Leone. There is also an emergency preparedness resilience and response group that meets weekly to review surveillance reports of the preceding week and plan for the coming week. Membership include head of surveillance, laboratory, communications, representatives from line ministries, and Partners. There are at least 2 trained surveillance officers in each of the 14 districts of the country.

 

Major disasters that the country is prone to include: flooding, mudslide, windstorm, Ebola, Cholera, Lassa Fever. However, there is no surveillance system for disasters.

 

Data for surveillance system is periodically analyzed on weekly basis and reports shared. There is improved communication mechanism through regular sharing of information and periodic meeting among Sierra Leon, Liberia and Guinea. There is some challenge with communication with French speaking Guinea.

 

Cross-Border Response

 

The country has been involved in cross-border preparedness and response activities with their neighbouring countries. An MoU has been developed with Liberia, Guinea and Cote d´Ivoire for data sharing and simulation exercises. Currently, Sierra Leone and Liberia exchange weekly epi bulletins. However, there is no Point of entry (PoE) contingency plan for the country.

 

Laboratory

 

Sierra Leone has level 4 National Public Health Reference Laboratory where samples for public health emergencies are sent for confirmatory diagnostic testing and regional reference laboratory. The country has a P3 lab which carries out tests such as EVD, Lassa Fever, Zika virus, Malaria.

 

The country has 5 level 3 laboratories. Central Public Health Reference Lab test for samples such as measles, influenza, yellow fever, Dengue, MDR TB, HIV serology, EID, HIV viral load. The only sample currently sent outside the country for testing is Anthrax.

 

Overall human capacity is inadequate in terms of number of adequately trained personnel. There are laboratory coordinators for clinical laboratories and the National Public health Laboratory at the National level but inadequate laboratory technicians and technologists.

 

One Health concept is partially considered as communication channels can be improved and enrolment into laboratory training institutions not guided by gender.

 

Public Health Emergency Communication/Risk communication

 

Sierra Leone has a public health emergency and response plan in the country. There are systems and mechanism within the plan to provide health education and improve awareness of the public on public health emergencies to help reduce epidemic and health emergency risk in country.

 

The Ministry of Health has established a fully functioning Risk Communication Department at the EOC. The key role of this Department is to engage and educate the public on all health emergencies during an outbreak response to effectively provide information and build trust within the affected community or communities, four main areas are considered. These are coordination, public communication, community engagement and rumour management.

 

Logistics

 

Directorate of health security and emergency together with the MoHs are responsible for ensuring the availability of logistics before, during, and after health emergencies. There is an inventory of resources needed to manage disasters and/or epidemics. The directorate of health security and emergency is responsible for managing logistics for preparedness and response. Also, the national Laboratory is charge of laboratory supplies for the country. Donor partners including WHO, MSF and CDC are the main source support for stocking logistics.

 

There are no available stockpiles currently within the country. WHO and MSF are main suppliers of standard essential items for emergency response but delivery time has been a challenge. There is no pre-supply agreements in place to expedite prompt procurements.

 

Rapid Response Capacity, IPC, Clinical Case Management

 

There are infection control practices in place in the country. The MoH, directorate of health security and emergency, and Partners train health-care workers on IPC measures. Activities embarked upon before epidemic and health emergency include capacity building and surveillance. There are infection prevention and control guidelines and SOPS in all health facilities. They provide health facilities with basic hygiene, sanitation, disinfection, PPE, and services including running water and electricity.

 

Medical Countermeasures and Personnel Deployment

 

Presently, there is no system in place for activating and coordinating medical countermeasures across borders during a public health emergency. There is no national countermeasure and personnel plan. No table top exercise was also conducted.

 

Vector Control

 

There is considerable capacity for vector control through the department of environmental health. The targeted vectors are black fly, mosquito (Anopheles and Aedes species) and flies. Written plans for these vectors does not exist. Malaria which seems to be by far the most important vector is managed under the malaria control program.

 

Availability of Epidemiological Surveillance and Related Capacity (Institutional Capacity)

 

Sierra Leone has a database of experts for epidemic response in the country kept in the EOC. The country has all required cadre of expertise or professionals who can support health emergency preparedness and response. However, the number of professionals is inadequate. A contingency plan exist which can be activated immediately in case of health emergencies.

 

Health Sector Workforce Development Plan

 

There is no Public Health Workforce development plan. Sierra Leone has a National Health Sector Strategic Plan (2017-2021). However, the Health sector Strategic Plan does not contain HR plan for public health emergency and response. The strategic plan does is not gender sensitive. The plan does not address the one health agenda as the focus is primarily on the health sector.

 

The U.S Centers for Disease Control and Prevention (US CDC) and Public Health England are engaged in training Health Workers at the different levels. The CDC through its FETP program has successfully trained one hundred (100) Frontline and Eleven (11) Intermediate FETP Health Workers. Public Health England is embarked on IPC trainings and technical support as well. There are no gender considerations. There are no training programmes for disaster preparedness and response. Sierra Leone has rapid response team capacities at both the national and sub-national levels.

 

International Health Regulation (IHR) and Joint External Evaluation (JEE)

 

The JEE conducted in 2016 showed considerable progress of the country´s performance in the development of the core capacities required to detect, assess, notify and report events, and respond to public health risks and emergencies of national and international concern. Following JEE, Sierra Leone has developed a 5-year National Action Plan for public health security. The plan has been costed and yet to be launched.

 

Stakeholder Engagement

 

Sierra Leone has engagement with many key stakeholders. Almost all the stakeholders are international partners who provide financial and technical support in the area of public health emergency preparedness and response. The partners are part of the process of planning, implementation and monitoring. However, the government is not able to coordinate the activities of partners who have more money and/or expertise that it does.

 

One Health Approach

 

Sierra Leone has developed a draft one health plan. One health platform was launched in 2017 and an MOU signed between MOHS, ministry of agriculture, environmental protection agency which was witnessed by the office of national security (ONS). There is some considerable collaboration between MOHS, ministry of Agriculture and Ministry of Environment.

 

Resource Mobilization and Sustainability

 

There is no resource mobilization plan for mobilizing resource towards disasters and epidemic preparedness. The Ministry of Finance is the ministry´s main domestic financing agency. International funding partners provide resources before, during and after public health emergencies. There is no dedicated budget line for outbreak response.

 

Monitoring and Evaluation

 

Sierra Leone has a monitoring and evaluation plan in place to track progress of epidemic preparedness and response activities. The country has a robust revitalized integrated disease surveillance and response (IDSR) system with countrywide coverage in human health, including indicators and event-based and syndromic surveillance systems is in place. Key Surveillance indicators exist for tracking at the national level. Sierra Leone has a national weekly epidemiological bulletin.

 

Research Research forms part of work in public health emergency preparedness and response. However, some challenges with research include: No legislation, policies, or SOPs on how to conduct research during public health emergency preparedness and response and difficulty in coordinating research activities.

 

Situational Analysis of the Sierra Leone´s Emergency Preparedness and Response System

 

A SWOT analysis was carried out to present the situational analysis of the Sierra Leone. This has been presented as strengths, weakness, opportunities and threats of epidemic preparedness and response in the country.

 

Strengths

 

-Availability of strategic plans, SOPs, and other operational guidelines for use at all levels

 

-A considerable human resource capacity following the Ebola Outbreak in 2014

 

-Improved Infrastructure following the Ebola Outbreak (Laboratories, and EOCs)

 

-Political will and commitment of state in the preparedness and response

 

-Improved awareness and appreciation of the importance of preparedness and response of the general public following their experiences during the Ebola outbreak

 

Weaknesses

 

-Lack of dedicated funding or budget line for preparedness and response

 

-Over dependence on donor partners to mobilize resources

 

-Lack of SOPs to govern the activities of partners

 

-Difficulty in coordinating efforts of donor partners according to country´s priority

 

-Lack of training institutions for advance level capacity building, i.e. Masters, advance field epidemiology, doctoral, membership and fellowship postgraduate medical training

 

Opportunities

 

-Considerable progress towards IHR core capacities

 

-Goodwill from partners and willingness to provide support

 

-The in-country training of frontline and intermediate level field epidemiologist

 

-Rich reserve in minerals e.g. diamond, bauxite, iron ore

 

Threats

 

-No formal plan for biosafety and biosecurity issues

 

-A fragile national economy

 

Other Observations

 

Sierra Leone has made some significant strides on public health-related efforts since the end of the Ebola epidemic in 2015. As a result of lessons learned from the epidemic, newly available resources for public health improvements, and fresh focus on the issue from the MoHS and other key partners, a number of strides have been made in recent months.

 

 

The health impacts of public health emergencies which have occurred recently have revealed the need to strengthen public health systems to better protect communities [8]. We assessed the epidemic preparedness and response capacity of Sierra Leone.

 

Sierra Leone has a number of policies and plans in place to respond to epidemics. Most of these are fully implemented, functional and are being used to handle outbreaks that occur in-country. in spite of the absence of the functional public health institute, the EOC plays a major role in coordinating all health emergencies in the country. The present roles the EOC plays in the country clearly portrays its effectiveness as a functional EOC which coordinates and manages responses in the face of public health emergencies [3, 9]. Groups and committees formed for public health emergencies are functional and meet frequently to handle emerging issues. Generally, EOC have been widely used for multi-agency collaborations during public health emergencies [3].

 

In the wake of the current public health emergencies occurring globally, there is the need for collaborative efforts by countries to be able to handle them. The 2014 EVD outbreak in West Africa highlighted the importance of this collaboration in handling public health emergencies [10]. Cross-border ties between Sierra Leone and neighboring countries have been strengthen by an MoU signed with them. Information sharing and planning for simulations across borders can help in containing outbreaks which may spread across borders.

 

Engaging in cross border activities with neighbouring countries helps to bridge the gaps in each countries PoE structure and also reduces the strain on limited resources as countries share assets and minimize the impact of emergencies which may occur [11]. In spite of all these efforts, there is no PoE contingency plan to guide actions and set the right targets. The country also has no system in place for coordinating medical countermeasure across borders. Simulation exercises are also not done in country. The PoE contingency plan is an essential minimum requirement countries are expected to meet under the international health regulations (IHR) [12].

 

There is a fully functional risk communication unit at the EOC. Communication during emergencies is therefore assured and issues of miscommunication and rumors can be fully dealt with. The well-defined and effective communication structures that exist in the country can be attributed to the presence of a functional EOC. Aside coordinating of activities during public health emergencies, the EOC also enhances information sharing and strengthens information management during epidemics [3, 13]. Effective communication determine the success of every emergency response [14].

 

Though the country has offices which manage logistics, take inventory and ensure their availability during emergencies. The country relies mainly on donors for logistics. Thus currently, there are no available stockpiles in country. In the absence of needed logistics, all plans and preparations for outbreak response cannot be achieved. Logistics are basics the country needs to be well equipped for outbreaks. There is a need for the country to look out for more sustainable ways of obtaining logistics aside donors.

 

Laboratories are essential in handling infectious disease outbreaks. With a strong laboratory capacity, samples can be easily tested, diagnosed and treated in an outbreak setting[15] Sierra Leone has high level laboratories across the country. They are therefore able to carry out a number of diagnostic testing in-country.

 

Trained human capacity for laboratory is however inadequate. To be adequately prepared for emergencies, there is a need for the accurate number of workforce needed to be available [14]. The country has no public health workforce development plan. The current workforce training is being done by partners. Sustainability is shaky, there is no plan to develop workforce capacity as a country, the country is heading towards doom. Health strategic plan doesn´t touch on health workforce development. In the state of emerging and re-emerging disease outbreaks, there is the need to continually develop and maintain capacity to effectively respond and manage to these emergencies [8].

 

The importance of the One Health concept, that is the multidisciplinary and intersectoral approaches in managing health emergencies has gradually become clear as the health of the people depends heavily on the environment [16]. In the face of an emergency, a multisectoral approach involving human, animal, environmental and other agencies are needed in order to effectively tackle public health emergencies. Sierra Leone has a One health plan drawn and launched but no implemented. A bit of collaboration goes on though between agencies. Unless the plan is fully implemented, the benefits of one health would not be fully derived by the country. Some reasons for the delay in implementing the plan could be lack of trained experts in one health and lack of infrastructure such as interdisciplinary laboratories. Again, since more than 75% of emerging and re-emerging epidemics are zoonotic in nature [14, 17], it is important that the country takes further steps to implement the One Health plan so that it would be well equipped to handle all public health emergencies.

 

International partners form key stakeholders. They provide both technical and financial support. Too much power has been given to stakeholders. Government is not able to coordinate or control their activities. The country´s aim and focus are therefore not met. On the contrary, partners rather have the opportunity to pursue their goals. This could be detrimental to the country´s development.

 

Following the JEE in Sierra Leone, the country has developed a NAPHS, which is yet to be launched. The Gaps in JEE would be addressed by implementing the NAPHS. The NAPHS implementation would lead to filling of urgent gaps in the public health system of the country and also inform emergency preparedness planning in the country [15].

 

No plans in place, no budget lines for emergencies, the Ministry of finance is the sole entity to raise funds for this. International donors are the main source of money during emergency. During the 2014 EVD outbreak, resource mobilization was key in moving Ebola interventions to be implemented. countries in West Africa have limited resources especially in its rural setting [10]. Therefore, without the ability to mobilise resources, the basic health needs of their communities would remain unmet and preparedness and response capacity to outbreaks a dream that can never be realized.

 

Limitations

 

One main limitation to this study was competing interest of stakeholders due to their other commitments. This made it difficult to have ample time to explore in-depth issues on the existing situation during interviews. To minimize this, we shared interview guides with stakeholders ahead of the interview.

 

 

Epidemic preparedness and response capacity in the country has seen a significant improvement after the EVD outbreak in 2014. From the assessment, Sierra Leone has a number of effective plan and policies developed and implemented to improve epidemic preparedness and response. However, the lack of an EOC serves as a limiting step to achieving the required preparedness the country needs. Again, over reliance on international partners could affect to the sustainability of their gains made if not addressed effectively. We recommend that the country create a sustainable and dedicated budget for epidemic and health emergency preparedness and accelerate work towards establishment of the National Public Health Agency as some of the major priority areas toward ensuring health security.

 

 

The authors declare no competing interests.

 

 

Conceptualization: MV, DAB, KMN, TA, EK, VKL, SA, EK. Data collection: MV, DAB, KMN, TA, VKL, EK. Report writing: MV, DAB, KMN, VKL, EK. Manuscript development and finalization: MV, DAB, KMN, TA, EK, VKL, SA, EK. All authors read and approved the final version of the manuscript.

 

 

We would like to thank all stakeholders and partners in health who granted us the audience and assisted us throughout this activity.

 

 

Table 1: Cadre of Staff Interviewed

 

 

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