Infectious Disease

Strengthening Sierra Leone Health Systems: Applying Lessons from the 2014 Ebola Outbreak to Future Emergencies

This guest post was written by Laurentiu Stan (laurentiu_stan@jsi.com), MD,MPH, MBA, Chief of Party, Advancing Partners and Communities (APC) Project, Sierra Leone, JSI Research & Training Institute, Inc. John Snow, Inc., a member of Global Health Council (GHC), and the nonprofit JSI Research & Training Institute, Inc., are public health management consulting and research organizations dedicated to improving the health of individuals and communities in the US and around the globe.

Zainab Jalloh, holding her one-year-old daughter Khadijatu, at the Gbanti Community Health Post (CHP) on April 3, 2017 in Bombali District, Sierra Leone.

I’ve lived in Sierra Leone for almost two years, working to help this country’s long-battered health system recover from the Ebola outbreak that took the lives of more than 200 health professionals. Now the country has been affected by an epic landslide. Despite these tremendous setbacks, health systems and health indicators are improving.

Even before the Ebola Virus Disease (EVD) outbreak, Sierra Leone had the world’s highest maternal mortality ratio: 1630 of 100,000 live births (UNICEF, 2010). By 2015, the ratio had dropped to 1360, but Sierra Leone still held the top spot in this dismal measurement. Ebola compounded the problem because about 1 in every 4 women stopped coming to clinics for prenatal care and delivery. In fact, although almost 4,000 Sierra Leoneans died due to the EVD outbreak (between May 2014 and January 2016), during that same period more than 4,500 women died in childbirth.

The Ministry of Health and Sanitation (MOHS) focused its post-Ebola health recovery priorities on strengthening the health system’s capacity to safely detect and prevent diseases and respond to future epidemics in cooperation with its neighbors. It also recognized the need to contribute to global health security to improve health and economic opportunities.

A health facility water pump before APC revitalization. Photo courtesy/ JSI Research & Training Institute, Inc.

Between September 2015 and August 2017, under the umbrella of the USAID-funded and JSI-managed Advancing Partners & Communities (APC) project, I have helped implement a number of programs that are contributing to MOHS recovery objectives by improving primary care service delivery in the communities hardest hit by Ebola. APC has revitalized 305 primary care facilities, ensuring access to basic health services—with a focus on improving quality of maternal health services—for almost 2 million Sierra Leoneans, including the 3,400 registered Ebola-survivors.

A health facility water pump after APC revitalization. Photo courtesy/ JSI Research & Training Institute, Inc.

APC’s community health facility upgrades dramatically improved water and sanitation standards, installed solar power systems, provided basic equipment, and trained more than 900 health professionals and 1,500 community health workers (CHWs) on reproductive, maternal, newborn, and child health and as—importantly, given how Ebola was spread—infection prevention and control practices. Today, more than 2 million Sierra Leoneans in five districts have access to revitalized primary care and community health services in these primary care units and their catchment villages.
We know that another epidemic or emergency could come at any time, and while the Sierra Leone health system is going through significant transformations as part of the five-year recovery plan, it is better equipped now to address it.

The tragic August 14 landslide was just such an emergency—and the new systems that the U.S. government has invested in are working. The emergency coordination and resource mobilization mechanisms put in place with CDC support reacted well and fast. Mental health nurses who were trained to support Ebola survivors are providing psychosocial support to the several-thousand people who lost homes and relatives: more than 1,000 people died in the landslide. The CHWs recently trained by APC have undergone a 15-day social mobilization exercise to identify and convey messages on the prevention of cholera and other waterborne diseases to at-risk populations. With USAID and DfID support, JSI is assisting the MOHS relief efforts with emergency delivery of essential pharmaceutical and medical consumables to one area hospital and six primary care units.

This most recent tragedy has demonstrated that the country’s service delivery system has improved. One year after the outbreak ended, the MOHS data showed about a 10% positive change in uptake of facility deliveries and outpatient services in the four districts where 70% of Ebola survivors live. Now that health facilities have been revitalized, and health care workers are providing higher-quality services, we are seeing more and more Sierra Leoneans returning to their local health facilities.

There is still much to be done, of course. But Sierra Leone is on its way to a health system that meets the needs of its people—and, given the toll that Ebola took, is ready to confront the next infectious disease—be it Ebola or some other virus—with stronger, better prepared health services. And that helps us all.

0
CDC Protects People from Disease Threats and Outbreaks in the U.S. and Around the World

This blog post was written by Carmen Villar, MPH, Deputy Director for Strategy, Policy and Communication, at the the Center for Global Health, Centers for Disease Control and Prevention.

Opinion polls show that the Centers for Disease Control and Prevention (CDC) is one of the federal government’s most admired and trusted agencies.

Since its founding in 1946, CDC’s history as America’s premier public health agency has been tightly intertwined with its work abroad. CDC experts were on the frontlines in the efforts to eradicate smallpox, the only disease in history to be eliminated. Now CDC experts are actively engaged in current efforts to eradicate polio, a disease that once ravaged the United States and countries worldwide. Today wild polio virus remains active in only three countries: Pakistan, Nigeria, and Afghanistan, and only five cases of wild polio virus have been reported this year, which is a record low number. These encouraging results reflect a novel partnership, the Global Polio Elimination Initiative (GPEI),that holds promise for future efforts to protect people’s health.

GPEI is a public-private partnership led by national governments with five partners – the World Health Organization, Rotary International, U.S. CDC, the United Nations Children’s Fund, and the Bill & Melinda Gates Foundation – who have locked arms to defeat polio. CDC’s record and commitment to global health is also evidenced in its work combatting HIV/AIDS, TB, malaria, neglected tropical diseases such as River Blindness, and its more recent, and widely reported, efforts to defeat Ebola in West Africa and Zika in numerous countries.

CDC has more than 1,700 staff stationed in more than 60 countries, including scientists, disease detectives, laboratory technicians, and other experts who are on the frontlines working to detect disease outbreaks at the earliest possible moment, to respond to them decisively, and to stop them from spreading. That mission is driven by the same principles CDC uses wherever it works – rigorous science, accurate data, quality training, and strong collaboration with partners.

Yet when it all works as designed, as it often does, the results can be hard to see. The best outcomes are an absence of disease outbreaks and the accompanying fear about their impact, an abundance of healthy people who contribute to U.S. interests by supporting more stable governments and more robust economies, and a lower chance of disease erupting and spreading.

CDC’s values and guiding principles are the same as they’ve been from the beginning – working to protect Americans by rapidly detecting and containing new health threats anywhere in the world before they can come to the United States. The focus is on providing strong, effective public health systems and on training healthcare professionals who can identify outbreaks in their own countries to prevent those threats from crossing borders.

For example, CDC’s Field Epidemiology Training Program (FETP), established in 1980, has trained more than 9,000 disease detectives to date in more than 70 countries. They provide critical frontline disease detection and surveillance, and, significantly, more than 80 percent of the FETP graduates continue working in their countries, with many moving into public health leadership positions. From 2009–2014, FETP graduates took part in more than 2,000 outbreak investigations, which kept their countries, and the world, safer and healthier.

It works with countries to immunize children and adults to protect them from vaccine-preventable diseases. Preventing diseases such as polio and measles allow children and adults to live healthy and productive lives. It means laboratorians from CDC’s world class laboratories work together to provide training and technical expertise to laboratorians in other countries to upgrade and expand laboratory services. This results in accurate and reliable laboratory networks, which are essential to finding and understanding disease threats, and in using resources for maximum public health benefit.

CDC’s dedication to global health can be measured by outbreak response mobilizations, staff trained and ready for deployment, person-days of response support, ensuring that all people have access to safe water and sanitation around the world, and collaboration with global partners.

An example is CDC’s participation in the Global Health Security Agenda (GHSA). Formed in 2014 with key contributions by CDC, GHSA is designed to implement the tools and practices necessary to prevent, detect, and respond to outbreaks at the earliest possible moment in countries throughout the world. To date, 31 countries are participating, with each pledging to meet universal standards for quality disease surveillance, a well-trained workforce, rapid and accurate public health laboratory capacity, and emergency response via emergency operation centers.

Another example is CDC’s Global Rapid Response Team (GRRT), a “boots-on-the-ground” program ensuring that, from a pool of 400 trained experts, 50 are on-call to travel anywhere in the world within 48 hours to confront an outbreak at its outset. The GRRT was mobilized more than 230 times in one year after it was created in 2016, and provided 8,000 person-days of response support in more than 90 outbreaks worldwide, including cholera, yellow fever, Ebola, Zika, measles, polio, and natural disasters. The GRRT also has experts in global health logistics, laboratory management and training, communication, and disease detection.With the world more connected than ever through travel and commerce, GHSA is a systematic effort to provide universal and tested standards to prevent, detect, and respond to disease outbreaks worldwide and to close gaps in these areas that allow disease to cross borders.

Taken together, all of CDC’s work abroad contributes to making the world and all Americans safer and more secure, healthier and more confident that threats to their health will be identified and resolved no matter where they live and travel.

Follow CDC Global on Twitter @CDCGlobal

0
Congress Returns After Summer Recess

Congress returned to Capitol Hill this week to deal with Fiscal Year 2017 (FY17) appropriations and funding the domestic response to Zika. With fewer than 20 days remaining in the Congressional schedule before the election and FY16 ending on September 30, little time remains for Congress to address these issues. Earlier this week, Senate Democrats rejected by a procedural vote to advance legislation that would have provided additional funding for the domestic Zika response. The$1.1 billion bill was rejected due to GOP riders, including one to defund Planned Parenthood, attached to the legislation. Congress could potentially attach Zika response funding to the FY17 legislative package. In regards to FY17, Congress is expected to pass a Continuing Resolution (CR) to keep the federal government open beyond September 30. However, it still remains unclear if the CR will expire in December, in which case Congress will return for a lame duck session to complete the federal budget, or if a longer CR will last until March and the new Congress will finish up the FY17 budget.

0
Zika Emergency Funding

Last week, the White House requested that unobligated Ebola funding be reprogrammed to combat the Zika virus. The President had previously requested $1.9 billion emergency funding, but the request had stalled as Republican appropriators pushed for the use of unobligated funds. It is unclear which accounts the funding will come from. It is expected that approximately $140 million will go to the Department of State and USAID.

0
The Unforeseen Consequences of Pandemics on Sexual & Reproductive Health & Rights (SRHR)

By Dr. Christine Sow, President & Executive Director, Global Health Council

BrazilphotoMNCHblog

© 2000 Alex Zusman, Courtesy of Photoshare

When HIV/AIDS was first identified in the early 1980s, it was labeled as a “gay” disease, and thus immediately linked to one aspect of sexuality. As the world learned more about it, we learned that it was not limited to men who have sex with men, but rather was sexually transmitted and could affect women as well. And it did. As a consequence of sexual transmission, women have borne the most significant burden of the HIV pandemic resulting in the disproportionate infection of women compared to men; as well as having drastic effects on women’s reproductive choices and outcomes because of mother-to-child transmission of the virus.

Fast forward thirty-odd years to 2014 and the height of the Ebola outbreak in West Africa. What we knew at that time was that Ebola is spread by contact with bodily fluids, but what we were still to learn is that Ebola can also be sexually transmitted. While only one case of sexual transmission has been confirmed, the consequences of this type of transmission are huge both in terms of the possibility of additional Ebola transmission, but also in terms of sexual behavior and reproductive choices that women and their partners will need to make to ensure their safety. WHO’s “Interim Advice on the Sexual Transmission of the Ebola Virus Disease,”[i] issued in January 2016, calls for couples counseling, use of condoms, and twelve months of regular semen testing for male survivors of Ebola. The practicalities and feasibility of putting this advice into practice in an Ebola-ravaged community are not addressed by this advice document, and are presumably left to the health system and individuals to figure out.

And now, as Ebola fades into the background of public consciousness, we are faced with the rapidly spreading Zika epidemic. The gravity of the Zika crisis was initially identified with the appearance in Brazil of an unexpectedly high number of babies born with microcephaly to women who had been infected with Zika during pregnancy. Immediately the sexual and reproductive health implications of the disease started to become clear – women were warned to postpone pregnancy; pregnancy termination was also offered as a theoretical option for fetuses identified with microcephaly. However these options pre-suppose availability of and access to reproductive health services and commodities – i.e. modern contraceptives and safe abortion. The reaction of the Catholic Church starkly underlines the political, practical, and ethical chaos surrounding the development of an appropriate response to the Zika pandemic. And, to make matters more complicated, sexual transmission of Zika has now been identified.

The upshot is this: while we fear infectious disease for its rapid spread, debilitating illness, and possible mortality, the real impact of a pandemic can be wider and more devastating than its immediately visible trajectory appears. The world’s women, most of whom have inadequate access to reproductive health, often pay a higher price and bear a heavier burden when pandemics occur; at the same time, policy makers and cultural leaders are slow to respond. The striking examples of HIV/AIDS, Ebola, and Zika must be heeded and used as the basis for strong and appropriate strategies that ensure women’s sexual and reproductive health, even, and especially, in times of widespread health crisis.


[i] This area of concern is so new it receives only “advice” rather than “guidance”!

0