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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.

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Let Us Talk

Let Us Talk

When: Thursday, October 30 at 7:30pm EDT

Where: City of Takoma Park, Municipal Government

7500 Maple Ave, Takoma Park, MD

 

“Leh Wi Tok” is a 40 minute documentary about the pioneers who started the independent radio movement during Sierra Leone’s 1991-2002 civil war. A discussion with the filmmaker – and representatives of the local Low Power FM radio effort – will follow the screening. Free.

 

Learn more here.

takoma

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Measuring the Impact of Ebola: Will it Reach 1.4 Million?

This post was originally found on Henry J. Kaiser Family Foundation by Josh Michaud and Jennifer Kates 

More than six months have passed since Ebola was first identified in West Africa, and the scale of the crisis continues to grow. Over the last few weeks cases and deaths have increased significantly in the two most affected countries – Liberia and Sierra Leone – setting the stage for even more explosive growth in the weeks and months to come if further action is not taken immediately. The sense of urgency in the face of an outbreak that has grown “out of control” has been palpable among public health leaders and politicians alike, including at the United Nations last week.  Some of this urgency has been driven by stark new data and modeling projections just released by the WHO and the U.S. Centers for Disease Control and Prevention (CDC).  To help shed light on these new data, we take a deeper look at several key measures of the epidemic’s impact including estimates of current cases, prevalence and death rates from Ebola, as well as a consideration of the future projections of Ebola’s burden in the months to come.

 How Many Cases?

The global health community relies on the World Health Organization (WHO) as the authoritative source on current Ebola case numbers.  WHO has published updates and situation reports about the West African Ebola epidemic, collected from the country governments, agencies, and organizations working on the ground, approximately every week since August. Even though they represent the “gold standard” of the moment, the WHO numbers cannot be taken at face value.  As WHO itself has stated, its numbers are “vast underestimates,” and the organization believes the true number of cases is two to four times greater than the official reported numbers because many cases go undetected or uncounted for a variety of reasons.

What Share of the Population Has Already Been Affected?

Recognizing these limitations, we used these data to calculate the cumulative prevalence of Ebola (the percent of the population that has been infected to date) in Liberia and Sierra Leone as of September 22 (see Table).  Based on officially reported numbers from WHO, cumulative prevalence across both countries stands at 0.049%.  Liberia has been hardest hit with an estimated cumulative prevalence of 0.07%, more than twice the rate for Sierra Leone.  For illustrative purposes, if we take into account the underreporting factor as estimated by WHO by tripling the officially reported case numbers, the cumulative prevalence across both countries would be 0.147%; in Liberia alone, the adjusted prevalence would be 0.22%, or approximately one in every 500 people having become infected already (see Table).  Moreover, the estimated number of new cases is rising exponentially.

Why Are Cases Growing Exponentially?

These constantly upward revisions are driven by a cruel epidemiologic statistic – the reproductive rate of disease, or average number of new infections each case creates. WHO’s most recent estimates of this number are 1.51 in Liberia and 1.38 in Sierra Leone.  As long as the reproductive rate remains above 1, the epidemic will continue to expand exponentially, unless something alters its trajectory.  At the current reproductive rates, case numbers are doubling approximately every 24 days in Liberia and every 30 days in Sierra Leone according to the WHO.

Sources: CIA World Factbook July 2014 Population Estimates; World Health Organization Ebola Situation Report (22 September).

Sources: CIA World Factbook July 2014 Population Estimates; World Health Organization Ebola Situation Report (22 September).

What Does the Future Hold?

CDC’s new Ebola model estimates the potential future impact of the epidemic.  According to the model’s worst case scenario, which assumes no change in the trajectory of the epidemic and also corrects for underreporting, the number of Ebola cases in Liberia and Sierra Leone together could reach 1.4 million by the end of January 2015. This translates into a whopping 14% cumulative prevalence rate. To put this in perspective, an equivalent rate in the U.S. population would be almost 45 million people nationally, and more than 90,000 in Washington, DC alone.

What’s the Relative Impact Compared to Other Diseases?

The available numbers also indicate that Ebola had, as of mid-September, already become the leading cause of death in Liberia. The WHO has estimated a case fatality rate of 70% for the West Africa Ebola outbreak; applying this rate to the officially reported cases from Liberia for the last 7 weeks, we find Ebola caused, on average, 263 deaths per week in the country.  By comparison, the top three leading causes of deaths in the country – malaria, lower respiratory infections, and diarrheal diseases (using data from the global burden of disease study for 2010) – caused an estimated 140, 89, and 88 deaths per week, respectively.  This means at its current rate, Ebola is killing people in Liberia at approximately twice the rate of the country’s previously biggest cause of death and, ominously, this rate is likely to increase for the foreseeable future as the epidemic continues to expand.

Policymaking in a Fog

One of the many challenging dimensions of the current Ebola outbreak in West Africa, and one that it shares with just about every other global health issue, has been the lack of timely and robust data.  Policymakers trying to deliver personnel, supplies, and services where they are most needed have their task made that much more difficult because we have only vague and time-delayed estimates for some of the core epidemiological aspects of the current outbreak, from exactly how many people are infected, geographic locations where transmission may rising or falling, the rate of growth or decline in cases, and how many people remain at risk of becoming infected.  These weaknesses are partly a reflection of the lack of vital statistics and general surveillance capacity in the affected countries, from before the current outbreak even began, and partly due to the rapidly changing, sometimes chaotic situation on the ground.  Arriving at such estimates typically requires coordination between governmental Ministries of Health, non-governmental organizations, multilateral institutions, and aid agencies in rural and urban areas that are spread out across multiple countries.  A difficult task under any circumstances, it has been made even more challenging in the current crisis situation.

With timely, reliable information so limited, crude estimates and projections are what the global health community has to work with at this point. Unfortunately, the story these estimates and projections tell is an exceedingly grim one, and should create an even greater incentive for the world as a whole to respond to this still-growing crisis. The numbers are stark enough, but they only hint at the full weight of the massive and growing toll that Ebola has inflicted on the people in affected countries and communities.

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