The National Government’s Capacity to Detect and Respond to a Public Health Emergency of International Concern

BY STEPHEN J. GAOJIA

Background

It seems every single generation of the human race (in the history of existence) is usually confronted with one kind of challenge or another. These challenges may range from natural disasters to manmade disasters. Our generation has faced many challenges, ranging from senseless rebel incursions, droughts, hurricanes and tsunamis to large scale viral epidemics. One such viral epidemic is the Ebola Virus Disease (EVD) that is currently ravaging the West African sub region.

The Ebola Hemorrhagic Fever (EHF)was brought to our attention in 1976 in the wake of the outbreak in the Democratic Republic of Congo (DRC) but it was never in the scope, scale, and nature that is being confronted in West Africa, and especially within the Mano River basin. The scale and scope was such that the United States Centres for Disease Control and Prevention (CDC) predicted in its Morbidity and Mortality Weekly Report(MMWR) Vol 63 that by January 2015, the world could witness up to 1.4 million West Africans being infected with the deadly Ebola Virus Disease (EVD) (predicated on some assumptions). The situation was so dire that by October 14, 2014, Bloomberg News suggested that as the Ebola virus spreads in and beyond Africa, it’s raising the possibility of a global pandemic that U.S. intelligence agencies have warned is among the greatest potential threats to global security.

But for the collaborative efforts of the international community and critical interventions at the national levels of the three worst affected countries, the saidprediction could have come to pass.

Pre-Ebola health infrastructure and the medical situation in Sierra Leone

Ebola exposed the state of quagmire of the medical and healthcare status of not only Sierra Leone, but the three worst affected countries in the West African sub region. Despite the significant strides made by the government of Sierra Leone to initiate the Free Healthcare Initiatives for lactating mothers, pregnant women, and Children under Five, it is saddened to note that at the time of the EVD outbreak, the country had barely half a dozen road worthy ambulances, one Hemorrhagic Fever Lab for Lassa Fever, only one virologist, and no specialised Treatment Centres for EVD.There were less than one hundred and thirty sixty (136) medical doctors nationwide, and 1,017 trained and qualified Nurses and Midwives and 114 registered Pharmacists for a population of more than six million (6,000,000) people.

The Advent of EVD into Sierra Leone

Sierra Leone was the last of the three countries that are worst hit by the EVD. The disease had ravaged neighbouring Guinea and Liberia for months before it entered into Sierra Leone. One would have expected Sierra Leone to institute processes and procedures in readiness for a possible advent of the disease. One would have expected a response that was better designed, adequately prepared and well-coordinated in the aftermath of the cholera outbreak reported in the country in 2012/13 as well as cases in neighbouring countries.

However, on the confirmation of a positive result of what was to be Sierra Leone’s index case, a scrambled design and adisorganizedresponse apparatus was about to unfold. Our initial response to the EVD scourge was very simplistic for the requirements needed to respond to a disease of that nature and virulence.Based on what we know now for any meaningful response to the nature and type of scourge like EVD, there would need to be robust mechanisms put in place within the healthcare governance structure, designed on realistic principles that are practicable within the country-specific context.

The Ministry of Health and Sanitation (MoHS) seemed to have an understanding of the true picture of what was at hand, but appeared severely constrained. The magnitude of the outbreak was such that it exposed the dearth for expertise required to respond adequately. Consequently, disjointed actions complicated efforts. For example, long and unproductive meetings were held at different levels. The president was eager to contain the outbreak and therefore he formed the Presidential Taskforce, comprising a large number of both national and international actors, which he personally chaired on a weekly basis, and he declared a Public Health State of Emergency. The inter-ministerial Committee was established with all relevant line-ministries Agencies and Departments meeting weekly; the Minister of Health and Sanitation held and chaired the daily technical meetings; District Level Ebola Taskforces that met daily were established, and Byelaws were quickly enacted to help municipal and local authorities swiftly contain the disease in their communities.

Despite all these efforts, little results were achieved at breaking the chain of transmission. The public remained largely unresponsive because accurate messaging and public relations strategy continued to be a challenge, thereby suggesting that more action was required in terms of a response capacity and expertise.

As the events unfolded in Liberia and Guinea, Sierra Leone could have learned some potential lessons.Key among these could have been to pre-positionrobust disease surveillance and social mobilisation apparatus coupled together with the establishment ofRapid Response Teams especially at, and near border regions. In Sierra Leone, the situation deteriorated so quickly that within a couple of months the outbreak which started in the farthest part of eastern Sierra Leone became a complete national epidemic.

Had there been a robust, efficient and effective preparedness and response mechanism in place, the outbreak could not have prolonged this far. The lessons learned from the cholera outbreak could have been utilised to improve the response mechanism, but the nature of outbreak and requirements were different. The EVD outbreak required setting up of specialised treatment facilities which the country could not afford due to financial constraints and the required matching technical expertise. The MoHS was aware of what was required, but some of the needed materials were to be imported. These challenges were compounded by procurement mechanisms where the government could not directly import but had to go through partners. These factors contributed to the prolong nature of the nature of the EVD scourge not only in Sierra Leone, but also in the Mano River Sub- region.

In short, the virus was ahead of us and we were in not prepared to rapidly contain it. In fact the WHO Director General, Dr Margaret Chan, who oversaw the response to the SARS outbreak in 2002 and 2003 and the Avian Flu epidemic in 2009, said in a statement released by her Geneva office that she had never seen an infectious disease contribute so strongly to potential state failure.The Mano River Basin had recently emerged from over a decadeof civil war with severe impact on both Sierra Leone and Liberia. Worse of all Sierra Leone now faces a price slump in iron ore, its biggest export earner and 16 percent of its GDP, reducing the government’s coffers just when it desperately needs resources to respond to the outbreak.

The Ebola Virus Diseaseand Response Challenges

In early 2014, if anyone had looked closely at the trend of EVD on themap of West Africa, you could have seen that Ebola Virus was Sierra Leone bound. There was no doubt about that. Under the circumstance, it would have been prudent to conduct a thorough scenario analysis together with a risk assessment on the possible outbreak of EVD in Sierra Leone. The questions then were when and by what scale, rather than if EVD was to be in Sierra Leone.

Precisely answering those questions could have provided the basis for the establishment of an Ebola Emergency Response mechanism even before the EVD outbreak in Sierra Leone. The country only had its Emergency Operations Centre (EOC) by August of 2014, about four months into the outbreak. Even with the establishment of the EOC, coordination and funding remained problematic. With the exception of the $14 plus million dollars initially provided by the Government of Sierra Leone, which funded the response for the first six months into the outbreak, funding was largely donor-driven.

Evidence now suggest that had the EOC been established long before August 2014, with clear terms of reference, adequate coordination and funding mechanisms, much more could have been achieved by way of containing the rapid spread of the virus across the country. This would have enabled the response team to develop realistic Response Plans for scaling up isolation and treatment beds in treatment facilities, develop standard operating procedures (SOPs) for quarantining, contact tracing, burials and other interventions in the response upon the confirmation of the index case.Such efforts should have been followed up with active case search, surveillance and robust contact tracing activities with a bid to removing all potential and confirmed cases from the communities to either isolation or treatment centres.

Furthermore,detection and containment measures within the country and along the borders with neighbouring countries that were already affected, and putting the whole country on high alert should have been robustly imitated. Community mobilisation, coupledwith heightened and bespoke public information targeting specific segments of society must have been done immediately and on a regular basis. A one size fit all approach to targeting communities with public information and social mobilisation was not only unsuccessful, but actually introduced some confusion in the response efforts.

There was a perceived high level of distrust by the communities of the authorities, another contributing factor towards the spread of EVD in Sierra Leone. At the onset of the campaign, community members were very apprehensive and suspicious of government social mobilization messages. This problem was further compounded by preconceived notions that the communities held high. One of which is the belief that the reported EVD deaths were actually as a result of witchcraft. Such mistrust and suspicion reached their all-time high when communities rejected potable water provided for quarantine homes in preference to water from the local streams. In other instances some people even refused soap intended to promote handwashing at the family level claiming that the soap will infect them with the virus.

Weakened Community coping strategies have added to the catastrophe, with Ebola and non-Ebola virus healthcare seekers adopting strategies such as self-prescription, and the concealing of sick housemates due to fear of Ebola related isolation. With these looming contexts, chances of achieving the UN Millennium Development Goals (MDG) related to child and maternal mortality, and combating HIV/AIDS, malaria and other diseases have been further delayed.

The National Ebola Response Centre (NERC)

As the EVD situationescalated, the government saw the need to establish a fully functioning and effective emergency response apparatus to provide strategic leadership and coordination of the entire efforts. This realisation saw the advent of the Emergency Operations Centre (EOC), which was headed by the National Coordinator, with technical meetings co-chaired by the Chief Medical Officer(CMO) and the WHO Representative (WR), and the different partners serving as members of the Centre. Key amongst them were the agencies, funds and programs of the United Nations, such as WHO, UNICEF, UNFPA, WFP, OCHA, etc. Other key partners are the Centres for Disease Control and Prevention of the USA and China, the International Federation of the Red Cross, MSF, the African Union,and a host of other key bilateral and multilateral Partners.

However, the EOC lacked executive authority. That need was identified as the epidemic spread. Therefore,the President saw the need to rebrand the EOC. The successor institution that emerged was the National Ebola Response Centre – NERC. The NERC was to be headed by a Chief Executive Officer with executive authority and powers.

The NERCfunctions through decentralised structures across the board. There are District Command and Control Centres housed at the District Ebola Response Centres (DERCs) and charged with coordinating the affairs of the response efforts at districts-level. Their operations are supported by subject matter specialists structured into pillars. The pillars also meet at the inter-Pillar Action Coordination Team (I-PACT) where peer review on technical matters are discussed with a view to improvingoperational efficiency for the response.

It must be noted that the Sierra Leone Ebola Response principles and operational model emphasized the following:

  • that the response effort iscoordinated at the strategic level by NERC,
  • that the districts lead the response at the tactical level,
  • that the response is informed by medical/technical guidance,
  • that the response issupported by partners,and
  • that the response focuseson astrong regional collaboration.

These principles and operational model have been the basis for implementing all the critical interventions, such as the Three-Day Sit at home campaigns, the Western Area Surge phases I & II, the current Operation Northern Push (ONP) and future interventions including the National Day of Remembrance

Establishing a Robust Public Emergency Architecture

Experts have advised that wherever EVD hasoccurred before, it is highly likely to come back. With this in mind, it is now an urgent priority of the Government of Sierra Leoneto design a robust strategic architecture that will form the basis for an Emergency Response apparatus that is fit for purpose. Such an establishment must be designed and built with rapid response capabilities that can detect with precision, identify, contain and eradicate threat of emerging epidemics.

The sad experiences learned from the EVD response shows that, no response can be effective without the active involvement and participation of the local communities. It is therefore imperative tocreate a common national aspiration with the collective and all-inclusive buy-in of the entire social fabric of the nation. Achieving this will largely depend on the extent and degree of alignment between and amongst the values of the communities and the priorities of government. This should form the basis upon which a legal framework to guide the establishment of the institution that may be charged with the responsibility of coordinating and directing future national emergency response efforts.

The going forward strategy for the long term should be the enactment of a statute establishing an emergency management structure with the legal stature, powers, resources (both human and financial) backed by the required executive powers and authority to be able to identify, contain and eradicate any emergency within Sierra Leone.Such emergency management agency should be equipped with well-designed planning and coordination capabilities.

A rapid response capability is a crucial element that any agency managing emergencies should have for it to succeed in the discharge of its duties and responsibilities. For this to be achieved, the agency should always be in preparedness mode to effectively respond to emerging problems.

In addition to the forgone is the capacity to be able to detect threats at an early stage. In health related emergencies, the surveillance capabilities need to be robust to be able to detect and ascertain the specific nature and extent of the disease. An adequately trained human resources pool is essential in this regard, if we are to be able to confront and combat future epidemics.

A closely related feature to a sound surveillance apparatus is the availability of a national public health laboratory capability. It is one thing to be able to carry out surveillance activities, but if that surveillance capability is not backed up by equally efficient national laboratory resources, we will remain vulnerable to the ramifications of future outbreaks.

Recommendations

Going forward, it should be emphasised that EVD in particular and alldiseases of threat to public health are no respecters of national borders. It is therefore important to strengthen the following aspects of incident management systemsto facilitate early detection of outbreaks. Therefore, there the following suggestions are proffered:

  • Cross border screening and monitoring. Monitoring of legal and illegal crossing points will be critical. All travellers from affected countries will need to be identified and monitored as they enter into the country.
  • Laboratory capacity is necessary for the timely confirmationof cases in outbreaks. Therefore fully equipped and functional laboratories should be strengthened at the national level as well as in districts with common borders with Guinea and Liberia.
  • Training of Rapid response teams is necessary to initiate response measures once a case is detected.
  • Case Management: maintaining the required materials to initiate isolation, care and treatment of confirmed cases is critical. Continued training of health worker especially in standard and acceptable Infection Control and Prevention (IPC) measures is necessary.
  • Logistics: There is need to have stockpiles of the needed medical equipment and materials. The need for an effective supply chain to facilitate the movement of logistics for a quick response is equally important.
  • There is an urgent need to facilitate the implementation of the provisions of International Health regulations at Ports of Entry.
  • Training of health workers and other stakeholders on management of diseases of public health importance is necessary.
  • In any effective Emergency Response, decision-making is critical as well as the ability to effectively communicate public health messages and manage expectations. Therefore, the following is required:

A strong strategic decision making body and its replication nationwide.