From the ground up: rebuilding health systems in the wake of Ebola
As the emergency phase of the response to the Ebola outbreak winds down in Guinea, Liberia and Sierra Leone, the 3 countries face an equally urgent and formidable task: building health systems capable of preventing, detecting and responding to outbreaks.
When Ebola first started spreading in West Africa, the early-warning systems that should have sounded the alarm bell failed to detect the outbreak until it was too late. That allowed the virus to spread rapidly, unhindered by fragile health systems that collapsed under its onslaught.
In Sierra Leone, that early-warning system, called Integrated Disease Surveillance and Response (IDSR), had existed since 2003, but was essentially dormant when Ebola hit. WHO worked with the government to revive it, adapt it for Ebola, and trained health workers across the country to use it. The effectiveness of that system in identifying and responding to cases sooner was a crucial step in helping to blunt the outbreak.
Now WHO is assisting Sierra Leone’s government to expand the system to track 26 priority diseases, including cholera, measles, malaria, typhoid fever as well as women who die in childbirth.
"It's not just about collecting data but making sure there's a response capacity, so we've worked with districts to make sure there is," said Anders Nordstrom, WHO Representative in Sierra Leone.
While Ebola killed almost 4000 people in Sierra Leone, about 26 000 children die every year of other causes such as malaria and measles. Expanded IDSR can help save those lives. The system works by training community health workers in all 14 districts to identify and report early symptoms of the 26 diseases, or rumours of outbreaks. Those reports are fed to the nearest public health unit, which dispatches a team to investigate.
It’s already paying dividends. On 11 January 2016, the system flagged a sudden increase of watery diarhoea and vomiting in Kania, a remote village in Kambia district near the border with Guinea. Within 8 hours, a team of investigators from WHO, the Ministry of Health and the United Nations Children’s Fund was on site, making sure infection prevention measures were in place to help prevent further cases.
"We were terrified thinking we had tripped back into the hands of Ebola since the people were vomiting and had diarrhoea, all typical of the deadly disease," said Mr Amadu Kamara, chief of the Kania village. Further investigation including water testing to establish the cause of the sickness and rule out cholera are underway.
The IDSR training was critical to ensure prompt reporting. "It is good that we now have the IDSR system in place to serve as a major trigger for prevention and response," said Dr Foday Sesay, Kambia’s District Medical Officer. "The ongoing investigation of the suspected cases, planning and preparedness that are happening were triggered because our health workers at the facility level were able to detect an unusual event, which if they had missed could have derailed our health gains," Dr Sesay said.
"It's not just about collecting data but making sure there's a response capacity, so we've worked with districts to make sure there is."
Anders Nordstrom, WHO Representative, Sierra Leone
Responding to measles
The IDSR system has also recently been instrumental in identifying and responding to an increasing number of measles cases that have arisen because of a breakdown in routine vaccination services during the Ebola outbreak. The next step is to develop the capacity for community-based reporting via mobile phone, Dr Nordstrom said.
More than 70% of clinics and hospitals are now reporting on time on all 26 diseases. The system is now being used to track maternal mortality, for which Sierra Leone has the world’s highest rate and where under-reporting has historically been the norm. Almost 3000 women die during childbirth every year, or about 50 a week. About 4 deaths a week are currently being reported through the IDSR system. While there is work to do to close that gap, it’s a vast improvement on the system that existed before Ebola, and which only concentrated on communicable diseases. Knowing where and why women are dying is key to taking the right steps to keep them alive and healthy.
"We’re using the infrastructure built for Ebola to help Sierra Leone and the world become safer," Dr Nordstrom said.
Toward a safer and healthier future
WHO is working with the government to strengthen other parts of the health system, including bolstering the capacity of government laboratories to detect the 10 diseases most likely to cause epidemics, and equipping 4 laboratories capable of handling high-risk samples.
Much work remains to be done, and Sierra Leone’s health system continues to face significant challenges. But in a country that lost 12 of its 220 doctors to Ebola, there are signs of progress toward a safer and healthier future.