Eric Osoro, Medical Epidemiologist, Washington State University

It’s 18 months since Sierra Leone was declared Ebola free after a two-year outbreak that left 4,000 people dead.

While the outbreak might be over, its effects will persist for many years. In the small nation with a population of just 7 million many lost relatives and friends to the disease. And its economy which was growing rapidly before the outbreak was devastated.

It will take time for Sierra Leone to rebuild. But there are valuable lessons learnt from the outbreak. The importance of engaging communities in outbreak response is one of the most important. The country’s commitment to public health awareness about the disease was critical in disease prevention and control. This was seen in the active participation of ordinary citizens in reporting the suspected cases.

The public health response to the outbreak was structured in three phases. In the first the government increased the treatment beds and encouraged behaviour changes like handwashing to prevent the spread of the disease.

In the second phase health workers engaged and worked in communities to identify infected people and those in close contact with them. Communicating with the community groups built trust and confidence in the response efforts.

In the third phase, the focus was on accurately defining and rapidly eliminating all new chains of Ebola transmission while restoring health services to normal.

I was a member of the response team as a consultant epidemiologist with the World Health Organisation during the third phase using my training on surveillance for diseases and management of outbreaks. We needed to address complex challenges such as the coordination of many actors in health and the way the disease was spreading through the community.

The field work

We had an immense task. Together with the local health teams, we established a monitoring system to detect infected people early and provide them with an effective response. Our daily routine included reviewing the number of cases reported, assessing the investigations and conducting field visits.

We also needed to ensure that hospitals’ health systems functioned normally. While Ebola was the most serious disease around, there were also cases of other common diseases such as malaria and pneumonia that also needed attention.

And we needed to implement a stronger surveillance system which would provide information on priority public health events like outbreaks as soon as they were detected. The Ebola outbreak had “surprised”, devastated and collapsed the health system. We wanted to avoid a repeat.

The outbreak was unanticipated and its magnitude overwhelming. In the initial phases, infection spread, killing many health workers which led to the closure of health facilities.

The power of public health education

With health facilities closed, communities were pushed to the forefront of the Ebola outbreak response. They became first responders. The Ebola treatment centres were few and community members had to initially attend to infected people.

The key messages from health authorities was that Ebola was incurable and sick people therefore needed to be taken to treatment centres. The message was factual but the citizens interpreted it as a death sentence.

Most stayed with their infected loved ones at home, fuelling the spread further and more aggressively. The community’s participation and response to the disease needed to be refocused urgently. And a massive public health awareness was rolled out.

The message development and deployment closely engaged local leaders and stakeholders to learn and address what influenced people’s decisions and their resistance to following advice on Ebola prevention.

Through the campaign, the residents realised their power in ending Ebola. Simple infection prevention and control lessons such as washing hands with soap regularly and avoiding contact with people likely to be infected with Ebola were key.

They learnt Ebola related symptoms and this triggered proactive reporting of suspected cases through a toll free line.

The road to recovery

When the outbreak was officially declared over, the country moved to maintaining a no-outbreak status (zero Ebola cases). The health facilities and the affected communities were recovering from the effects of the outbreak.

During this time, there were fears that Ebola would re-emerge but the strong reporting collaborations between the health workers and the community members was commendable.

For example, one Sunday afternoon, we received a call of a sick person. This description required a rapid response. A team was activated and dispatched within an hour. By the time we arrived the person had died after bleeding from the mouth and nose. But there were crowds, anxious to know whether Ebola had comeback.

They had isolated the body and closed contact. We urgently delivered samples for testing and when the results returned negative the following morning, there was a sigh of relief.

This was a powerful demonstration of health promotion from communities.

The way forward

The Ebola outbreak in Sierra Leone reflects the challenges facing health systems at local, national and international levels. When the national health system is inaccessible and unresponsive to community needs, alternative solutions outside the health system are sought. This makes it more difficult to identify acute health problems.

In 2005, the World Health Assembly foresaw an outbreak whose magnitude was closer to the devastation caused by Ebola and adopted a code of conduct, International Health Regulations.

This international protocol was signed by about 200 countries and is aimed at preventing, protecting, controlling and providing a public health response to the international spread of disease. These minimum capacities were to be achieved by 2004, but less than 30 countries have fulfilled. None of these are from Africa.

The code is a relevant and critical mechanism to help countries work together to prevent the spread of diseases and other health risks. It’s evident that gaps in early detection and rapid response to a disease outbreak leads to a public health crisis.

An efficient disease surveillance system rapidly detects and reports public health events. Disease outbreak preparedness should be in place before an outbreak, information shared and resources adequately determined.

Finally, winning the trust and confidence of communities plays a central role in the rapid control of an outbreak – it saves lives.

Original article