Sunday, September 21, 2014

Ebola: Sierra Leone's Ose-to-Ose campaign & "lockdown" end...

A few hours ago I received a report from the Ministry of Health and Sanitation, Emergency Operations Centre (EOC) in Sierra Leone - the Ebola House to House Sensitization Campaign is officially over. After 3 days of lockdown, people are no longer confined to their homes. There was a discussion about extending the lockdown since not all of the houses were reached, but it was decided to end the official lockdown and continue the house-to-house social mobilization exercise in the hot spot areas around the country.

It's hard to know how successful a campaign like this was. It sounds like 75% of the households were reached nationwide, which sounds like a reasonable percentage in a 3 day period to me in a country with over 6 million people. Besides one incident in the East of Freetown, the nation was peaceful, which says a lot about people's willingness to cooperate and some trust in the government. From what I have heard, the quality of health talks varied but that's to be expected with over 21,000 volunteers with varying backgrounds and very recent training. I have heard that in some homes a bar of soap was given but little information about Ebola itself was provided and no questions were asked about sick people on the compound. In other homes, talks were more extensive and sick people were identified and taken to holding units. Hopefully overall, awareness increased. Although the main aim was raising awareness, suspected Ebola patients were also identified and dead bodies were also discovered. Of course, not all of the deaths will be due to Ebola.

The campaign is over but the outbreak is not. It is important that the general public realizes this. There are often strange beliefs and already I have heard that some people think that Ebola is now gone. Also, a message was sent around today by a Bishop urging all citizens to call on the name of Jesus at 6 pm this evening to 'kick Ebola out'. From friends in the city, I heard that at 6 pm they did hear loud cries of 'Jesus, Jesus, Jesus'. Some people may well believe that this is all it takes. And while I believe that divine intervention is possible, I also believe that people need to be wise and sensible. Giving people hope is good, but not if it leads to people being careless. We need people to continue taking this disease seriously and move forward with extreme caution. There are still many challenges with sick people being too afraid to go to health facilities, health care workers not feeling protected enough to work, lack of beds in isolation/holding units and treatment centres, lack of staff, etc. It is also good to remember that many more people are now dying of diseases such as malaria, typhoid and pneumonia than they are of Ebola due to lack of general health care. There is still much to be done.

Hopefully this campaign was a step in the right direction...

Thursday, September 18, 2014

Ebola: Ose to Ose Ebola Tok...

Today marks the start of the nationwide House-to-House Family Sensitization on Ebola Campaign in Sierra Leone. The campaign is entitled 'Ose to Ose Ebola tok' and is scheduled for the 18th - 21st of September. Three of these days (19th-21st) will be stay at home days for the entire population, except for health care workers and those sensitizing the public.

The main objective is to reverse the trend of new Ebola cases as well as to enhance interpersonal communication and engagement of communities in the fight against Ebola. In total 28,544 (7136 teams of 4 people) will be mobilized across Sierra Leone. 

While the situation continues to worsen in Sierra Leone, it is important that communication is clear and people work together to fight Ebola. Let us hope that these days will be effective and that more people will come to realize  how real Ebola is and what needs to be done to break the chain of transmission.

Let us pray for peace in the country. The fact that people will need to stay at home for 3 days straight can pose many challenges. For some, it will be difficult to ensure that there is enough food and water available in their household. Pray for God's provision for these people and that this will not lead to any rioting. Pray for cooperation and understanding amongst the general public and for wisdom and protection of those leading and participating in the delivery of this campaign.

Thursday, September 11, 2014

The impact of the Ebola outbreak on child health in Sierra Leone...

The worst Ebola outbreak in the world is confirmed to have infected 1,305 people in Sierra Leone to date1 though the actual rates may be higher. Of the Ebola confirmed cases, around 22% are children between the ages of 0 and 17 years2. Children are not only getting infected with this disease, but many have either been separated from their parents or been orphaned due to Ebola and many more children can no longer access basic health services for non-Ebola illnesses.

The loss of over 240 healthcare workers due to Ebola infections in the affected countries of Sierra Leone, Guinea, Liberia and Nigeria, with long-standing shortages of healthcare professionals, has understandably instilled fear amongst hospital staff and has led to a demand for more training, sufficient protective equipment and incentives before they feel confident to proceed with their work on the front line. This, in combination with a fear amongst the general public to report at health facilities and the difficulty in identifying suspected cases when reliable histories are not forthcoming, has resulted in many health facilities closing or only running outpatient services. Amongst these health facilities is the Ola During Children’s Hospital (ODCH); the only government run Children’s hospital in the country, which is now temporarily closed.

At ODCH, which Welbodi Partnership has supported for over 5 years now, preparations were made in collaboration with hospital staff and partnering organisations at the start of the outbreak for the possible arrival of suspected Ebola cases. This included setting up a small isolation unit, ensuring the availability of personal protective equipment in the unit, training of staff and screening of patients at the entrance of the hospital. It also involved the reinforcement of using universal precautions on all of the wards.  

The screening questions are based on the case definition for Ebola, which includes specific symptoms, travel to/from an affected district and contact history with an Ebola patient.  Since the transmission of Ebola is through contact with bodily fluids of an Ebola patient, the contact and travel history are important. It is estimated that prior to the outbreak, 80-90% of children presenting to hospital come with symptoms such as fever, diarrhoea, vomiting, and weakness; symptoms that not only categorize Ebola, but many other common diseases such as malaria, typhoid and gastroenteritis. If the case definition were only to focus on symptoms, this would mean that the majority of children presenting to the hospital would need to be isolated, which with approximately 1000 admissions a month at ODCH, would be a daunting task. It would require a rapid turn around of laboratory results and a large medical and logistics team on the ground, as frequent entry into the unit would be required to assure that infants and young children are receiving adequate hydration and care, particularly as it is not guaranteed that these children could be isolated with a dedicated caregiver.

The agreed procedure at ODCH in dealing with suspected Ebola cases was put to the test in early August: a child arrived at the hospital and was screened at the entrance. The history revealed fever, vomiting, weakness and a positive contact and travel history. Since the patient met the case definition, the child was immediately isolated in the hospital’s isolation unit while testing was carried out. Two days later when the test result came back positive, the child was taken to an Ebola treatment centre in the east of the country. All staff that came into contact with this patient were aware that she very likely had Ebola and took the necessary precautions. Although this case brought up a few challenges in the process, it did go according to plan and the hospital continued with the same procedure.

Only a week later, however, another child arrived at the hospital. This child had symptoms of fever, diarrhoea and vomiting, but the father denied any history of contact with an Ebola patient or travel from an affected district, most likely because he was afraid to hear that his child might have Ebola. For many, the diagnosis of Ebola is seen as a death sentence. Since the father withheld essential information, the child did not meet the case definition and was admitted to the Emergency Room. It was not until two days later that one of the doctors found out from another relative that the child had been in contact with an Ebola case. Alarm bells rang and preparations were immediately made to transfer the child to an isolation unit for testing for Ebola. All other patients were moved onto another ward and the Emergency Room was decontaminated.

As one can imagine, hospital staff was nervous, having cared for this patient for two days on a general ward, using gloves and universal precautions, but not using the full protective suits since the patient was not admitted as a suspected case. It was decided that all staff in direct contact with this case, would be quarantined in their homes where they would sit out the 21-day incubation period with the hope that they had not been infected.  Since that day, ODCH has been closed to new admissions, because without reliable histories during screening it is impossible to identify a suspected case and isolating all cases arriving at the hospital was an impossible task due to size limitations of the initial isolation ward. Over the next few days, most children were discharged from the hospital. Two days later, the result for the child was announced: positive.

Thankfully, 21 days has passed and none of the staff that came in contact with this case have shown any signs of Ebola, but to date, ODCH, the country’s only government-run paediatric hospital, remains closed.

This story is not unique. Many health facilities across the country and in the sub-region are in similar situations. The impact of this outbreak on the already fragile health systems throughout West Africa will be immense. On average, ODCH admits 1000 patients in the month of August. The fact that ODCH was shut for the second half of the month means that 500 children who would normally have access to health care services, did not. What is the fate of these children? Children with diseases such as malaria, pneumonia, gastroenteritis and other common diseases may well die. The implications will also be severe for services such as outpatient paediatric HIV/AIDS and tuberculosis treatment, as these patients are either afraid to come to the hospital to receive their medications, or health staff are placed at high risk without proper protective equipment to allow them to safely conduct consultations. The immunization programmes will be hindered and many children may not be immunized adequately during this outbreak. It is fair to say that we will see an increase in both morbidity and mortality over the next months. Extrapolating data from a Lancet article in 20133,4 it is estimated that 2,500 women and children die in Sierra Leone every month. With the current strains on the health care services this number is inevitably going to increase, and this will never be accounted for in national Ebola mortality statistics. The closure of the hospital has also had an impact on the few remaining health facilities in the area, already overburdened by the demands of the Ebola outbreak, and with limited experience in paediatric care.

Efforts are underway to re-open the hospital, but this must be done in such a way to ensure the safety of both staff and patients. An effective screening method needs to be put in place so that the hospital is not, once again, forced to close. With a high level of fear amongst the general public, it could be that other caregivers will not be forthcoming with the actual history, for fear of their child being isolated. Finding a safe way to re-open the hospital potentially means that a large proportion of children presenting to the hospital will need to be isolated and tested prior to being admitted, since the symptoms of Ebola mimic that of other diseases. NGOs currently on the ground at ODCH are working with hospital staff, the Ministry of Health and Sanitation and other agencies to discuss plans to set up a larger isolation unit adjacent to the hospital for this purpose. In the meantime, training of hospital staff is ongoing with a big focus on infection control measures, including the use of personal protective equipment. Welbodi Partnership is currently providing advice from afar but hopes to return soon to support the efforts at ODCH.

In itself, Ebola is a terrible disease, causing suffering and death, but the impact on the fragile public health systems in the country means that the morbidity and mortality from more common illnesses will be on the increase. Measures to stop the transmission of Ebola need to be scaled up to control this outbreak.  At the same time, and continuing into the future, the current health systems need to be strengthened to ensure the availability of high quality health care in Sierra Leone, as well as to prevent and control such outbreaks in the future.

MOHS Sierra Leone Situational Report - 9 September 2014
2 UNICEF Sierra Leone - Ebola Virus Disease - Weekly update (1-7 September 2014)
Written by: Sandra Lako, Welbodi Partnership

Tuesday, September 09, 2014

Ebola: The current situation...

As of the 9th of September 2014, the number of people that have been confirmed to have the Ebola Viral Disease in Sierra Leone is now 1,305. Of those, 893 of the cases are in the two districts of Kenema and Kailahun in the east of the country and 118 of the cases are in the Western Area district, which includes the capital city of Freetown. The rest of the cases are scattered all across the country in all but one district, Koinadugu, the only district with no known Ebola cases.

The situation is getting worse. These numbers are bad enough, but I am certain they are just the tip of the iceberg. The cases mentioned are those who have had laboratory testing, in other words, those who have presented at a health facility. The issue is that many people are not presenting to health facilities. They are either too scared to go for fear of being isolated or contracting the disease, likewise, health care workers are afraid to work for fear of becoming infected. 

All this to say that the numbers reported are likely to be a gross underestimation of the actual situation. There are probably hundreds if not thousands more Ebola cases throughout the country. Many people are sick and dying in their homes, and while suffering they are at the same time spreading the disease to other family members. It is a sad situation.

And now, even if patients want to access healthcare, many health facilities are shut and even the Ebola treatment centres in the country are currently full. This provides a signifiant challenge. The few holding units (isolation centres) in the country that are isolating and testing patients now have nowhere to send their positive patients too. This means that their beds are full and new patients cannot be admitted for isolation and testing. This means that patients are forced to go back into their communities, which leads to further spread of the disease.

The only solution to this problem is to set up more treatment and isolation units across the country, which asks for a strong human resource and logistical commitment from both the government of Sierra Leone, partner organisations and the international community at large. 

There are plans to set up new isolation and treatment centres, but unfortunately it has proven to take weeks, if not months, for these centres to be functional. What will happen to those with Ebola in the meantime and how much more will this virus spread before patients can be properly isolated, tested and treated again? 

I know that both the US and UK governments have agreed to help with setting up (and possibly running?) treatment centres in Liberia and Sierra Leone? But will the proposed 25 and 62 beds respectively be enough? I think the answer is obvious. The international community and the government of Sierra Leone need to scale up their efforts considerably. It is already expected that thousands of additional cases will surface in the next few weeks. What happens next?

~ Act Justly. Love Mercy. Walk Humbly. micah 6:8 ~