• The Ebola Outbreak and Staffing in Public Health Facilities in Rural Sierra Leone: Who is Left to do the Job?

      Sylvester Squire, J; Hann, K; Denisiuk, O; Kamara, M; Tamang, D; Zachariah, R (International Union Against Tuberculosis and Lung Disease, 2017-06-21)
      Setting: The 82 public health facilities of rural Kailahun District, Sierra Leone. Objective: The 2014-2015 Ebola virus disease outbreak in Sierra Leone led the Ministry of Health and Sanitation and stakeholders to set minimum standards of staffing (medical/non-medical) for a basic package of essential health services (BPEHS). No district-level information exists on staffing levels in relation to the Ebola outbreak. We examined the staffing levels before the Ebola outbreak, during the last month of the outbreak and 4 months after the outbreak, as well as Ebola-related deaths among health care workers (HCWs). Design: This was a retrospective cross-sectional study. Results: Of 805 recommended medical staff (the minimum requirement for 82 health facilities), there were deficits of 539 (67%) pre-Ebola, 528 (65%) during the Ebola outbreak and 501 (62%) post-Ebola, hovering at staff shortages of >50% at all levels of health facilities. Of the 569 requisite non-medical staff, the gap remained consistent, at 92%, in the three time periods. Of the 1374 overall HCWs recommended by the BPEHS, the current staff shortage is 1026 (75%). Of 321 facility-based HCWs present during Ebola, there were 15 (14 medical and one non-medical staff) Ebola-related and three non-Ebola related deaths among HCWs. Conclusion: The post-Ebola health-related human resource deficit is alarmingly high, with very few staff available to work. We call for urgent political will, resources and international collaboration to address this situation.
    • Knockdown and recovery of malaria diagnosis and treatment in Liberia during and after the 2014 Ebola outbreak

      Dunbar, NK; Richards, EE; Woldeyohannes, D; Van den Bergh, R; Wilkinson, E; Tamang, D; Owiti, P (International Union Against Tuberculosis and Lung Disease, 2017-06-21)
      Setting: The malaria-endemic country of Liberia, before, during and after the 2014 Ebola outbreak. Objective: To describe the consequences of the Ebola outbreak on Liberia's National Malaria Programme and its post-Ebola recovery. Design: A retrospective cross-sectional study using routine countrywide programme data. Results: Malaria caseloads decreased by 47% during the Ebola outbreak and by 11% after, compared to the pre-Ebola period. In those counties most affected by Ebola, a caseload reduction of >20% was sustained for 12 consecutive months, while this lasted for only 4 consecutive months in the counties least affected by Ebola. Linear regression of monthly proportions of confirmed malaria cases-as a proxy indicator of programme performance-over the pre- and post-Ebola periods indicated that the malaria programme could require 26 months after the end of the acute phase of the Ebola outbreak to recover to pre-Ebola levels. Conclusions: The differential persistence of reduced caseloads in the least- and most-affected counties, all of which experienced similar emergency measures, suggest that factors other than Ebola-related security measures played a key role in the programme's reduced performance. Clear guidance on when to abandon the emergency measures after an outbreak may be needed to ensure faster recovery of malaria programme performance.
    • Management of malaria in children with fever in rural Sierra Leone in relation to the 2014-2015 Ebola outbreak

      Moses, FL; Tamang, D; Denisiuk, O; Dumbuya, U; Hann, K; Zachariah, R (International Union Against Tuberculosis and Lung Disease, 2017-06-21)
      Setting: Sixty-eight primary health facilities, Koinadugu District, rural Sierra Leone. Objectives: Sierra Leone, a country with one of the highest burdens of malaria, was severely affected by the 2014-2015 Ebola virus disease outbreak. In under-five children, we compared trends in the completeness of malaria reports sent to the district office during the pre-Ebola, Ebola and post-Ebola periods, including the number of children with reported fever, malaria diagnostic testing performed and treatment for malaria initiated with artemisinin-based combination therapy (ACT). Design: A cross-sectional study. Results: Of 1904 expected malaria reports, 1289 (68%) were received. Completeness of reporting was 61% pre-Ebola, increased to 88% during the outbreak and dropped to 44% post-Ebola (P = 0.003). Total malaria testing (n = 105 558) exceeded the number of fever cases (n = 105 320). Pre-Ebola, 75% (n = 43 245) of all reported fever cases received malaria treatment, dropping to 34% (n = 50 453) during the Ebola outbreak. Of 36 804 confirmed malaria cases during Ebola, 17 438 (47%) were treated, significantly fewer than in the pre-Ebola period (96%, P < 0.001). Of the fever cases, 95% in both the pre- and post-Ebola periods received ACT, a rate that increased to 99% during the Ebola outbreak. Conclusion: Pre-existing gaps in malaria reporting worsened after the Ebola outbreak. Reassuringly, malaria testing matched fever cases, although only half of all confirmed cases received treatment during the outbreak, possibly explained by outbreak-related operational difficulties. These findings could be useful to guide health systems strengthening and recovery.