Coronavirus - 19 Lessons Learned from the Ebola Outbreak in Sierra Leone

During the 2014-2015 devastating Ebola outbreak in West Africa I worked as the UNICEF Representative in Freetown, Sierra Leone and as one of the very few expats participated in the different national Ebola fora right from the beginning of the outbreak throughout its peak period until it declined and the country recorded only a few cases per week in selected chiefdoms. As the Coronavirus is affecting us around the globe so many memories of challenges, different considerations and shifting responses resurfaced. In this note I provide ‘19 lessons learned from the Ebola outbreak in Sierra Leone’. Low, medium and high-income countries have different capacities to respond and have been affected at different rates. Not all lessons might be relevant for all countries but many will be useful to keep in mind as we manage the fight against Coronavirus disease (COVID-19) around the globe.

1-Social Mobilisation is absolutely key: Continuous fact-based education and communication should be part of every step in the response

The fight against Ebola was not won in the hospitals. It was all about stopping transmission at the family & community level. Initially there was a lot of confusion and mixed messaging about the Ebola virus in Sierra Leone. While neighbouring countries were affected, there was a belief that it would not come to the country. Once it hit the initial districts misconceptions, miscommunication and rumours created enormous anxiety. 

Continuous, fact-based education and communication with the population was necessary. Studies on rumours and misconceptions informed media continuously and resulted in updating messaging. All avenues were used, including radio, TV, social media involving traditional leaders, religious leaders, artists and celebrities. The most important lesson is to educate and communicate and mobilise the community clearly and continuously to take preventive, prudent measures. As the country got closer to zero there was a relapse of risky-behaviour. It is important to keep the momentum going to avoid people getting back to old habits too early. 

2-Contact Tracing: Important at different moments

Initially contact tracing was central to interrupt the ongoing transmission and reduce spread of the infection. However, once the situation spun out of control contact tracing became less of a priority (and practically unmanageable). At that stage, it was important to reprioritise and redirect resources to other public health interventions. Later in the epidemic when the curve had come down significantly and the ‘end game to get to zero’ commenced, contact tracing became again a central part of the response.

3-Quarantine of Communities & Households: The risk of imposing with force

To contain the spread people who had been (potentially) exposed to the virus were put in quarantine for 21 days. This important intervention was in some instances implemented with too much (police) force, which was counterproductive. It created anxiety and suspicion and resulted in people fleeing. Finding a balance between adherence and community acceptance is important. Support by other community members to provide for food and other necessities was essential. It is very important to continually explain why it is important to have quarantine measures in place, as people tend to ease after an initial period. Encourage those in real quarantine to stay the course through supportive messaging by phone/social media. 

4-Isolation/Safe beds: Have a ‘no regret’ policy in place – It’s better to have too many than too few safe beds

There was a serious shortage of ‘safe beds’ during the initial Ebola response. A major investment was required in the establishment of additional beds and special Ebola facilities. At UNICEF we had a ‘No Regret’ policy in order to respond to the ‘unknown’. Within 6 weeks we established with district health teams nearly 50 community care centers with over 400 beds and nearly 1000 nurses and support staff. ‘Only’ 500 patients were ultimately admitted. 

Interestingly, the Ebola facility established by the Ministry of Health (Hastings) turned out to be the best performing Ebola facility in the country. The doctors immediately applied lessons-learned from this unprecedented experience. While in other new facilities, mainly established by international NGOs, inexperience and fear hampered efficient operation.

5-Health Care Supplies: Don’t be afraid to re-distribute health care supplies between facilities

Every health worker in every health facility demanded that his/her facility was fully stocked with all required supplies. However, not all facilities had the same need. As supplies in the country were most of the time only sufficient for about one (1) week it was important to develop a flexible logistics system in order to be able to redistribute supplies based on real need while the pipeline of new supplies continuously were flown in. After UNICEF took over the responsibility of the entire supply system, within 48 hours we had a system running that ensured uninterrupted supplies despite major logistical challenges. There were no shortages of personal protective equipment and medicines in the Ebola centres around the country and mortality among health workers dramatically reduced instantly. Don’t be afraid to re-distribute health care supplies based on real need.

6-Health Workers require special attention

Health workers were at an increased risk of becoming infected. Especially during the initial months there was a high mortality rate among those who treated patients. Adequate protective clothing and equipment is ofcourse key. An important measure was the establishment of continuous infection control and prevention training programs for all health workers. While there was a fear of significant shortages of health workers, after a clear hazard pay scheme was established there was no shortage of staff that was willing to treat infected patients. There was initially confusion about payments and some wrong expectations that lead to strikes etc. A timely and clear hazard pay/incentive scheme will ensure adequate motivated personnel. 

7-Testing of cases & Epidemiology: It is all about trends not the actual numbers

Labs and testing facilities were close to non-existent during the initial months of the Ebola outbreak. In addition, the case definition changed several times during the outbreak resulting in shifting numbers. This created confusion, anxiety and misinformation. It is important to monitor and communicate to the public trends and not hinge on exact numbers. Explain very clearly, why the numbers change if this happens. The reporting of numbers of COVID-19 cases in China recently shifted for one day with many more new cases due to administrative adjustments. This instantly presented a different picture from the ongoing downward trend. Stay focused. The surveillance data and epidemiological trends will at certain stages require a change in response. Accept the unknown, don’t be afraid to make difficult decisions based on new data.

8-Survivors: Celebrate and provide support & protection

Ebola is a very deadly virus so celebrating Ebola survivors was an important moral boost during difficult times. It created hope and reminded the population that early detection and timely care increased chances of survival (and reduced spread in community). This again resulted in more appropriate health care seeking behaviour and an overall positive attitude towards the health care system. However, survivors were also stigmatised and special communication messages were required to avoid discrimination and exclusion from the community. Use survivors to tell positive stories. It will help reduce anxiety. 

9-Burials: Safe and respectful procedures & counselling

Different from Corona, burials were during the Ebola outbreak a central place of contagion due to cultural practices, which facilitated transmission of the virus. Implementing a very strict burial policy was the game-changer that ultimately controlled the Ebola epidemic. Public health rules and practices around burials may be adjusted during the COVID-19 response as part of general measures to prevent population concentrations. However, measures should be put in place to respect and support those who lost loved-ones and find the right balance in limiting burial attendance. Special teams can provide counselling and support and follow-up including opportunities to mourn and allow different ways of paying respect to the deceased (regardless of the cause of death). 

10-Avoid reduction of Health Services Utilisation for fatal non-related diseases

Many people were afraid either to be diagnosed with Ebola or to become infected by the Ebola virus while visiting a health facility. This resulted in a significant reduction in use of health services for other diseases and an increase in non-Ebola related mortality. Safe triage and clear communication is essential to avoid reduction of use of essential health services out of fear.  

11-A Cure: Don’t expect a miracle medicine

During the Ebola outbreak there were continuous rumours about new Ebola medicines and vaccines that would be available very soon. This created anxiety and false hope among the population, which tended to relax their behaviour immediately. While research was ongoing around the world to find a cure it was clear that it would take ample time. News about new drugs should not distract the ongoing response to contain the virus and provide other support to those infected. 

12-Education/School: When to re-open school?

Schools were closed to reduce transmission. While some segments of society resisted this measure resulting in nearly two million children missing their education, overall there was quick acceptance. Alternative approaches were established, including daily lessons via radio. With the latest EdTech approaches, alternative studying opportunities have increased enormously since then. 

However, the biggest challenge we faced was agreeing on when to re-open schools. There was strong pressure to keep schools closed until the outbreak was officially announced over. While on the other side there was an urgent need to get children back to school and learn. Schools are beside a place to study also safe spaces. Teenage pregnancies increased significantly during the Ebola period. Different interest groups will put enormous pressure on decision makers to keep schools closed too long or open too early. In Sierra Leone it was the international donor community that opposed opening of schools (which would have been another nine months). Fortunately, no children were infected in a school setting. An objective independent assessment will help in making the right decision to re-open at the right time. Use the re-opening of schools as an opportunity to bring back 'pre-outbreak' out-of-school children back into the system.

13-Be mindful of the poor and vulnerable population in your country

Ebola had a negative impact on the entire society, including the local economy and means of earning a living. Sierra Leone only made limited use of ‘lock-down’ measures to halt society from moving around. These stringent measures were applied at specific strategic moments and in targeted locations. Large segments of society needed to be able to move for daily survival. This ranged from simple activities like water collection to informal trading. Any period beyond two weeks would have been counterproductive. When serious ‘limitations of movement’ policies are implemented special attention and support (food handouts, water trucking, etc) for the poor and most vulnerable segments of society should be considered.

14 – Focus on a multi-sectoral approach

Stopping the epidemic required a multi-sectoral response. During the initial months of the outbreak in Sierra Leone it was mainly a health sector response. Other sectors were only supporting the health authorities upon request. One cannot start early enough with accelerating availability of other means and services to the population while fighting the virus. Therefore, strategies for uninterrupted delivery of water and sanitation, nutrition, social welfare, incentive schemes, and support to small businesses cannot start soon enough. The outbreak should be seen as an opportunity to improve inter-sectoral collaboration. 

15 – Don’t wait for international support 

The health system in Sierra Leone could be characterised as weak compared to international standards. It badly needed additional international aid to contain the virus. However, it took nearly five months before serious global support (both financial & technical) was provided. This delayed assistance was only triggered after there were serious fears by donor nations that the virus could spread to their countries. Corona-19 has already affected the international financial capitals of the world. Donor governments and their technical epidemiological expertise will have different priorities this time around. Don’t wait for them.

16 – You have to make decisions in uncharted territories

The Ebola outbreak meant for everyone that we were moving in uncharted territories. There was a lack of experience in responding, as the outbreak became a national crisis. Even internationally, there were no epidemiological experts who had experienced this before. The few global specialists present during the early days were also learning on the spot and were mainly observing and taking notes. Little international expert guidance was provided, especially during the initial period of the outbreak. The health authorities on the ground had to make their own quick assessments and decisions.

17 – Organise an efficient & transparent system of disbursement of response funds

Governments in different countries will have different capacities to provide financial support to control the outbreak and mitigate the impact on the population. But even in Sierra Leone, one of the poorest countries in the world, a national fund was established. To avoid inappropriate usage of finances senior international UN staff had to sign off on payments from the fund. With all its limitations, this was probably the most appropriate approach at the time for the country. It is important to set a clear, transparent and lean system of decision-making and disbursement in order to use limited resources effectively and efficiently.

18 – National coordination mechanism should be lean but not exclusive

During the outbreak, the national Ebola coordination mechanism evolved and was ‘reset’ three times because it was considered at times too health focused and ineffective. A National Ebola Response Centre with direct links to the national leadership, district authorities (with District Ebola Response Centres), international community and different sectoral pillars turned out to be the preferred model for Sierra Leone. Make sure the national coordination is lean but not exclusive.

19 – Act quickly but be prepared for a long journey 

The final point relates to speediness of the response. When the first Ebola case was reported in Sierra Leone it was in a remote district. National authorities felt they could manage it at local level with increased measures. It didn’t work. The response was always one or more steps behind the virus. Be prepared to be in it for the long haul. This means that people will become impatient. Furthermore, politics will get involved and pressures to change strategy not based on evidence will reappear. Stay focused, be open-minded and communicate continuously (back to lesson 1).

Finally, we need to be mindful of the side-effects and the costs of the global COVID-19 response in terms of life and misery. Because of the great unknown we are now closing business and borders which is restricting trade and plunges the economy into a recession. It is the poor who will suffer most again. Over the past 3 months 5000 people died from corona whereas every day 15,000 children alone die from mainly preventable diseases, so we should not lose perspective. Governments are now putting hundreds of billions into fighting the economic crisis, but should have shown the same commitment in building resiliency among the vulnerable through effective health, education & protection systems; this commitment will need to continue long after the COVID-19 outbreak has gone.