The Ebola outbreak laid bare the fragility of the health system in Sierra Leone, resulting in more than 4,000 deaths between May 2014 and January 2016, and 3,600 indirect deaths among mothers and babies. The epidemic exacerbated chronic weaknesses in the health and laboratory system, which was not sufficiently equipped or skilled to diagnose Ebola. This resulted in cases remaining undiagnosed for long periods and sub-optimal isolation of patients, which hindered control of the epidemic. More broadly, the availability of services was reduced, thus contributing to increased mortality, as health workers were concerned about the risk of exposure to the virus, and many laboratories were unable to provide routine basic diagnostic services as staff were diverted to the epidemic response.
The announcement of the Ebola outbreak on 23rd March 2014 by the World Health Organisation (WHO) brought about a large international response with many new organisations working in the country. Mobile molecular ‘Ebola laboratories’ and systems for transporting and testing blood and biological samples were established by international agencies. Insufficient coordination and planning in the initial stages resulted in a duplication of efforts.
As a result, some laboratories were unable to cope with the volume of samples, whereas others were operating below capacity. Ebola test results were sometimes taking several days to be completed and communicated to the attending clinicians and health facilities. This resulted in delays in diagnosing patients, thus preventing the timely isolation of those that contracted Ebola and contributing to wastage of scarce resources in Emergency Treatment Centres.
This led to a quick increase in the number of cases and an increased threat to both national and international health security. The epidemic brought renewed attention to the need to strengthen laboratory systems, an essential yet often overlooked component of International Health Regulations and health systems strengthening initiatives. The Sierra Leone Ministry of Health and Sanitation (MoHS) and the UK Department for International Development (DFID) took strategic steps to ensure timely diagnosis of Ebola, while contributing to building a more resilient laboratory system through a project implemented by Options.
Interventions and achievements
To ensure that Ebola test results were communicated on time, a key intervention was the placement of Laboratory Liaison Officers (LLOs) at each Ebola laboratory. The LLOs recorded the movement of Ebola samples and communicated test results immediately and directly to the clinicians at health facilities, ensuring timely isolation and management of patients. The LLOs also facilitated direct communication with the specimen transport system and burial teams. The availability of data from Ebola testing laboratories enabled better partner coordination, joined-up problem solving and evidence-informed public health decision-making by MoHS and its partners. It also provided the foundation for the development of a laboratory information system. These interventions reduced the turnaround time for Ebola sample testing from more than 48 hours to below 24 hours within two months.
In June 2015, a nationwide capacity assessment of the laboratory system was commissioned by the MoHS. The assessment confirmed the major weaknesses of the laboratory system and identified priorities for addressing these. The assessment showed how laboratory workers were performing tasks without standardised training or qualifications, shortages of consumables and equipment and inconsistent supply of water and electricity. Only 13% of the 184 laboratories were able to deliver eight basic tests that were identified as essential. The assessment also costed priority activities required to strengthen the laboratory system and advised MoHS on priorities for improving laboratory services that would help early detection of disease, mitigating the threat of potential future epidemics.
To prioritise and track progress made by the laboratory strengthening efforts that followed, laboratory score cards were established which measured laboratory capacity on a quarterly basis using colour coding to indicate the capacity status at laboratories in district hospitals. The scorecard data showed that between October 2015 and December 2016, laboratory capacity improved at eleven out of a total of fourteen laboratory hospitals.
The high number of deaths and morbidity from Ebola calls for building more resilient health systems that are able to contain the shocks from widespread epidemics. Emergency preparedness procedures must be established to ensure the supply of essential resources and services during times of crises. DFID and Options implemented this emergency laboratory intervention whilst planning for strengthening health systems in parallel.
This project demonstrated the crucial need to invest in reliable health data systems for timely problem solving and public health decision-making. This is crucial to maintaining a fully functional and responsive health system.
The challenges in the response highlight the importance of joined-up and well-coordinated approaches to crises. Emergency responses may inadvertently overlook and therefore further weaken national health systems. A sudden influx of new organisations could lead to the weakening of the stewardship role of the MoHS. Partners with country experience can help ‘new’ implementing partners or responders to navigate national systems and actors to ensure that approaches are responding to the local context and dynamics of the health system. DFID and Options were uniquely placed to do this, primarily due to the long-standing working relationships built over several years.
The West African Ebola crisis had the potential to be a global pandemic. Countries with weak health systems require support to achieve international health regulations for global health security. The UK government played an important role in mitigating the Ebola threat and highlighting lessons for controlling future epidemics through its support to Sierra Leone’s MoHS. It is critical that laboratory systems are strengthened with adequate resources and manpower and that they are an integral component of health systems approaches to emergencies that build on and strengthen existing foundations for sustainable national response.
Written by Marleen Vellekoop, Technical Specialist, Dr Sara L. Nam, Technical Specialist, Dr Kwalombota Kwalombota, Assistant Technical Director