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Goal - Surveillance.Pdf (English) EBOLA RESPONSE LESSONS LEARNED SERIES Two market women are screened for Ebola as they take their goods across the border between Guinea and neighbouring Kambia district in Sierra Leone. Photo by GOAL SURVEILLANCE GOAL’s surveillance activities began in Port Loko district in January 2015 and FACT FILE expanded to Kambia district in March 2015. The programme includes support to case investigation teams who investigate all sick and death alerts across the Project: Surveillance two districts in order to establish an Ebola transmission link or otherwise. GOAL Duration: January 2015 – began supporting contact tracing activities in April 2015, which involve twice- ongoing daily health screening of known Ebola contacts and patients discharged Ebola Location: Port Loko, Kambia Donor: DFID through Ebola negative from an Ebola Treatment Centre (ETC) for 21 days. Response Consortium INTRODUCTION Since GOAL began surveillance and contact tracing activities, the quality and efficiency of case investigation has rapidly increased, providing the World Health Organisation (WHO), the Centers for Disease Control and Prevention (CDC) and District Health Management Team with the information they need for effectively understanding the Ebola transmission chains in Port Loko and Kambia Districts. There has been a drastic improvement in the percentage of new cases that had already been identified as Ebola contacts before becoming symtomatic. When GOAL started surveillance activities in January, only 15-20 percent of all new Ebola cases had been ‘line listed’. This figure improved to almost 100 percent for both districts, meaning that almost every new Ebola case was anticipated and either quarantined or monitored daily. Additionally, the quality of monitoring of all known Ebola contacts and ETC negative discharges has seen major improvements in Port Loko. GOAL Sierra Leone 89s Main Road Congo Town, Freetown METHODOLOGY Sierra Leone www.goalglobal.org Surveillance officers respond to passive live and death alerts – reported via the 117-Ebola hotline or alerts system – together with burial teams and dead body swabbers. In addition to passive alerts, officers conduct active surveillance activities, which involve visiting communities to establish stronger links between traditional structures including chiefs and traditional healers, Ebola response workers deployed in the area and government institutions such as health facilities and schools. Building this trust allows surveillance officers to more effectively seek out sick people or determine whether there have been any unreported deaths or unsafe burials. At the end of each day, all field staff meet in a central location to discuss their daily activities and findings, which inform future planning. The focus of the surveillance pillar is to ensure all significant Ebola events (a sick person or a death) are properly investigated. GOAL has strengthened the pillar’s ability to do this by successfully comparing alerts, national mortality data and demographic data in order to identify areas that are under- reporting. Subsequently, GOAL could make recommendations to other A DAY IN THE LIFE surveillance and social mobilisation pillar partners on how to stimulate stronger reporting by actively engaging these ‘silent’ areas. Underlying “My name is Alhaji D reasons for communities under-reporting include communication and Kamara and I am a 30- phone network difficulties, fear and resistance towards being quarantined. year-old surveillance officer with the Port Loko District Surveillance and contact tracing in quarantined homes further improved Health Management team, from May onwards when interdisciplinary teams were set up to monitor supported by GOAL in quarantined contacts during ‘Operation Northern Push’. These teams often northern Sierra Leone. included a clinician, a contact tracer, a psychosocial support officer, a In the early days of the social mobiliser and an epidemiologist. While the clinician could identify if outbreak, we had to anyone was sick in the homes, the psychosocial support officer could convince people that Ebola counsel anyone who was experiencing the trauma of having lost a family was not the work of member to Ebola. Another benefit of these multi-disciplinary teams was witchcraft. I remember that they minimised the number of people visiting the homes and repeating when the first case was the same questions, which had been frustrating to those under quarantine. admitted to my health centre in Port Loko, some young men chased me CHALLENGES away one night, threatening to torture and burn me inside the health Payment of salaries has been a major challenge for surveillance officers centre because I had given who are employed and paid by the National Ebola Response Centre their village a bad (NERC) – some had not been paid for up to 10 months. The staff had reputation. I fled to persistently gone on strike due to their frustration, greatly impacting the Freetown for a week. Not efficiency and consistency of the programme. This issue could have been only was I terrified for my safety, I was worried I’d resolved if implementing partners processed the payments instead, as the government lacked the capacity to carry out this function. become infected by my patient – at that time we had no protective gear Staff turnover in partner organisations such as WHO and CDC has also except for gloves.” resulted in a lack of institutional memory and the need to constantly buffer ‘new’ ideas not grounded in operational knowledge. The programme also requires consistent dialogue and collaboration with organisations that have considerably more political clout, despite GOAL’s advanced on the ground know-how. For example, in Kambia, the DEST showed reservations in GOAL Sierra Leone 89s Main Road fully involving GOAL in decision-making processes. Networking and social engagements went a long way towards generating a greater sense of Congo Town, Freetown Sierra Leone www.goalglobal.org trust and cooperation between GOAL and partner organisations. Internally, procurement and recruitment setbacks caused delays in project implementation, adding to the frustration of staff. Additionally, the slow supply of petrol for contact tracers’ motorbikes meant some contacts and Ebola negative discharges were not adequately monitored. TRANSFERRABLE LESSONS During the first four weeks of intensified surveillance efforts under ‘Operation Northern Push’, the number of sick alerts in Port Loko and Kambia increased by almost 150 percent and reported deaths rose by 16 percent, illustrating the success of surveillance as an approach. Launched TOP 5 LESSONS by the NERC in June 2015, the campaign aims to reach zero cases as quickly as possible, with a focus on the northern districts where the 1. Local ownership is transmission chains have been difficult to break. crucial While much of the Ebola response and surveillance was rightfully focused 2. Salaries of screeners on event management and increasing the quality of investigations, the lack should be administered of capacity building on how to detect significant events hampered much of through a reliable system the response. By engaging with community structures (traditional, to avoid strikes and low government and Ebola response workers) GOAL could ensure that motivation significant events were properly investigated. This increased partners’ confidence that fewer secret burials and covert Ebola transmissions were 3. High turn-around of occurring. partner organisation staff (e.g. WHO and CDC) Ensuring that different pillars were integrated with each other (especially creates inefficiencies contact tracing, surveillance and social mobilisation) helped boost the quality of surveillance throughout the districts. The social mobilisation pillar 4. Social mobilisation was crucial for building trust within communities, which encouraged should work hand-in-hand community members to call in alerts for investigation by the surveillance with surveillance to pillar. By continuously sharing information and localised data on under- encourage communities to reporting, the social mobilisation pillar was also able to more accurately report live and death alerts and target messaging target its messaging campaigns towards areas that needed it most. Local ownership and buy-in from the different localities was another key to 5. Surveillance teams successful surveillance activities. It worked well when daily operational should be allocated to specific locations for daily controls and reporting were the responsibility of national staff, with monitoring to enable them oversight and support provided by international staff. Given the politicised to build epidemiological environment, GOAL employees in roles that required significant interaction knowledge with international partners needed to be diplomatic and sensitive to inter- agency politics. To overcome delays in payments to surveillance officers in a future programme, GOAL could process the payments itself using an appropriate funding source. Stronger logistics, especially around the supply of fuel, and vehicles that can withstand the poor road conditions would also be required in order for teams to effectively reach their monitoring targets and GOAL Sierra Leone carry out their surveillance duties. 89s Main Road Congo Town, Freetown Sierra Leone www.goalglobal.org .
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