Beyond Lassa Fever: Systemic and structural barriers to disease detection and response in Sierra Leone

Abstract

Background Lassa fever (LF) often presents clinically as undifferentiated febrile illness. Lassa Fever cases in Sierra Leone have been falling since the 2014–2016 Ebola epidemic. Data from other LF endemic countries suggest that this is not a true reflection of local epidemiological decline, but rather a function of either health seeking behaviour or the health/referral system. In Sierra Leone, many other diseases present with a similar early clinical picture, including COVID-19 and Marburg Disease (which has recently emerged in neighbouring Guinea). This empirical study explores the implementation of health system processes associated with International Health Regulations (IHR) requirements for early detection and timely and effective responses to the spread of febrile disease, through the case study of LF in Sierra Leone. Methodology/Principal findings This study used a qualitative approach to analyse local policy and guidance documents, key informant interviews with policy and practice actors, and focus group discussions and in-depth interviews with health care workers (HCWs) and community health workers (CHWs) in Kenema District to examine the ways in which undifferentiated fever surveillance and response policies and processes were implemented in the post-Ebola period. Multiple challenges were identified, including: issues with the LF case definition, approaches to differential diagnosis, specimen transport and the provision of results, and ownership of laboratory data. These issues lead to delays in diagnosis, and potentially worse outcomes for individual patients, as well as affecting the system’s ability to respond to outbreak-prone disease. Conclusions/Significance Identification of ways to improve the system requires balancing vertical disease surveillance programmes against other population health needs. Therefore, health system challenges to early identification of LF specifically have implications for the effectiveness of the wider Integrated Disease Surveillance and Response (IDSR) system in Sierra Leone more generally. Sentinel surveillance or improved surveillance at maternity facilities would help improve viral haemorrhagic fever (VHF) surveillance, as well as knowledge of LF epidemiology. Strengthening surveillance for vertical disease programmes, if correctly targeted, could have downstream benefits for COVID-19 surveillance and response as well as the wider health system—and therefore patient outcomes more generally.

The Perspectives of Healthcare Professionals on the Strategies, Challenges, and Community Responses to Health System Response and Interventions Towards Lassa Fever Infections and Mortality in Sierra Leone

“…50,57 This can pose a significant risk of Healthcare-Associated Infections (HAIs) among staff working at the Lassa unit of PGH. The findings of this study are consistent with studies conducted in Liberia 59 and Sierra Leone 60,61 which confirm the threat posed due to delays of test results. Another study done in Nigeria also mentioned delays in obtaining laboratory test results for LF patients, which was a major challenge in managing the disease.…”

“…Since the peak of the outbreak in March 2019, there has been a decline in confirmed cases of LF in Sierra Leone. 37 This decrease is credited to the effective implementation of the LF Response Plan, which involved strengthening surveillance, contact tracing, laboratory testing, infection prevention, case management, and community engagement. The World Health Organization (WHO) and partners like CDC, Tulane University, Harvard University, and MSF have been essential in this effort.…”

“…The Kenema Government Hospital (KGH) is the primary referral, diagnostic, and treatment facility for LF interventions and response in Sierra Leone and the Mano River Union nations. 57,60 In addition, the study highlighted communication issues between the upper and lower levels of management when it comes to Lassa fever intervention strategies. The participants have reported that the senior management has failed to effectively communicate new strategies, resulting in knowledge gaps in Lassa fever interventions.…”

“…Lack of communication has harmed strategic operations, especially among laboratory technicians who struggled with implementing Lassa fever infection prevention, control, and case management approaches. 60 To address these gaps and enhance the effectiveness of LF programs and interventions, the participants have recommended continuous communication and training, and further suggested feedback will be crucial for effective Lassa fever program interventions. 60 Based on the latest findings, healthcare workers have established effective communication channels to keep the community informed about LF activities professionally and ethically, thereby preventing panic.…”

Rapid diagnostic test: a critical need for outbreak preparedness and response for high priority pathogens

“…Disease surveillance provides timely data for public health planning and rapid response initiation. Despite the importance of these data, there is at present inadequate surveillance for high priority diseases in endemic countries 8 10 11. Near-POC tests would not only enable patients to be treated and appropriate containment measures implemented, but test results can be reported in real-time to a national surveillance system to enable better understanding of trends in the incidence of infections due to priority pathogens.…”