A challenge like no other: How Sierra Leone’s NTD Program is weathering the Ebola epidemic

December 30th, 2014

It’s been very tough going for Sierra Leone’s NTD Program in the wake of the devastating Ebola crisis in that country. END in Africa recently asked Mustapha Sonnie and Stephanie Palmer, with END in Africa sub-grantee Helen Keller International, to tell us how the Ebola crisis has affected Sierra Leone’s progress toward NTD control and elimination.[i]

A community in Sierra Leone receives medicines against NTDs before the Ebola epidemic began. Photo: HKI

END in Africa (EIA): Where did things stand with NTD elimination and control efforts in Sierra Leone right before the Ebola crisis hit?

Stephanie Palmer (SP): Before the Ebola epidemic, Sierra Leone’s National NTD Program was operating at full scale. They were ready to start doing transmission assessment surveys (TAS) for lymphatic filariasis (LF) and we fully expected the results to show that the country was ready to stop mass drug administration (MDA) for LF. But then the Ebola crisis hit and brought things to a standstill. They had to stop everything.

Mustapha Sonnie (MS): The National NTD program had achieved 100% geographical coverage during MDAs and 80% programmatic coverage since 2010. Eight of Sierra Leone’s 14 health districts were preparing for stop-MDA TAS in September 2014; and the program was also planning to assess for schistosomiasis and soil-transmitted helminthiasis (SCH and STH) in 12 districts in May 2015, but both of these surveys will be delayed.

EIA: How was HKI working with Sierra Leone’s National NTD Program when the Ebola crisis hit? What was going on at that point?

Mustapha Sonnie, HKI’s NTD Program Manager in Freetown, Sierra Leone. Photo: HKI

SP: HKI was supporting the National Program to prepare for TAS. It was supporting training and village sensitization activities for the SCH MDA, since the National Program was also planning the MDA for July. The Program did manage to hold the trainings, even though the Ebola outbreak had already begun; but once the trainings finished, the Program wasn’t able to move ahead with the MDA or other activities. By then, it was no longer safe to send personnel into the communities.

MS: The Ebola epidemic hit last May, right around the time of work planning for FY2015. The National Program had already started training, advocacy meetings and social mobilization for the SCH MDA, but it had to cancel the whole MDA as more and more areas were affected by the epidemic. The Program couldn’t start training health staff on LF and Oncho, either, and it had to cancel the LF MDA that had been planned in Western Area.

The National NTD Program and HKI had begun working with the five schools in Sierra Leone that train nurses and paramedics on incorporating NTDs into their curricula. Although most of the front-line workers are peripheral health unit staff who already receive NTD training as part of a three-year training program, we also wanted to heighten awareness at the national level.

EIA: Where did things stand in Sierra Leone with regard to disease control and elimination at the start of the Ebola epidemic?

A technician from Sierra Leone’s NTD Program takes capillary blood to test for lymphatic filariasis. Photo: HKI

MS: With LF, we were pretty sure that the TAS would have shown that transmission had stopped in eight districts and thus, we could stop MDA there; but we can’t be sure now, without having done a TAS.

The National Program had done an epidemiological evaluation for onchocerciasis in 2010, with encouraging results. The number of disease cases in every district had already dropped substantially; and the National Program continued doing MDAs each year since then. The National NTD Program is planning another epidemiological evaluation in FY2015. However, it’s unclear whether they will be able to carry it out; it’ll depend on where things stand with Ebola and whether the funding that’d been identified is still available [note: USAID does not currently supporting surveys for onchocerciasis; and so, funding must come from another source].

The National Program also conducted SCH impact assessments in 2012, which also showed very encouraging results.

EIA: When the Ebola outbreak hit, how was the NTD program affected initially, and how did the situation evolve as things got worse?

Training district-level NTD Program technicians prior to conducting a disease assessment exercise. Photo: HKI

MS: When the epidemic was first announced, the national NTD Program assumed that it would be able to continue some activities because at first, the outbreak appeared to be limited to Kailahun, near the Guinean border. Then, the epidemic spread to Kenema and we all [the National NTD Program and HKI] realized that we’d have to postpone the MDA in a couple of districts. However, we still thought we could continue elsewhere.

When the epidemic reached Port Loko, we knew that it was more serious than we’d realized. By then, most health workers had been dedicated to the Ebola response. That was when the NTD Program realized it would need to stop activities. Even then, we still thought it would be over in a few months. But the situation just kept getting worse. We had to cancel the SCH MDA by the end of June, and in July, the President declared a state of emergency.

HKI has worked very closely with the National NTD Program to monitor the situation. We continue to keep in touch with National NTD Program staff to discuss the situation and how to move forward once the epidemic finally ends. We have discussed at length Ebola’s impact on NTDs and on the activities we’d planned for the end of FY2014, as well as on our ability to plan and implement activities in FY2015.

The National NTD Program now thinks that it’s unlikely that they’ll be able to start any activities before the second quarter of FY2015. Among the reasons are that the epidemic has caused communities to mistrust the Ministry of Health (MOH) because initially, they believed the government could help them with Ebola. When they realized that the government didn’t have a cure, after all, they were very disillusioned. To make things worse, there was a perception in some communities that health workers were spreading the disease instead of helping control it! So, trust is a big issue; and this will have a ripple effect on everyone who is associated with the MOH, including the Community Drug Distributors (CDDs) who provide medicine to prevent NTDs. If the National Program tries to do NTD MDA too soon, some people may think that the medicines cause Ebola! It will take some time to earn back enough trust to be able to restart MDAs and assessments. Plus, we’d have to deal with poor compliance and poor coverage. We will really need to focus on communication and advocacy in the communities first.

Second, we have to consider the risk to field workers, particularly during the TAS, which involved collecting blood samples. In addition, if Ebola is still present while we’re doing the TAS, people may think they are being tested for Ebola. Thus, the National Program doesn’t expect TAS to take place before September 2015, at the earliest.

Finally, we have to consider health worker availability. Not only has Ebola had a high fatality rate among health workers, it has also exposed weaknesses in the health system. The government is planning to overhaul the system after the epidemic ends, which may lead to change in the NTD Program, especially considering that health workers will be under significant pressure from the many different disease sectors that will be clamoring to restart their activities.

Last year’s MDA launch in Western Area, Sierra Leone. Photo: HKI

EIA: What is it like to be in Sierra Leone now? How has the epidemic affected you?

MS: From a psychological standpoint, it is very challenging. People ask themselves why they stay in Sierra Leone—to some degree, the disease is difficult to prevent because there is a lot of physical contact. Traditionally, people visit each other all the time; but now, people are suspicious of each other because you don’t know who others have touched. But at the same time, people need to go out. Children need to play with each other, but they’re being told that they can’t.

Even when you go to the office, there’s some fear among your colleagues; you don’t want them to touch you. This is why a lot of people want to work from home, so they can avoid that potential risk. The problem is that people need to work closely together for the work to be accomplished. There are challenges since people are suspicious of each other and there’s always the potential for disease transmission, but we need to have frequent meetings with our partners and the MOH. We need to maintain our contacts.

EIA: How do you think the delays will affect Sierra Leone’s NTD control and elimination efforts?

MS: So far, the National Program hasn’t missed the opportunity to do LF MDA; it has been rescheduled for March 2015. For SCH, missing one calendar year shouldn’t have too big of an impact on our overall goals; plus, we should be able to do TAS once the situation improves. People’s perceptions of the National NTD Program, HKI and END in Africa haven’t changed, except potentially at the community level, where people are generally more suspicious. However, as long as the National NTD Program does proper social mobilization activities before MDAs, it still should be able to meet its MDA targets. The biggest challenge will be taking blood, urine or stool samples during the surveys, and ensuring that people understand they have nothing to do with Ebola.

SP: HKI also wants to emphasize how important it is that USAID and FHI360 have allowed us to put a contingency plan in place for 2015. Throughout the Ebola crisis, our donors have continued supporting HKI staff through the END in Africa project, and by extension, Sierra Leone’s NTD Program, even after all our work in the country had been halted by necessity.

FHI 360 and USAID also agreed to support sending HKI staff from Sierra Leone to Niger to provide technical assistance to the latter country. This shows their exceptional commitment to controlling and eliminating NTDs in both countries. The HKI staff from Sierra Leone have also participated in the TAS for LF in Niger, which has enabled them to get training in preparation for the TAS in Sierra Leone.

END in Africa has been very supportive of the HKI NTD team from the start of the Ebola epidemic; and it continues showing that same level of support now, some five or six months later. This will pay off after the crisis ends. With their combined technical ability, knowledge and experience, HKI’s staff is already in place to help the Sierra Leone’s National NTD Program start up again quickly when it’s safe to move ahead.

EIA: What activities do you envision occurring as the NTD Program in Sierra Leone starts up again after the crisis?

MS: I think the National NTD Program will likely need to have a strategic planning meeting at the national level and invite top MOH officials and the whole NTD Program to re-strategize. Since both the MDA and TAS have been postponed, the National Program will need to prioritize. The National Program also need to do advocacy with the District Ebola Response Centers, to let them know it is planning to start MDAs and that it will need their help. The National Program will need to implement a robust sensitization program to provide information about MDAs and ensure people understand that they are not related to Ebola.   The national strategic planning meeting doesn’t yet have funding for this, but they do have funding for district-level advocacy meetings. This can all happen in a month, once the National Program is able to get started.

The Ebola response was transferred to the Ministry of Defense on November 1st, so this frees up some people at the MOH to get started on other things, as soon as it is safe to do so.

EIA: To learn more, see HKI’s Briefing on the Ebola Crisis in Sierra Leone.

[i] Mustapha Sonnie is HKI’s NTD Program Manager in Sierra Leone and is based in Freetown, and Stephanie Palmer is an NTD Program Officer working out of HKI’s New York office.