by Stephen Taylor – Schar School of Policy and Government, George Mason University
In late 2013 and early 2014, the West African nation of Guinea was caught unprepared when Ebola cases began spreading in its southeastern districts. The outbreak rapidly spread to the neighboring countries of Sierra Leone and Liberia. Lacking the public health capabilities of tracing and isolating Ebola cases and lacking the medical capacity to safely treat Ebola patients, all three countries were quickly overwhelmed as the outbreak grew to pandemic proportions. The pandemic spread to urban centers and then to seven other countries around the world. In Guinea, Sierra Leone, and Liberia, the pandemic spanned three years and cost over 6 billion USD to bring under control. Over 28,000 West Africans contracted Ebola virus disease and over 11,000 died. 10% of GDP disappeared in Guinea, Liberia, and Sierra Leone due to lost workforce and productivity. This further resulted in lowered investment and a loss in private sector growth.
In the midst of this disaster, the U.S. Centers for Disease Control turned to health security experts at the Georgetown Center for Global Health Science and Security to support the expansion and augmentation of the Guinean public health infrastructure. Dr. Alpha Barry, Dr. Erin Sorrell, Dr. Claire Standley, and Ms. Aurelia Attal-Juncqua supported on-the-ground efforts to develop and implement improved health security policy that would make Guinea more resilient against future infectious disease outbreaks. The Guinean government’s priorities for capacity and capability building were to prevent further outbreaks of zoonotic diseases, improve the capacity of surveillance laboratories and capabilities of the healthcare workforce to identify outbreaks, and to better respond to outbreaks by streamlining and coordinating emergency response operations. On September 14th, 2018, as part of its Global Health Security Seminar Series, Georgetown University hosted a panel discussion of Dr Sorrell, Dr. Standley, and Ms. Attal-Juncqua on their efforts in Guinea. Below is a synopsis of their comments.
The Georgetown team worked with national and international stakeholders to draft a national specimen referral policy. The ability of medical professionals to collect medical specimens (i.e. blood, bodily fluids, stool) and direct them to a laboratory with the capability of testing for suspected infections was identified as a critical gap in the Guinean healthcare system. There were disease-specific programs in place, especially for diseases with vaccines available; however, specimen referral was all vertically integrated. Separate funding and response structures were tied to respective diseases at different levels of government. This provided incomplete coverage of all communities and all potential outbreaks across Guinea. A unified national specimen referral policy was needed to provide comprehensive detection capacities of dangerous diseases of epidemic and pandemic potential across Guinea.
The national specimen referral policy exemplified just one opportunity to build on capacities developed as part of the mid and post-Ebola pandemic response. Georgetown worked with the ministry of health to develop policy, then partnered with the International Medical Corps to build pilot projects based on the policies drafted. These pilot projects would ensure that new policies were usable, feasible, and sustainable in the long term. On-the-ground implementation also helped include more local stakeholders in the implementation process, including local patients, public health workers, and health care professionals. After a number of months of piloting, policies would be finalized based on pilot feedback and validated by the Guinean Minister of Health.
Once revamped national prevention, detection, and response activities were in place, of course, they had to be implemented across the Guinean healthcare system. This was challenging in Guinea, which has a peripherally focused healthcare system in which capacity building is tailored to local level needs. The Georgetown team had to ensure that all of the disparate nodes in Guinea’s healthcare system were on the same page for rapid and early detection of priority diseases under surveillance. This included identifying priority diseases to be included in this effort, as well as developing standard operating procedures, job aides, and decision algorithms to support decision making from the local level all the way up to the ministerial level in deciding to how to respond to an outbreak, once detected. To date, these supporting frameworks have been distributed to all 34 prefectures in Guinea and the Center for Global Health Security has supported trainings of trainers to disseminate knowledge and skills to colleagues in labs at the local level.
In determining priority diseases, it was important to take a holistic One Health approach, which included considerations of potential outbreak impact on the human, animal, and environmental spheres. This meant paying special attention to zoonotic diseases, which can be transmitted between animals and humans, known to be circulating in Guinea. The Center partnered with the Ministries of Agriculture, Health, and Environment to weigh numerous considerations from diverse stakeholders in determining priority diseases. Some considerations included:
-Which diseases would cause substantial human morbidity and mortality in Guinea?
-What pathogens are of concern to the international community for pandemic spread?
-Rural Guinea is highly agrarian. Which diseases could spill over into livestock, potentially causing ruinous economic damage for farmers?
The Georgetown team also mapped the nodes of communication between sectors from detection to coordination of response, determining which disease programs are effective and where there were gaps across priority diseases. Ultimately, the Center team helped stakeholders identify key areas for improvement and produced a list of priority diseases. The zoonoses deemed to pose the most urgent threat to Guinea included rabies, brucellosis, anthrax, avian influenza, trypanosomiasis, and viral hemorrhagic fevers. While Ebola was at the forefront of everyone’s mind during the outbreak, other viral hemorrhagic fevers (e.g. Lassa fever) also circulate in Guinea and could pose an equally perilous threat in urban centers. The team produced a report on OneHealth systems strengths and weaknesses, as well as a report on rabies, a disease of particular concern even amongst the other priority diseases. These reports were utilized in 2016 as the Georgetown team transitioned their efforts to an incoming USAID-funded preparedness and response project, which has supported the implementation of several of their recommendations.
The Center also collaborated with the International Organization for Migration (IOM) on improving Guinean emergency response operations. The team traveled to Guinea to perform needs and systems assessments at the prefectural level. They provided technical input to the national operations center in drafting a national emergency response plan and emergency operations procedures. In order to facilitate effective emergency communication with Guinean citizens, they provided guidelines for government communication with the media and the public during and after the emergency.
A well-defined legislative framework for health security is critical to codifying a strong emergency response posture and is, therefore, a central priority of the Global Health Security Agenda and the International Health Regulations. The Georgetown team undertook a legislative landscape assessment of the whole government, reviewing every legal document that supports emergency management agencies. They organized a legal workshop for key ministers and technical experts, playing through a scenario-based outbreak simulation to identify the overlaps and gaps produced by the disparate efforts of different ministries. The team then facilitated a discussion of how ministries might better collaborate and who would support which response efforts.
Today, capacity and capability implementers like the Georgetown team are closing out their efforts and transitioning their work to local organizations. It is important however, that Guinea continue to have access to resources and expertise from the international community. Rebecca Katz, Director of the Center for Global Health Science and Security, observed that the Guinean health system collapsed under the pressure of Ebola. Only by virtue of financial and technical support from other countries (especially the United States) did the health system end up in a better state today than it was before the Ebola pandemic. Without international staff and funding, the Guinean health system would likely not have recovered. With the continued threats of viral hemorrhagic fevers (e.g. Ebola, Lassa), rabies, brucellosis, anthrax, and avian influenza imperiling Guinean, West African, and global health security, it is imperative that highly developed countries like the United States take a principle role in supporting Guinean health security.