While international attention is often focused on novel pathogens and larger epidemics like Ebola, familiar pathogens like measles still threaten the lives of millions of people in lower-income countries like Sierra Leone, where measles is one of the leading causes of death among children. In early 2024, four primary health facilities in Port Loko and Bombali, Sierra Leone reported a sudden surge in measles cases. By March, a total of 52 cases had been detected.
And yet, all four health facilities managed to promptly detect, report and manage the cases with no recorded deaths. They also met 7-1-7 timeliness targets to promptly detect and report all 52 confirmed cases, averaging 3 days to detect and 1 day to notify cases.
These impressive results are no doubt in part due to the Sierra Leone’s serious efforts to strengthen its public health infrastructure in the wake of the 2014-2016 West African Ebola virus epidemic, focusing on filling critical gaps in disease surveillance and infection prevention and control. At the same time, these four facilities all took part in a program with Resolve to Save Lives called Epidemic-Ready Primary Health Care.
What is Epidemic-Ready Primary Health Care?
An Epidemic-Ready Primary Health Care (ERPHC) system is one that can prevent, detect, and respond to outbreaks while maintaining essential health services. An ERPHC system can find cases quickly, manage them safely and cope with the increased demands they bring. Through our ERPHC initiative, we’re partnering with primary health care facilities to ensure they are “epidemic-ready”—by strengthening relationships between facilities and the communities they serve and by training and mentoring health care workers to prevent, detect, and manage outbreaks while protecting themselves and others.
“Broadly, ERPHC ensures primary health facilities—which are often the point of contact for disease outbreaks—can successfully contain outbreaks without disrupting routine health services,” said E-beth Barrera at Resolve to Save Lives, who has been supporting these efforts in Sierra Leone. “By providing mentoring to primary health care workers, and making sure facilities are well connected to the broader health system, ERPHC is ensuring facilities are set up for success when the next outbreak inevitably strikes.”
Getting facilities “Epidemic-Ready”
Timeliness is an important factor in successfully containing an outbreak, and previous analysis has shown that low clinical suspicion—workers being able to correctly detect and report cases—is a major bottleneck in many outbreaks. In this recent surge in measles cases, health care workers at the ERPHC facilities had increased clinical suspicion that enabled them to overcome this common bottleneck. Barrera says these tangible improvements are a direct consequence the training and mentorship strategies implemented through the ERPHC program, which primed staff to spot symptoms and report suspected cases. “ERPHC makes finding outbreaks everyone’s business,” said Barrera.
Prior to implementing ERPHC, there were also delays in critical safety steps needed to contain an outbreak and keep health care workers safe, like implementing infection and control measures. Previously, whenever a facility reported a suspected case, district-level response teams would only find out about suspected case through national surveillance mechanisms, leaving infectious diseases to spread unchecked during the time it would take them to mount a response. ERPHC has reduced delays in response by encouraging more direct interactions between health care workers at primary health facilities and their district-level colleagues, thereby removing the need to rely on national-level infrastructure.
Training and mentorship
Every facility has an assigned mentor who develops an ongoing relationship with health care workers at the facility. In contrast to other programs offering one-day, one-off opportunities to connect with and learn from facilitators, the ERPHC program provides depth and continuity. After leading an initial full day workshop exploring how to spot symptoms, report suspected cases, and keep themselves and patients safe, the mentors return to each facility twice a month to meet with health care workers and provide ongoing guidance. The mentors are also trained to prime their mentees to think about any predictable surges in disease, such as the seasonal rises in cholera cases that are typical during periods of heavier rain.
“ERPHC makes finding outbreaks everyone’s business.”— E-beth Barrera, Resolve to Save Lives
Abdulai Hashim Kamara, the district surveillance officer in Port Loko, remarked, “prior to the project, any training was focused on Integrated Disease Surveillance and Response (IDSR) focal points. This mentorship targets all health workers, ensuring they all know the case definitions. We have seen the impact with the measles outbreak. Whoever is on-call will detect and report, not just the facility IDSR focal point. This is what happens when we pay attention to all the health workers, not just the IDSR Focal Points. They all know the case definition; they are all detecting cases.”
Oliver Eleeza from ICAP at Columbia University, who is coordinating the ERPHC program in Sierra Leone, added, “The death of a health care worker or community member used to be the trigger for awareness of health threat. ERPHC changes that narrative. It seamlessly integrates clinical service with public health, building trust between health facilities and their catchment communities to collaborate to promptly detect and respond to health risk before they spiral out of control.”
Addressing bottlenecks
While the recent measles outbreak demonstrates the power of the team’s approach, it also revealed some important bottlenecks to be addressed. In particular, encouraging health facility workers to report the cases through e-Case-Based Disease Surveillance, or eCBDS, an electronic reporting system that provides notifications to the national emergency operations center, was challenging. In some instances, this was due to limitations in local infrastructure, such as lack of electricity limiting both computer and internet access. In others, workers simply preferred to report cases by text or phone, a behavioral preference the team is now seeking to shift.
“The death of a health care worker or community member used to be the trigger for awareness of health threat. ERPHC changes that narrative.”— Oliver Eleeza, ICAP at Columbia University
Furthermore, the success of health facilities participating in the ERPHC program hinges on a facility’s relationships with its local community. In addition to improving how primary health facilities function in times of outbreaks, another important aspect of ERPHC focuses on those relationships outside of crises, and emphasizes the importance of developing them over time to make sure local residents report to the facility quickly if they suspect a case of disease in their community. Barrera noted this as an area requiring additional support at participating facilities as the team continues to implement ERPHC.
Next, Barrera says, the team will continue working to address these bottlenecks, including efforts to provide additional training for health care workers on the eCBDS reporting system and strengthen relationships with communities. The team will also explore how to strengthen other aspects of primary health care, including critical gaps in infrastructure, policy and financing that have profound consequences for day-to-day operations at primary health facilities. “The improvements in surveillance we’re seeing in ERPHC facilities are promising,” she says. “And it just goes to show—even modest investments in health care workers and primary health facilities can transform their ability to keep their communities, and themselves, safe.”
Find out more about Epidemic-Ready Primary Health Care (ERPHC) here.