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No more simulations: pandemic preparedness gets real

Participants in a case management training

Liberian-German cooperation takes on new meaning in the era of COVID-19

Since 2016 the Liberian-German Health Programme has worked to strengthen systems for disease surveillance and response at the national, county and community levels. With the arrival of the novel coronavirus, years of preparation are now being put into practice. The quick activation of the epidemic preparedness and response system shows the progress that has been made.

On March 16, 2020 the first case of the novel coronavirus disease (COVID-19) was confirmed in Liberia. The announcement was not entirely unexpected, given the rapid spread of the virus around the globe, yet it was still a sobering moment. Some 4,800 Liberians lost their lives in the last major infectious disease outbreak to affect the country – the devastating Ebola virus disease outbreak of 2014-2016.

For the Liberian-German Health Programme, the arrival of the novel coronavirus meant one thing: it was time to shift gears from strengthening pandemic preparedness to directly supporting pandemic response.

Four years of intensive preparation for the next public health emergency

Since Ebola the Government of Liberia and its partners have worked hard to improve surveillance systems and the response to highly infectious diseases. Over the past four years, the Liberian-German Health Programme – implemented by the Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ) GmbH on behalf of the Federal Ministry for Economic Cooperation and Development (BMZ) – has played its part. It has helped to improve surveillance systems at the county and community levels, to establish referral networks for epidemic-prone diseases, to improve the functioning of isolation units, to train health workers in the proper management of highly infectious diseases, and to test readiness through simulation exercises. Its main partners in this effort have been the National Public Health Institute of Liberia and the Ministry of Health at the national level, and County Health Teams in Grand Kru, Maryland and River Gee, in Liberia’s remote Southeast, and in Montserrado, home to the capital, Monrovia. Significant progress has been made, but as is the case across health systems in low-income settings, the challenges posed by this novel virus are great.

With the emergence of COVID-19 in Liberia, programme staff are engaging in real time with partners to ensure that cases are promptly detected, diagnosed, referred, and treated – and that contacts are traced in a timely manner to prevent the further spread of infections. ‘There is now widespread community transmission in Monrovia, and Southeast Liberia, which borders Cote d’Ivoire, is also an area at risk,’ says Damien Bishop, the director of the the Post-Ebola Health System Strengthening (PEGSS) and Integrated Severe Infections Treatment Unit (inSITU) projects. ‘We are using every opportunity we can as a technical assistance agency to support the Liberian government, which is in full-on response mode, to implement measures to contain the spread of the virus and to treat those who are infected.’

This article describes some of the existing and new measures being supported by the Liberian-German Health Programme which contribute to Liberia’s COVID-19 response.

A well-timed training course refreshes case management skills

With hindsight, the timing was uncanny: In January and February 2020, as cases of COVID-19 were mounting in China and beginning to appear in other parts of the world, the Liberian-German Health Programme supported a long-planned series of case management trainings for staff working in the inSITUs at the Fish Town Hospital, in River Gee County, and Redemption Hospital, in Monrovia. Ninety-one health workers, many of whom supported the Ebola emergency response, completed five-day trainings covering differential diagnosis and early warning signs of key diseases (Lassa fever, cholera, meningitis, measles and viral haemorrhagic fevers, including Ebola), approaches to triaging patients, infection prevention control and hand hygiene, and use of personal protective equipment (PPE).

Donning and doffing PPEs
Donning and doffing PPEs

Although COVID-19 was not formally part of the training, there was ample discussion of the novel coronavirus in view of its pandemic potential. The course content was highly relevant for what would come next. ‘Even for those of us who have experience with infectious diseases, refresher trainings are very important,’ says John Shakpeh, the Nursing Director at Redemption Hospital. ‘They keep you on track, and remind you of both your responsibilities and the precautions you need to take when working in the isolation unit.’

‘The experience we had during the Ebola outbreak has given us confidence to handle infectious diseases, but we also know that preparation and training are critically important,’ Shakpeh adds. ‘You have to be ready at all times, because you don’t know when a patient with a serious infection will come through the door.’

Doubling down to detect COVID-19 cases early in Maryland County

Training on community case definitions
Training on community case definitions

‘Early detection of disease outbreaks in the community is what surveillance is all about,’ says Damien Bishop. ‘Getting good data from the community is key to the whole system.’

In Maryland County the programme is planning to enter into a new cooperation with one of its implementing partners, Partners In Health, to bolster county-, district- and community-level disease surveillance systems and to conduct outreach activities to raise awareness of COVID-19 among the general public. Working hand in hand with the County Health Team, Partners In Health will build on a previous grant aimed at strengthening surveillance activities in the Southeast, which culminated in a regional simulation exercise involving Grand Kru, River Gee and Maryland Counties and which tested the referral pathway to the inSITU in River Gee.

Preparing the regional isolation unit in Fish Town to receive COVID-19 patients

Early detection of cases is not sufficient if there are no systems for referring patients, isolating them and treating them. In River Gee, the programme is extending its cooperation with the non-governmental organisation Samaritan’s Purse to strengthen operations at a newly built 10-bed isolation unit at the Fish Town Hospital.

Fish Town Hospital Isolation Unit
Fish Town Hospital Isolation Unit

The inSITU was constructed by Deutsche Welthungerhilfe e.V. with financial support from the German government through KfW, and is intended to serve as a regional facility for cases of infectious diseases, now including COVID-19, referred from Maryland, River Gee and Grand Kru counties. Since last year, the programme has been helping to strengthen the governance and oversight of the inSITU through the establishment of protocols and standard operating procedures. It has also advised on systems for stock management, equipment maintenance and the storage of medical supplies, as well as safe waste management. These tasks have now taken on new urgency and the existing grant will be extended to allow this support to continue. Three new ambulances have also been provided to enable the inSITU to play its role as a regional treatment centre. The ambulances were delivered in March after 27 staff members completed training in vehicle maintenance, infection prevention and control, and basic lifesaving skills.

Strengthening systems in Montserrado County

The programme is also extending an agreement with the International Rescue Committee (IRC) to provide direct support to systems, structures and operations in Montserrado County, including Monrovia, which is the part of Liberia most affected by COVID-19 thus far. The IRC will provide technical assistance to the County Health Team, NPHIL and community organisations to support the COVID-19 response and to advance the core inSITU project objectives: surveillance, infectious disease recognition, and community engagement. The proposed activities will improve knowledge and application of Integrated Disease Surveillance and Response (IDSR) principles, drive meaningful community engagement in line with social distancing requirements, and strengthen broad surveillance efforts.

Flexible support for training, capacity building and procurement

Training in the era of social distancing
Training in the era of social distancing

With Liberia under lockdown to prevent the spread of COVID-19, it is anything but business as usual for development partners and their government counterparts. Face-to-face meetings are being replaced by the use of digital platforms and people are learning to use the new technology, despite poor Internet connectivity. Travel between counties is virtually impossible.

The staff with the Liberian-German Health Programme are adapting their routines accordingly and have enthusiastically adopted virtual communication tools and working from home. They are also doing their best to respond swiftly and flexibly when opportunities arise to support their partners. For example, the whole team pulled together to help organise training sessions on contact tracing, conducted by the Montserrado County Health Team, for 250 community volunteers. They rapidly procured materials to support the contact tracers, such as infrared thermometers, contact tracing forms, and backpacks and raingear, and also helped to organise food and logistics. The volunteer contact tracers were deployed immediately after their training and are now following up the household contacts of confirmed or suspected cases so that these contacts can be logged, monitored, tested and, if necessary, quarantined.  A similar training programme will be rolled out in the south-eastern counties in the coming weeks.

Experience and commitment when they’re needed most

The programme team is no stranger to crisis. Several of the Liberian staff were part of the Ebola response. Damien Bishop, the Project Director, oversaw the United Kingdom’s clinical countermeasures during the 2009 swine flu pandemic. Drawing on these experiences, and working under difficult conditions with safety at the forefront, the team members are pragmatically deploying expertise and resources wherever they can to bolster the efforts of their partners. In this global crisis, Liberia still faces major hurdles in terms of preparedness, but the country now has a more systematic approach to disease surveillance, a network of isolation facilities, and a cohort of trained case managers as a result of the programme’s work over the past four years.

The commitment is there among partners, as well. ‘When Ebola came in 2014, it was a strange disease to us. We didn’t know what to do,’ says John Shakpeh, the Nursing Director at Redemption Hospital. ‘Before the situation eventually stabilised, people were panicking and dying due to fear. They weren’t getting proper care. But the way I see it now, it is a big advantage for us in handling COVID-19. Every day I have health workers coming into my office who say that they worked with Ebola teams and are willing to work on COVID-19 response. They are ready.’

May 2020

© GIZ/Viktor Siebert
© GIZ/Damien Bishop
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