Overcoming Operational Challenges to Ebola Case Investigation in Sierra Leone

Abstract

The Ebola virus disease (EVD) epidemic that hit West Africa in 2013 was the worst outbreak of EVD in recorded history. While much has been published regarding the international and national-level EVD responses, there is a dearth of literature on district-level coordination and operational structures, successes, and failures. This article seeks to understand how the EVD response unfolded at the district level, namely the challenges to operationalizing EVD surveillance over the course of the outbreak in Port Loko and Kambia districts of Sierra Leone. We present here GOAL Global's understanding of the fundamental challenges to case investigation operations during the EVD response, including environmental and infrastructural, sociocultural, and political and organizational challenges, with insight complemented by a survey of 42 case investigators. Major challenges included deficiencies in transportation and communication resources, low morale and fatigue among case investigators, mismanagement of data, mistrust among communities, and leadership challenges. Without addressing these operational challenges, technical surveillance solutions are difficult to implement and hold limited relevance, due to the poor quality and quantity of data being collected. The low prioritization of operational needs came at a high cost. To mediate this, GOAL addressed these operational challenges by acquiring critical transportation and communication resources to facilitate case investigation, including vehicles, boats, fuel, drivers, phones, and closed user groups; addressing fatigue and low morale by hiring more case investigators, making timely payments, arranging for time off, and providing meals and personal protective equipment; improving data tracking efforts through standard operating procedures, training, and mentorship to build higher-quality case histories and make it easier to access information; strengthening trust in communities by ensuring familiarity and consistency of case investigators; and improving operational leadership challenges through meetings and regular coordination, establishing an active surveillance strategy in Port Loko, and conducting an after-action review. Resolving or addressing these challenges was of primary importance, and requisite for the implementation of technical epidemiological complements to EVD case investigation.

A safe burial cemetery in Kambia, Sierra Leone.

In Sierra Leone, case investigators had to navigate unpaved roads and riverine areas.

FIGURE 1

Challenges Identified by Case Investigators as Most Significant^a to EVD Case Investigation, Port Loko and Kambia Districts, Sierra Leone (N=42) Abbreviations: ERW, Ebola response workers; EVD, Ebola virus disease. ^a On a scale of 1 to 5 (1=not significant at all, 5=most significant).

FIGURE 2

Flow Chart of Ebola Disease Alert Response, Sierra Leone Abbreviations: CM, case management; EVD, Ebola virus disease; MCD, meets case definition. Notes: A “117 call” is the national EVD alert hotline, the mechanism by which most occurrences of sickness and death were reported to the District Ebola Response Centres (DERCs). “EHealth” is an NGO that supported the DERC. This flow chart is part of the standard operating procedures developed by Samuel Boland on behalf of GOAL.

Community members in Kambia, Sierra Leone, welcome case investigators and their release from quarantine.

FIGURE 3

GOAL Ebola Virus Disease Response Structure, Sierra Leone Abbreviations: CEBS, community event-based surveillance; DC, District Coordinator; DMO, District Medical Officer; DO, District Officer. Note: Developed by Samuel Boland on behalf of GOAL.