The document provides an overview of disease surveillance strategies in Africa, specifically the Integrated Disease Surveillance and Response (IDSR) strategy. It then discusses the state of public health in Liberia prior to and after the 2014-2016 Ebola outbreak, including lessons learned from field work observing Liberia's incident management system. Key recommendations include strengthening Liberia's public health workforce, decentralizing health services, and improving disease prevention and management.

1. Lessons from the Field: Post-Ebola recovery strategies and
ongoing disease surveillance and operations of an Incident
Management System (IMS) in Liberia
Sheikh K. Dukuly, II
MPH, Ph.D. Student
Advisors : Ebun O. Ebunlomo, Ph.D., & Mosoka Papa Fallah, Ph.D.
*Some personal information have been redacted for privacy compliance.

2. Overview
• Learning Objectives
• Background
– Disease Surveillance Strategy in Africa (IDSR)
– State of Public Health in Liberia
– Ebola outbreak till date
• Field Work Summary
• Lessons Learned
• Recommendations

3. Learning Objectives
• Provide an overview of disease surveillance in
Africa
• Discuss Post-Ebola recovery strategies in Liberia
• Describe lessons learned from field observations
and literature review
• Explain future implications for disease
surveillance and operations of an Incident
Management System in Liberia

4. DISEASE SURVEILLANCE STRATEGY
IN AFRICA (IDSR)

5. What is Integrated Disease Surveillance
and Response (IDSR)?
• Strategy to strengthen national public
health surveillance and response
systems per Resolution AFR/RC48/R2
by WHO/AFRO (1998)
• Eight (8) core functions for
surveillance and response in alignment
with International Health Regulations
(2005)
• Forty seven (47) countries have
adopted the IDSR technical guidelines
http://www.cdc.gov/globalhealth/healthprotection/idsr
IDSR 101

6. 2009-2010 Meningococcal Meningitis
14,000 cases and 1,000 deaths
2008-2010 Cholera
Thousands of cases in Southern and
Central Africa
2008-2010 Yellow fever
Reported outbreaks in 13 countries
Ebola 1990s and 2000s
DRC and Gabon with high case
fatality rates 68% to 90%
HISTORY OF IDSR
2000-2010 Emerging priorities
Non-communicable diseases and
Neglected tropical diseases

7. SURVEILLANCE AND RESPONSE FUNCTIONS IN IDSR
• Identify / Detect
• Report
• Analysis
• Interpretation
• Investigation and
Confirmation
• Respond
• Communication and
feedback
• Evaluation
• Preparedness

8. Epidemic prone
diseases
Diseases targeted for
eradication or
elimination
Other major diseases of public
health importance
Cholera1
Meningococcal meningitis
Diarrhoea with blood
(Shigella)
Viral hemorrhagic fevers*1
Dengue
Typhoid fever
Yellow fever 1
Measles
Influenza-like illness
Plague 1
Anthrax
Chikungunya
1 Disease specified by IHR (2005)
for notification.
*Ebola, Marburg, Rift Valley, Lassa,
Crimean Congo, West Nile Fever
Neonatal tetanus
Poliomyelitis 1 (AFP)
Dracunculiasis
Leprosy
Onchocerciasis
Buruli ulcer
Filariasis
Noma
Diarrhoea with dehydration <5
Severe pneumonia
New HIV/AIDS
STIs
Tuberculosis
Malaria
Trypanosomiasis
Trachoma
Acute viral hepatitis
Rabies
Malnutrition
Maternal deaths
Hypertension
Diabetes mellitus
Adverse events following immunization
(AEFI)
Diseases or events of international concern
In addition to those noted in other columns
Any public health event of international concern (infectious, zoonotic,
food borne, chemical, radio nuclear, or due to unknown condition)
PRIORITY DISEASES FOR SURVEILLANCE IN AFRICA

9. MATRIX OF SKILLS AND ACTIVITIES FOR SURVEILLANCE

10. Use simple case
definitions to identify
priority diseases, events,
conditions or other
hazards in the community.
Collect and transport
specimens for laboratory
confirmation.
MATRIX OF SKILLS AND ACTIVITIES FOR SURVEILLANCE

11. STATE OF PUBLIC HEALTH IN LIBERIA

12. STATE OF PUBLIC HEALTH IN LIBERIA
• “The poor public health
standards and the
inadequacies of the
medical infrastructure in
Liberia were exposed by
the burgeoning EVD
outbreak” (Butler, 2014,
para. 6).
• Biweekly data reports from
various counties across
Liberia are periodically
reviewed at the Ministry
Health (MOHSW)’s Incident
Management System (IMS).
Butler, Y. S. (2014). Ebola virus: Exposing the inadequacies of public health in Liberia. Mayo Clinic
Proceedings, 89(12), 1596-1598. DOI:http://dx.doi.org/10.1016/j.mayocp.2014.10.006

13. EARLY WARNING AND DISEASE SURVEILLANCE SYSTEM
Appendix 1: Summary of suspected cases and conditions by county during the current
epidemiologic week, and cumulative numbers, 2015.
Summary of suspected cases reported from county during the reporting week
Counties
No.ofExpected
HealthDistricts
No.ofHealth
Districtreported
EbolaViralDisease
LassaFever
YellowFever
BloodyDiarrhea
Cholera
AFP
GuineaWorm
Measles
Neo-NatalTetanus
Neo-NatalMortality
MaternalMortality
C D C D C D C D C D C D C C D C D D D
Bomi 4 4 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Bong 8 8 0 7 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0
Gbarpolu 5 5 19 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Grand Bassa 7 7 88 4 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0
GC Mount 5 5 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Grand Gedeh 6 6 39 2 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Grand Kru 5 5 50 5 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Lofa 6 6 0 4 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Margibi 4 4 41 0 0 0 0 0 1 0 0 0 0 0 0 4 1 0 0 0 0
Maryland 6 6 92 9 0 0 1 0 0 0 0 0 0 0 0 1 0 0 0 0 0
Montserrado 7 7 134 0 0 0 0 0 2 0 0 0 0 0 0 5 0 0 0 0 0
Nimba 6 6 13 2 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 1
Rivercess 6 6 22 3 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
River Gee 6 6 16 2 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Sinoe 10 8 32 7 0 0 0 0 2 0 0 0 0 0 0 0 0 0 0 0 0
Total Weekly 91 89 546 46 0 0 1 0 5 0 0 0 1 0 0 11 0 0 0 1 1
Cumulative
suspected since
01/01/2016 0 1 0 5 0 0 0 1 0 0 11 1 0 0
Cumulative
confirmed 0 0 0 0 0 0 0 0 0 0 0 0 0 4 0
Cumulative
deaths 0 0 0 0 0 0 0 1 1

14. STATE OF PUBLIC HEALTH IN LIBERIA
• Liberia’s public health system
has continued to evolve since
the EVD epidemic in West
Africa.
• All but 4 counties in Liberia
now has a Disease
Prevention & Control (DPC)
Department though not fully
functionally.
• The future of Public Health in
Liberia is promising if the
current progress is sustained.

15. ROLE OF EXTERNAL PARTNERS
• The CDC has been
instrumental in helping
Liberia develop a
functional public health
and disease management
system.
• The CDC Foundation,
Mark Zuckerberg and the
Silicon Valley Foundation
garnered funding for the
building of the Country’s
first Incident
Management System
(IMS).

16. EBOLA OUTBREAK TILL DATE

17. EBOLA OUTBREAK TILL DATE IN AFRICA
• The epidemic in West Africa has been contained through the
help of international, regional and local organizations including
USAID, WHO, CDC, UNDP, MSF, Last Mile and MOHSW among
others.
• There were flares of 13 cases and 3 fatalities in Guinea and
Liberia during the month of March.
• While the disease has not been completely eradicated, IDSR
strategies are being implemented in the affected countries
including effective isolation and contact tracing have helped to
avoid flares up from escalating.
CDC (2016). CDC’s ongoing work to contain Ebola in West Africa.
https://www.cdc.gov/vhf/ebola/pdf/cdcs-ongoing-work.pdf

18. EBOLA OUTBREAK TILL DATE IN AFRICA
• About 28,616 associated
cases of EVD in total
• 10,767 suspected cases
• 2,622 probable cases
• 15,227 confirmed cases
in Africa and elsewhere
WHO (2016). Ebola data and statistics. http://apps.who.int/gho/data/view.ebola-
sitrep.ebola-summary-20160511?lang=en

19. EBOLA OUTBREAK TILL DATE IN LIBERIA
• Total of 733 suspected cases of
EVD were reported: 591 alive
and 141 dead.
• 678 specimens were submitted
for testing and all tested
negative.
• 18.1% decrease observed in
samples tested from week 23 to
24.
• Cumulatively, 24,096 suspected
EVD cases have been reported
out of which three (3) were
confirmed positive.
MOHSW (2016). IDSR Bulletin Week 23-24. Retrieved from a Portable Digital Document.

20. FIELD WORK SUMMARY

21. FIELD WORK SUMMARY
• Assisted in active case finding in
Hotspots during the March 26, 2016
EVD case.
• Engaged community members in areas
of last known EVD case.
• Sensitize residents about informing
health authorities about ailing
relatives and or visitors.
• Help case finders organize daily data
for transmission to the EOC.
• Attended biweekly MOHSW’S IMS
meetings.

22. PROJECT OVERVIEW
Guiding Questions:
• What is the state of Liberia’s public health system?
• Which area of the health system was improved on post Ebola outbreak?
• If there was a communicable disease management system, was the health
system tracking diseases?
• What went wrong within the public health leadership from the inception of
the Ebola outbreak?
Method:
• Desk review of existing scholarly and primary data on public health services
in Liberia
• Literature review highlighted a plethora of challenges to Liberia public
health system prior to the EVD epidemic including non-existent disease
surveillance system.
• Conduct field work in Liberia to validate findings from a robust literature
review of scholarly and peer-reviewed articles.

23. PROJECT FINDINGS
• Liberia had a struggling or almost non-existent public health
system prior to the EVD epidemic.
• The country had no disease surveillance system in place nor a full-
scale functioning laboratory before the burgeoning epidemic.
• The entire health system was damaged by 14 years of civil war.
• Most of the health centers in Liberia are either privately owned or
operated by local non-governmental or international aid
organizations.
• The epidemic has taught us that public health has global
dimension and that Liberia would not have recovered without the
intervention of regional and international assistance.

24. LESSONS LEARNED & FUTURE
IMPLICATIONS

25. DISEASE SURVEILLANCE AND PREVENTION
• Robust cross-border disease surveillance is crucial.
• Proactive leadership in global health is important on the
continental and inter-continental levels (e.g. WHO).
• The best way to empower developing countries is to
strengthen their capacity through technical training and
provision of logistical support.
• Developing countries must be transparent in the allocation
of resources particularly for health and education.

26. LESSONS LEARNED: PERSONAL
• Conducting a research in a resource-challenged environment can
be overwhelming.
• Unless you have funding for a research, conducting research in
another country is very costly with Liberia being no exception.
• Be prepared to complete two IRBs applications including one
with PIRE-Liberia that costs $500 USD.
• Many communities we visited expected monetary assistance for
their participation in research endeavors.
• Getting access to primary data was initially challenging.

27. LESSONS LEARNED: PUBLIC HEALTH
• Public Health and the entire health
sector in Liberia is underfunded.
• Most of MOHSW and EOC staff are
volunteers due to budget
constraints.
• Bad roads impede efficient field
work due to long hours of
commute.
• Corruption along with bureaucracy
continues to stunt potential growth
of Liberia’s health sector.

28. • United Nations Security Council
established the United Nations Mission
on Ebola Emergency Response
(UNMEER) to help coordinate response
efforts in Liberia and the other affected
countries.
• More than $493 million was raised by
donors to provide logistics, health
professionals on the ground and help
train local caregivers.
• WHO, USAID and the CDC led the way in
the international campaign after the
epidemic was declared to have global
health implications.
INTERNATIONAL INVOLVEMENT
Global Ebola Response (2016). Liberia. Retrieved on from http://ebolaresponse.un.org/liberia

29. INTERNATIONAL INVOLVEMENT
• Cuba, China, the United States, Great
Britain, the African Union and East
African Community sent health care
professionals to Liberia and the other
affected countries.
• UNICEF distributed learning and teaching
materials to more 29, 776 students and
1942 teachers in more than 995 schools.
• UNICEF also trained 9, 238 teachers and
4619 parents across various communities
in Monrovia and its environs (Global
Ebola Response, 2016).

30. RECOMMENDATIONS

31. RECOMMENDATIONS: WORKFORCE
• Encourage professional development of healthcare
workers and promote people to leadership based on merit
• Set up an interdisciplinary board of experts to conduct
routine monitoring and evaluation of ethical soundness
and quality of services
• Encourage dialogue among community leaders and
healthcare professionals and instill a patient-centered
public health system

32. RECOMMENDATIONS: SYSTEM-LEVEL
• Develop and ensure that
effective health policies are
enacted into law
• Decentralize public health
services to all areas of Liberia
including rural Liberia
• Strengthen disease prevention
and management including
periodic immunization for
preventable diseases