The resurgence of polio in Syria in 2013 has shown how a breakdown in public health can lead to the re-emergence of previously well-controlled diseases. In 2014 and early 2015 Liberia, Guinea and Sierra Leone have focused all resources on the Ebola response at the expense of other health programmes. Combined with losing a large proportion of the health-care workforce and the population’s reluctance to attend health-care facilities for fear of Ebola, this means the three countries are now at increased risk of other diseases that their health programmes usually target.
As they turn towards health-system recovery, these countries will have to re-establish routine immunization and other disease control programmes to avoid increases in the incidence of measles and malaria and in the prevalence of tuberculosis or HIV/AIDS. The resources mobilized for Ebola are potentially transferable to infectious disease control programmes and could be used to prevent a surge in communicable diseases. The transfer from response to recovery, as important as it is, cannot however take priority over continued Ebola outbreak control measures until the World Health Organization (WHO) has declared the outbreak over.
Several factors increase the risk of communicable disease outbreaks in Ebola-affected countries. The first is decreased vaccination coverage, particularly for measles. In Liberia, during the Ebola outbreak, measles immunization coverage dropped from 71 per cent to 55 per cent, and measles increased from no reported cases in 2013 to four cases in Lofa County alone, one of the areas hardest hit by Ebola. In Sierra Leone, measles vaccination rates fell from 99 per cent to 76 per cent during the outbreak of Ebola, and the country reported 39 confirmed cases of measles in 2014 compared with 13 cases the year before. Similarly, in Guinea, reported measles cases increased from 59 in 2013 to 215 in 2014.
The second factor is the disruption of programmes for tuberculosis, HIV/AIDS and malaria. Sierra Leone, Guinea and Liberia have a high incidence of tuberculosis, with about 53,000 new cases each year in the three countries. In 2014, clinical teams and facilities for tuberculosis were repurposed to the Ebola response. Consequently, many new and existing patients could not receive treatment for tuberculosis. There are about 210,000 people with HIV and 50,000 on antiretroviral therapy in the three countries. In Liberia, before the Ebola outbreak, more than 70 per cent of 30,000 patients with HIV had access to treatment. Since the onset of the outbreak, 60 per cent of the 144 HIV/AIDS care centres in the country have closed. The decrease in the proportion of people with HIV on antiretroviral therapy is thought to be due to non-functioning health facilities and patients not attending clinics for fear of contracting Ebola. Similarly, in Sierra Leone 80 per cent of clinics that offer services for pregnant women with HIV are closed, leading to concerns of increased vertical transmission.
Ebola has also interfered with malaria control efforts. The WHO warned that progress on malaria is at risk in Ebola-affected countries, because the outbreak has halted malaria programmes in some areas. In Liberia, a campaign to distribute bednets was hindered in 2014 because workers were repurposed to Ebola efforts. Malaria programmes have faltered as health workers have moved their focus to Ebola, healthcare facilities have closed and patients have stayed away for fear of contracting Ebola or fear that the fever from malaria would be mistaken for early symptoms of Ebola. In addition, health workers have suspended simple malaria diagnostic tests due to the fear of spreading Ebola.
The third and underlying factor is a shortage of health-care staff − a problem that preceded the Ebola outbreak and has been exacerbated by the tragic death of more than 800 health workers. There were about 100,000 patients per physician in Liberia, 50,000 in Sierra Leone, and 10,000 in Guinea, compared with 400 patients per physician in the US. These rates, already among the world’s lowest, have fallen even more with health-care worker infections during the Ebola outbreak. There is also a shortage of other health workers, and up to 1.5 per cent in Guinea, 21 per cent in Sierra Leone and 15 per cent in Liberia have died from Ebola infection. Many of the doctors who died were medical educators in their nations; their deaths present a major loss for the next generation of health workers in these countries. Additionally, no new doctor or nurse cohorts will graduate in 2015, because medical and nursing schools in Liberia and Sierra Leone have been closed throughout the outbreak.
Governments and non-governmental organizations in affected countries have made efforts to maintain health programmes through the outbreak. In Liberia, the National AIDS and STI Control Programme is delivering antiretroviral drugs in the community or referring people to mobile treatment centres. Meanwhile, Médecins Sans Frontières has rolled out blanket distribution of antimalarials in Ebola-hit areas, and UNICEF has restarted routine vaccine campaigns in the affected countries.
These efforts may not be sufficient, and additional human resources could be needed to compensate for the loss of health-care professionals, the lack of new graduates, and the pre-existing low number of health-care workers. The skill sets used for one disease are transferable to others: in Nigeria polio centres were repurposed for Ebola contract tracing and response, and a hospital deployed 200 healthcare workers to interview 18,500 individuals who might have been exposed to Ebola. Importantly, thousands of community health volunteers have been trained during the Ebola outbreak and could be used after the outbreak to promote vaccination, encourage attendance at healthcare facilities, or distribute medication. In Sierra Leone, about 2,000 community health workers had been trained before the outbreak to go into villages to find and treat malaria. Although some have been retrained to detect Ebola cases, they will need to revert to their original role as the outbreak subsides and surveillance confirms that transmission has been interrupted.
The resources in place for Ebola present an opportunity to minimize the risk of an increase in the incidence of other established diseases once the outbreak is over. Now is the time to secure additional resources to organize vaccination catch-up campaigns, to ensure patients with tuberculosis and HIV are identified and treated, and to roll out malaria prevention programmes. The large sums spent on the response to Ebola should have a legacy of stronger and more sustainable infrastructure for other disease control programmes in the affected countries.
This article was originally published in the Lancet.
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