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Sample Essay & Outline on Bio terrorism

Bio terrorism, for this paper, is defined as the deliberate release of biological agents or bio agents to cause harm to the environment or people. Due to technological advancements, the number of biological attacks has skyrocketed globally. The increased attacks culminate from the availability of tools and materials that are engineered in laboratories. Bacteria, viruses, fungi or parasites are some of the biological agents that are used for such intentions. These bio agents have the power to affect humans in some ways, ranging from allergies to serious effects such as disease or death. It is important to note that most of these agents are found in nature but are altered in laboratories to make them more potent on their targets.

Bio terrorism is a major worry for most nations as it can be very hard to detect and contain once an attack happens. During the recent decades, the improvement in biotechnology and genetic engineering has made it easier for scientists to create such agents increasing the threat of bio terrorism (Mugavero et al., 2015). Some of these biological agents can be spread quickly through, air, water or even in the food we consume. Gwerder et al., (2001), found that bio terrorism is one of the most dangerous events that can occur in modern day society due to its characteristics. According to the author, terrorists may release bio weapons to attack various sites to enable the spread of the virus to other individuals. For instance, terrorists may attack a work site to enable the virus to spread via air or water to the community, or through secondary infections to other workmates.

According to Riedel, bio terrorism is not a new phenomenon as it was used in the past during warfare, as early as 600 BC infectious diseases were recognized to have adverse effects on people and the military (2004). In the early days, cadavers and animal corpses were used to spread diseases in the enemies’ territories. Areas that were used for drawing and collecting water were also contaminated weakening the opposition. A good example of bio terrorism in earlier times is the Caffa siege of 1396 in modern day Ukraine. The Tartars who had experienced a plague used the corpses of their dead colleagues to spread the disease outbreak in the city.

This move subsequently led to the death of more than 20 million people in Europe and some parts of North Africa marking one of the greatest instances of bio terrorism documented to date. Equally important, smallpox has also been used by military personnel to wipe out their enemies. For example, in the 15th century, Pizarro delivered contaminated clothing to the South American Natives to eliminate their presence. Moreover, Amherst, who controlled the British forces in North America, decided to use smallpox to eradicate the Indians who were very hostile to the British army; as a result, a considerable number of fomites were evident, and this paved the way for the British army to execute their mission.

In 2001, the US suffered Anthrax attacks, which were later determined to be acts of bio terrorism. This attack came shortly after the 9/11 bombings of the same year. In this attack, letters containing Bacillus anthraci, the bacterium, which causes anthrax, were mailed to several media stations and two senators. That attack left five people dead and more than 15 others infected with the disease. Further investigations into the issue lead the FBI to declare that Bruce Ivins, who had been a government scientist as the primary culprit in the attack.

The studies and method of surveillance by the FBI did however not convince everyone that Irvin, who had already committed suicide in 2005, was behind the attacks. Following these attacks, the US Congress hurriedly passed the Public Health Security and Bio terrorism Preparedness and Response Act of 2002. Among the significant changes that the law introduced, is the requirement for organizations involved in the food industry must register with Food and Drug department. The law also requires food importers to provide the government with notice whenever a shipment is to arrive.

Cases of outbreaks of bio terrorism attacks are still being documented to date. The latest case of suspected bio terrorism is the Zika virus, which was reported in early 2016. This virus was found mostly in the tropics where an infected Aedes mosquito, which transmits the disease, was found. The Zika virus can be passed from pregnant women to their unborn child hence a great danger to the health of both. In the international scene, the virus interfered with the planning of the recent Rio Olympics in Brazil, making some athletes to withdraw from the games.

Many countries have boards, which have the mandate of detecting and responding to bio terrorism attacks to prevent or minimize the threat of bio terrorism, especially on the food system. Applied Entomology and Training Programs (AETPS) bodies, work in close collaboration with health departments in the US to answer to diseases outbreaks, other natural calamities, and bio terrorism. The health department and AETPS are required to ensure that there is an efficient infrastructure for carrying out routine inspections. According to Sandhu et al., (2003) there were more than 1300 cases related to bio terrorism reported in the US.

Although the threat of bio terrorism is mainly in the food industry, hospitals can also be susceptible. The US government, for example, provides funds to local authorities to aid in preparedness. The bulk of this money is intended for hospitals. In addition to funding, the government also came up with other measures to prevent bio terrorism. One of these measures is community involvement. Community involvement includes educating the public on bio terrorism, its dangers, and prevention and mitigation methods. It requires the whole community to participate in the case of any emergency of this nature. Hospital staff education is another vital area of focus. Hospital staff education involves training staff on programs such as AETP, how to provide care to bio terrorism patients and drugs to administer. Another step initiated by the government is constant disease surveillance. Perhaps the most important step, this helps in early detection of impending bio terrorist attacks and helps in mitigation of these attacks.

In dealing with the threat of bio terrorism, it is important for bodies given that task to think along the lines of what possible targets exist. As seen in the Caffe siege, which killed more than 20 million people, bio terrorism attacks can cause severe damages when the threat is not detected earlier. Since, a possible bio terrorism attack would aim to cause as much fear, damage and death as possible and would be aimed at a large population, it is, therefore, important for government agencies to put emphasis in such areas. Though not all agents can be altered for bio terrorism, it is important to conduct further research on the remedies for all of the documented bio agents. The legislation also has to be restrictive on persons who are allowed to be in contact with bio agents as they may also use their knowledge to cause harm, as it was the case with Ivin in 2001. Some of the bio agents that terrorist might be interested in due to their functionality; availability and efficiency of destruction are mentioned below.

Anthrax

Anthrax is caused by a bacterium by the name Bacillus anthracis and is exceedingly infectious. Anthrax is found mainly in cattle, specifically herbivores but can be transmitted to when there is contact with humans. As a bio terrorism threat, the first record of anthrax was in the early 20th century. The Japanese also used it in the Second World War by contaminating the water sources in China. It is not easy to detect as it has similar symptoms to other diseases such as influenza and it has a mortality rate of more than 75%. It is advisable that health authorities be informed as soon as possible when there is suspicion of anthrax as it kills in an average of 36 hours from the development of symptoms.

Smallpox

Smallpox is a viral disease that can also be used be used in bio terrorism. Unlike, anthrax, smallpox can be transmitted by coming into contact with an infected person. There is a vaccine for smallpox, and the World Health Organization recommends routine immunization although the disease was eradicated in the 1980s. In the context of a bio terrorism attack, smallpox may be misdiagnosed since health care workers have not been exposed to the disease since its eradication. The terrorist may also use smallpox due to the few numbers of laboratories with the capability of detecting the disease; thus, it would take a long time before it is contained.

Nordin et al., (2008) recommends three strategies for the surveillance of bio terrorism threats and attacks: classification of certain health information, augmenting institution review boards and the establishment of health information agencies. Following the 2001 attacks, Nordin et al. propose the synchronization of all medical records and a system that reports real-time information on health issues. A Real-time feed of information they reckon, will help in early detection of bio terrorist attacks and curb the spreading of the same.

Classification of individual health information will also contribute during an intentional assault, as the enemy will not be privy to the government’s activities. In addition to that, privatization of such information will reduce access to information on bio agents since the terrorist’s goal to cause harm although issues of ethics and suspicion may arise between the government and its citizens can use such knowledge. Synchronization of medical records helps in keeping records of attacks, patients, vaccines and symptoms of diseases caused by such bio agents. This also helps in predicting future trends in bio terrorism. Health information agencies will provide people with symptoms of the diseases and measures to take in case of suspicion or diagnosis.

According to Yahav et al., most countries are more susceptible to bio terrorism attacks than conventional forms of warfare (2013). The paper also estimates that more than a quarter of the population in the US could be affected if an anthrax attack happened. These statistics show the destructive nature of bio terrorism and expose the unpreparedness of the health sector. In the event of an outbreak of a disease such as smallpox, it may be hard to determine whether an outbreak is due to natural calamity or an act of terror. We have also seen that diseases such as smallpox and anthrax may be difficult to diagnose since they have symptoms of other diseases. Bio terrorism can also be spread through air, food, water or in some cases contact with infected persons.

It is with this understanding that governments around the world should do more to reduce the risk of bio terrorism because the threat has its origins from early years and continues to increase because of higher technological developments. Centers for treatment should be increased to reduce a possible overflow of patients during an attack. Methods for establishing whether an attack is natural or premeditated should be put in place to aid in the prevention of further attacks. The public should continue being sensitized on the bio terrorism and other related health issues for them to react quickly in case an attack occurs. Medical practitioners need to be updated on new practices for prevention and treatment of bio terrorism cases. Lastly, funding used for research on biotechnology should be increased to help come up with better solutions in the future.

References

Gwerder, Laurie Jean, MS,R.N., E.M.T., Beaton, Randal,PhD., E.M.T., & Daniell, William,M.D., M.P.H. (2001). Bioterrorism: Implications for the occupational and environmental health nurse. AAOHN Journal, 49(11), 512-518.
Mugavero, R., Sabato, V., Basso, M., D'Amico, W., & Benolli, F. (2015). Bioterrorism: New technologies for global emergencies and public health. Journal of Information Privacy & Security, 11(4), 262-273.
Nordin, James D,M.D., M.P.H., Kasimow, S., B.A., Levitt, M. J., M.B.C., & Goodman, M. J., PhD. (2008). Bioterrorism surveillance and privacy: Intersection of HIPAA, the common rule, and public health law. American Journal of Public Health, 98(5), 802-7
Riedel, S. (2004). Biological warfare and bioterrorism: a historical review. Proceedings (Baylor University. Medical Center), 17(4), 400–406.
Sandhu, H. S., Thomas, C., Nsubuga, P., & White, M. E. (2003). A global network for early warning and response to infectious diseases and bioterrorism: Applied epidemiology and training programs, 2001. American Journal of Public Health, 93(10), 1640-2.
Yahav, I., Barnes, S., Golden, B., & Wasil, E. (2013). Early detection of bioterrorism: Monitoring disease diffusion through a multilayered network. IIE Annual Conference.Proceedings, , 2561-2570.

Ebola Virus Disease (EVD) Sample Essay & Outline

Abstract

The Ebola virus disease (EVD), formerly known as hemorrhagic fever is a severe condition and in most cases it causes death. The epidemic has affected several West African countries such as Liberia, Sierra-Leone, and Guinea. The number of deaths currently stands at 9,380 and the numbers keep climbing. The inadequacies of the health care system in the three countries that are most affected can help to explain how the outbreak got this far. Spain often spend $3,000 per person at purchasing power parity when it comes to healthcare; however, fore Sierra Leone, the figure is under $300. The U.S has 245 doctors per every 100,000 people while Guinea has 10. There is a need to build robust health systems in order to better deal with outbreaks such as Ebola in the future.

Public Health significance of strengthening health systems

Improved performance in controlling of emerging as well as re-emerging diseases in different developing countries is mainly dependent on the quality, efficiency and equity of health systems. There is a need to make rapid progress in order to improve the weak, poorly functioning and in some cases non-existent health systems. These new health systems will be better equipped to deal with disasters.

Literature review

1) Factors that have led to increased transmission of Ebola Virus

(a) Culture- Most West African Countries believe in the family cleansing the body of the dead before burial. This is one area that has led to increased infection.

(b) Poor health systems- The bed capacity initially in the three most affected countries was catastrophic and this led to increased infections and death as persons were not being treated

(c) Economy- The economy of the three countries is still developing and consequently, they did not have the necessary funds to deal with such a widespread epidemic.

2) Effects of Ebola on the Economy

(a)The Ebola Virus has greatly impacted the world economy with the loss of labor, closure of factories and quarantine.

(b) The movement to affected areas has been halted. The refusal of Morocco to host the African Cup of Nations because of Ebola fears goes to show how the world economy has been affected.

3) The Building of strong health systems

(a) A strong health system starts from the ground up. In order to build a comprehensive the multi-sectorial plan, there is a need for all round involvement by individuals, communities, and state. This includes training doctors, providing education to the communities about health related issues and making sure that there is an elaborate system to control epidemics.

(b) Feasibility prevention is of utmost importance. There should be more and more studies being undertaken to further understand the cause and all the prevention measures that are suitable for prevention of diseases such as Ebola. Feasibility studies are essential for prevention of any diseases.

(c) The creation of the multi-sectorial plan should start with endeavor that is concentrated on provision to men, women, and children of what is human: healthcare, education, shelter, drinking water, sanitation, and sufficient nourishment. The most defenseless categories of society need to be given individualized attention: women, children, and the aged, giving priority of their physical and mental prospects.

Discussion and Recommendation

In order to limit the human costs and impacts of Ebola Virus Diseases, there is a need for significant financial resources, effective co-ordination between international partners with the affected countries and complete commitment to the stopping of the disease. However, this is for the short term, in the long term, there is a need to strengthen the surveillance, treatment capacity and detection capacity of the Health systems in the countries.

References

Bausch DG, Schwarz L (2014) Outbreak of Ebola Virus Disease in Guinea: Where Ecology Meets Economy. PLoS Negl Trop Dis 8(7): e3056. doi:10.1371/journal.pntd.0003056
Centers for Disease Control and Prevention (U.S.),. (2014). West Africa Ebola outbreak.
In Evans, D., & World Bank Group,. (2014). The economic impact of the 2014 Ebola epidemic: short- and medium-term estimates for West Africa.

Disaster Risk Reduction Through Building a Resilient Health System, using Ebola as a case Study Sample Essay & Outline

ABSTRACT

A resilient health system is one that can accommodate medical emergencies and still continue to provide adequate healthcare services to the other sectors of the country. The outbreak of the Ebola virus claimed lives and wasted the economy and development of the affected countries in West Africa. The GDP of Liberia descended to 2.2% from 5.9%. Sierra Leone GDP has gone down from 11% to 4%. According to the World Bank, billions of dollars were spent trying to combat the virus. This proves that there is interdependence between healthcare and the socioeconomic landscape of a country. Ebola outbreak has the potential to seriously affect the world’s economy by crippling the tourism sector, trade, productivity and the economic sector. It can also affect agricultural productivity and development. A weak public health system gives way to public mistrust, fear and denial. All these are factors that have created a barrier to the provision of adequate healthcare services in the affected countries.

According to the World Bank’s senior economist David Evans, with the Ebola outbreak spreading to other countries, more children are bound to be orphaned and households will lose their breadwinners. Businesses will shut down due to illness, fear or death. The fragile health system is under duress during this period and the crisis has diverted resources from other health conditions such as HIV, malaria and measles. Developmental sectors have also been ignored due to the Ebola crisis. There needs to be an integrated approach that prepares and equips countries to deal with such unforeseen disasters. The only way to achieve this is to rebuild the health sector. This needs to be integrated together with other developmental sectors that are responsible for social services.

To contribute towards a resilient healthcare system that can respond effectively, and address health needs ,and still sustain other health services during disasters; the multi-sectoral plan for this program is built on strategic management in education, health education, human resources, training and disaster resources.

PUBLIC HEALTH SIGNIFICANCE

The outbreak of the Ebola virus aggravates challenges of the healthcare system such as shortage of workers, financing, a fragmented information system and lack of leadership in providing good quality services. The cases in Spain and Texas also revealed that even well prepared public health systems can make errors in identifying the Ebola virus which poses a great risk to everyone. Out of the 136 doctors in Sierra Leone, only a fraction have been trained. Their working conditions are poor. They lack personal equipment for protection, basic sanitation and electricity. The public health care system in the Ebola stricken countries can be rebuilt by learning from previous crises as a guide to the revitalization process.

Resilient health systems are needed to give person centered quality and integrated health care services to the public. The district and county levels should be the main points of focus when planning and implementing towards a resilient health care system. These approaches need strong management and coordination. Sierra Leone is leading by formation of regional hubs with qualified professionals who act as stop gags in delivering services in a bid to improve the quality of care by training onsite and supervision.

OBJECTIVES

The proposed program is to be implemented in a phase starting with coverage of the six counties in Liberia in the first phase. This will be later scaled to the national level which is a total of 15 counties in the second phase. This multisectoral plan is build on strategic investment in the public health sector, education sector, gender and social protection and youth sectors to generate inputs that are a requisite of a resilient health system.

SUPPORT SOURCES

Building a resilient healthcare system is dependent on the social capacity to deal with threats, and enabling policy environment. We have the ability to undertake major sectoral reforms and significant institutional improvement. There is need for extensive experience in building government’s institutional capacity and influencing policies for making reforms that are conducive for increasing access to health care.

The Ministry of Health and Social Welfare with support from development partners is currently engaged in developing a concept for a Health system restoration to target the World Bank and other major donors for funding. Also, this concept proposes new thinking and ideas on managing restoring of health services that are not necessarily included in the Ministry led process, since it’s limited by its very principle of its existence i.e. for resource mobilization and not long term sustainable reform based on critical gap assessment, and linked to socio-economic growth. An example of this process’ shortfall is the limited scope of its technical working groups to enable a holistic health system strengthening as well as resilience planning.

EVALUATION METHODS

We will first take the inclusive development approach where individuals will be placed at the core of understanding issues they are faced with and their social capacity built to deal with threats that arise from these issues especially during disasters.

Secondly, we will take a dynamic development approach where the health sector is supported to withstand future disasters. In this regard, specific investments will be made in supporting planned or influence policy and sectoral reforms that can sustain delivery of quality basic health services during disasters.

METHODS OF PROMOTING RESILIENT PUBLIC HEALTH SYSTEMS

The following key actions will be undertaken to promote a resilient public health system
Preparedness plans should be activated and tested.

This involves setting up and activating the committee of epidemic preparedness. It also involves developing and updating national and district epidemic preparedness and plans of response. These plans include plans for laboratory support, plans for establishing isolation units and dealing with rumors and investigations. It also involves availability of financial and human resources mobilization. Conduction assessments of IPC situations in the hot spot areas. The plans should also test the training of health workers, standard precautions and provisions for basic supplies and address the issue with gaps. There should be meetings between the partners and stakeholders to mobilize adequate resources for capacity building and support implementation of relevant tasks

Strengthening Active surveillance

This should be actively done along the border towns and major road networks. Surveillance systems should orient and facilitate the response teams to conduct and verify investigations of the outbreak and the suspected cases. They should be able to carry out immediate response interventions. Strengthening of an active surveillance system should be informative to the local health workers on the case definition of Ebola. It includes immediate reports of EVD, unknown public health events and undiagnosed illnesses and unexplained death, it also is inclusive of community surveillance alerts. The risk assessment test should be carried out in areas with the highest Ebola risk
Strengthening of the laboratory diagnostic capacity

This is important especially for carrying out virology testing. The capacity for appropriate specimen collection, processing and packaging should be strengthened at all provincial and district levels. An efficient system for transportation and shipment of specimen to the national reference should be established within and without the borders. The laboratory diagnostic capacity, safety and quality system should be reviewed. This is essential in preventing dangerous pathogens including the EVD. It will also enhance cross border collaboration and networking of laboratories in different countries.

Strengthening case management and infection prevention and control capacities

This is conducting rapid assessments of IPC situations in healthcare settings, addressing gaps. Ensuring provision of essential supplies such as disinfectants, clean water and gloves. It also cover training of health workers on assessment, prevention, case management, and control practices of high risk groups. Management and infection control also involves the designation of potential isolation facilities and treatment centers in strategic locations. It includes mapping the much needed human resource needs for the critical staff and providing technical support.

Immediate action should be taken to support the country. This can be achieved through the following actions:

Strengthening field response

The people on the ground should be at the frontline of combating the outbreak. Adequate staffing is crucial to scale the level of implementation and critical response. The Ebola response team in West Africa consists of local and international teams. The response by the global outbreak alert and response should be scaled up to support faster and more efficient response. The ngo’s and the government should be able to plan and send technical experts and teams that will address priority cases and provide support in the field. There should also be adequate human resources mobilization.

We will also ensure the presence of a local response team in each hot spot to respond to local operations concerning the evolving situation. The team will be comprised of a coordinator, a clinician, a data manager, a communications expert, a logistician, a control expert and an epidemiologist. There will also be presence of a mental and psychosocial expert who will provide support across the hotspots for the population and national and international workers on the frontline.

Evaluation of public relations and reputation management, social mobilization and risk communications.

Public relations management

This can be evaluated by developing and reviewing product of public health information that is tailored for certain target populations. These should be based on the proper assessment of communities practices, knowledge and behavior. The information should be regularly disseminated updates information and risk management on the outbreak to the concerned stakeholders.

Social mobilization

Social mobilization involves engaging experts from various languages and cultural backgrounds to: engage the community in dialogue with the traditional and community leaders to share information on the virus and adopt common solutions to avoid transmission. It also involves tracking rumors and analyzing them together with the cultural beliefs to advocate for proper information. Mobilization involves supporting a particular community to implement relevant solutions available to them.

It enable for the development, updating and review of the information available to the citizens for various audiences. It is usually based on careful assessment of the community knowledge and behavior and cultural practices.

Risk communication and capacity building

This involves the engagement of national and local authorities together with the NGO’S engaging in building capacity for risk communication. It ensures that communication interventions and workshops are sustained. Joint communications, sharing knowledge and experiences and learning from other countries will be among the possible formats that will be put up to implement risk communication.

Coordination of the outbreak response

A successful outbreak response is dependent on strong governance and coordination of the stakeholders. A few actions should be prioritized such as:

Management of the Ebola operations center

This is the main hub for strengthening proper operation and coordination to ensure optimal use of resources across outbreak control activities at the sub regional level in the country. The center connects major partners to harmonize, streamline and control activities to the affected countries. They also assist in resource mobilization

Strengthening cross border response

The national and district task force should be strengthened to include all the major key players to line up with a one health approach. They should also have meeting across borders that involve the affected countries to ensure they are implementing the given recommendations. This will also allow provision of services across borders and information sharing. It will also assist in coordinating the development of plans of operations that describe the current situation, financial, logistics and human needs

Strengthening of field coordination, collaboration and operational management.

This can be done through high level advocacy that engages the national institutions to promote a stronghold in political and government leadership for effective coordination. It will also encourage mobilization of the necessary financial, human and logistical resources. Field coordination and collaboration of the response needs the engagement of partners to strengthen their ties, cooperation and intersectoral collaboration. An example is ECOWAS. It allows for mobilization of resources and proper coordination during an outbreak. It will also ensure for an effective coordination response of the outbreak which will also include liaising with the donors for harmonization and reporting. When the management of the outbreak is strengthened in the field. It allows for supervision of the administrative, logistics and finance managements for the operations. It supports the plans and training's put in place to prepare the national staff.

Strengthening the logistics management system to support response activities

The logistics management system should support response activities by providing support to the laboratories through supplies, facilities for sample transfer, maintenance and availability of energy. It should be able to coordinate the logistics committee work and activities with international and local partners. It should also be able to transport and deliver protective equipments to the medical personnel in affected areas to facilitate quick and rapid response. Logistics management should support procurement implementation, adaptation, inventory and supply chain management systems and tools.

Provision of global communication and information

This should be at the fore front and will involve coordination of communication across all levels with full engagement of regional and sub regional offices. It involves coordinating with donors on a wider scale. It also involves coordinating communication among major actors operating in Ebola response program including government and non governmental organizations. This will ensure the existence of a fully fledged action on capacity building on risk communicators. It will achieve high level capacities and expertise in the country which will be available for dealing with future emergency outbreak.

Development of new treatments and interventions against Ebola

This will require identification of the new medical products and interventions that look promising, to prevent and control EVD. It also involves evaluating potential efficacy of non licensed interventions which include ethical analysis of deployment. It also includes identification of partners, product sources and potential producers. It involves defining treatment modalities and systems to establish the effectiveness and tracking down of adverse effects and implementing effective management of data.

EVIDENCE BASED STRATEGIES OF DEALING WITH EBOLA

a) Social capacity building

The experience of Ebola in Liberia exposed a weak social system that perpetuated denial, mistrust and failure for individuals to practice simple protocols that the health sector provided to control transmission of the disease. The first stepping stone to building a resilient health system is achieving human security where individuals are placed at the core when building their ability to address issues they fear like infectious diseases.

There needs to be an encounter between a functional health system and the affected community to control such outbreaks. The time to build this trust and establish communication is not during the outbreak of an epidemic when there is a lot of panic and fear. Fostering trust and communication is an essential part of building a resilient health system. After the Ebola outbreak in Uganda in 2001.The ministry of health of Uganda took steps to educate health personnel and the general public about the symptoms and prevention of Ebola. Since then Ebola has been controlled to a larger extent in Uganda.

The virus took a heavy toll on the health workers in Guinea, Liberia and Sierra Leone due to lack of sufficient training and PPE. The health system can become a reservoir of infections and expose the health workers who can carry the virus to the general public. Since the virus has no cure, health service providers can only give supportive care to the patients as their immune system tries to combat the infection, yet these facilities are in disarray.

b) Decentralization of public health management;

The indicators of a fragile health system during the Ebola epidemic was poor coordination of the response at the county level, failure of a timely response to identification, isolation and treatment of cases in communities and poor disease surveillance. This was mainly as a result of a centralized public health management. A major sectoral reform that will support the decentralization of public health management should be put in place to ensure that counties and districts in Liberia have the institutional capacity to manage and coordinate a timely health response. Decentralization of public health management will not only strengthen resilience of the health system at the lower level but also accelerate an improvement of major performance indicators. These include increased access to human resource, financing, data management, health commodities and supplies at the county level.

Decentralization demands attention to gaps and failures in collection, management and rapid sharing of information on cases, contacts and laboratory results. It also calls for tackling factors that drive transmission in the affected areas. Decentralization calls for adequate investigation and analytical epidemiology. The government also needs to standardize and provide the necessary tools for collecting and sharing information. Innovative strategies should be encouraged and channeled into control strategies when appropriate. Mali used trained medical students in epidemiology as contact tracers. Guinea used its young doctors to strengthen its response to the outbreak after being trained by WHO epidemiologist.

c) Capacity building for human resource;

Community trust and engagement is a major key player in building a healthcare system that is resilient. This involves strengthening the capacity of the community health workers. Sierra Leone, Liberia and Guinea have a shortage of health workers and it is the insufficiently trained personnel that are conducting treatment and diagnosis, contact tracing and logistics management. Control and management of the virus will also require partnering with the community. There is need to employ and train more health workers to get them prepared for the right competencies. This will create employment opportunities for the youths which will also foster economic growth. There also needs to be a system of early warning for threats on health which fully complies with the international regulations of health. Surveillance and information systems need to be employed efficiently and deployed at all levels through networks around the country. This will also allow cross border control and response.

d) Institutional improvements;

The capacity of the public health department to deal with disease control and prevention has not been put in place. Some of the challenges include lack of requisite isolation centers to deal with the load of patients being admitted. There is also a lack of capacity of the laboratories to conduct virology tests. An efficient health system is required for resilience to disaster. We plan to support the health sector in the implementation of its essential package of health services. This will be done by focusing on closing gaps that have been identified through reviews and evaluation. Strengthening and ensuring a functional supply chain for health commodities is a primary focus area.

Another area that will be supported for improvement is management of information systems. This will ensure it is properly utilized for the management and policy decision making by the health sector. We will also continue to support the health sector in its planning function with technical assistance in the integration of resilience indicators within current sector strategic plan and subsequent monitoring and evaluation framework. With few health facilities in Liberia, it’s imperative that new health facilities are constructed and improvements made on existing health facilities. We will contribute towards construction of these facilities and procurement of medical equipment for these facilities.

e) Research, knowledge management and Policy dialogue

The health sector’s capacity to conduct research and utilize data for decision making will be enhanced through this intervention. There has been a distinct gap in the sector on conducting robust research or surveys and its use in informing policy and programs to improve health through dialogue. We will systematically build the health sector’s capacity to conduct quality research and undertake frequent surveys in order to build a body of evidence that can be used to improve policy formulation, review and inform delivery of health services.

Who?
Behavior Risk
Behavior Objectives

Primary Everybody

Ignorance of symptoms

Lack of physical hygiene (hand washing with soap, use of latrines, use of sterilized water)
Handling or consumption of sick or dead monkeys or other wild animals
Attendance to gatherings
Panic-led behaviors (non-collaborating to case tracking, fleeing the area)
Dangerous traditional practices (depending on local context: scarification, etc.) Knowledge of symptoms
Improvement of physical hygiene (hand washing, use of latrines, use of sterilized water)
No handling or consumption of sick or dead monkeys or other wild animals
No gatherings
Collaborating with case tracking, non-fleeing from the area
Avoidance of dangerous traditional practices (depending on local context

Family of suspect case/victims

Non recognition of symptoms
No referral of suspect case
No hygiene around suspect case
Unhygienic handling of corpse
Late burial of victims
Organization of funeral
Panic-led behaviors (hiding the sick person, hiding the dead body, non-collaboration to the monitoring of persons in contact with the victim, non-collaborating to case tracking, fleeing the area)
Recognition of symptoms
Referral of suspect cases
Adoption of hygienic measures around suspect cases
Hygienic handling of corpse
Quick burial of corpse
No funeral organized
No hiding of sick persons, no hiding of dead bodies, collaborating to the monitoring of the persons in contact with victims, collaborating to case tracking, no fleeing from the area

Health personnel

Ignorance of how to identify suspect cases
Ignorance of how to handle case
Lack of hygiene practices in handling the case
Fear of handling the case
Abandonment of professional duties
No sanitation of victim’s household
Late burial of victims
No case tracking
Capacity to identify suspect cases
Capacity to handle suspect cases
Adoption of hygiene practices in handling the case
Confidence in handling the case
Conducting proper sanitation of case’s household
Quick burial of victims
Conduction of case tracking

Funeral personnel

Unhygienic handling of corpse
Late burial of victims
Hygienic handling of corpse
Quick burial of victims

Secondary

Specify depending on local contexts
Secondary participants do not support primary participants in key practices
Secondary participants support primary participants in key practices
Tertiary

Local leaders

Village development committee
Specify depending on local contexts
They are not involved in Ebola-related activities
Village chiefs mobilize community initiatives for fight against Ebola
Local leaders conduct peer-to-peer to encourage community members, to take responsibility for contributing to the fight against Ebola (specify depending on local contexts)

Example of Activities and Results

Agent of change Current situation
Activity and expected results
MESO

Community health workers

They are not involved in Ebola-related activities
Community health workers conduct door to door and group discussion on Ebola prevention and fighting.

Results:

Understanding of the disease improved
Knowledge of symptoms improved
Knowledge of key practices improved (refer to above list of behavioral objectives for each category)
Trust towards health authorities improved
Possibility to debate available
Possibility to get clarifications from experts available
Sense of self confidence improved
Community mobilization improved

Media

Media products with no or incorrect information on Ebola
Spreading panic: media products based on sensationalism regarding the high risk of the crisis.
Media products feature correct information about Ebola
Media products based on positive communication: focusing on the fact that that simple measures exist to prevent getting infected as families and health staff and that everybody should collaborate.
Avoid reports on fatality but focus reports on safe handling of cases.

Results:

Understanding of the disease improved
Knowledge of symptoms improved
Knowledge of key practices improved (refer to above list of behavioral objectives for each category)
Trust towards health authorities improved
Possibility to debate available
Possibility to get clarifications from experts available
Rumors dispelled
Panic prevented

Health authorities

No involvement in Ebola prevention and fight
Health authorities train health personnel on safe handling of Ebola cases and follow up actions at family level

Results:

Capacity to identify suspect cases
Capacity to handle suspect cases
Adoption of hygiene practices in handling the case
Confidence in handling the case
Conducting proper sanitation of case’s household
Quick burial of victims
Conduction of case tracking
MACRO
National authorities
Media products based on sensationalism regarding the high risk of the crisis.
Authorities should be vigilant and encourage media to use positive communication
Results:

Media use positive communication

Quality principles of C4D in Emergency[Adapted from « World Health Organization Outbreak CommunicationPlanning Guide »] 
Announcing early
- even with incomplete information
– prevents rumors and misinformation.

Transparency: communicating facts as they are available
Dialogical communication: creating mechanisms which allow population to express their concerns and recommendations for the response activities
Using general messages for the wide population and specific messages to specific groups (for instance health personnel must protect themselves from contact with patients, who is responsible for burial of corps must do it quickly, avoid direct contact with the corpses and wash their hands after)

Practicing positive communication: in this type of outbreak panic can be very dangerous. It is important to focus information on positive aspects (existence of simple preventive measures, stories describing appropriate behaviors successfully being adopted by the population) rather than stories based on virus lethality.
Proactively preventing and fighting rumors: mechanism must be put into place to detect early diffusion of rumors regarding the disease and control measures; response activities are prepared ahead and triggered quickly when need be.

Moreover, usual good principles for quality programming in C4D remain valid, specifically:

Aiming for a change at multiple levels: individual, social and community participation
Being measureable by indicators for each of these three levels
Being equitable through the creation of mechanisms aiming at ensuring participation of the most vulnerable and marginalized populations
Using of a mix of communication strategies, channels and agents of change
Promoting a dialogical communication

1. KEY ACTIVITIES

a) Social Capacity building;

Within this strategy, the key activities that have been proposed include fostering of trust and communication between the community and the functional health system. It also promotes community engagement, trust and ownership. Social capacity building supports the community health worker capacity and encourages partnering with the community in an effective and meaningful way. It involves Provide protective adequate training and protective gear to health workers to prevent infections to the general public by the health workers. It involves providing education and adequate information about control and prevention of the virus and ensures the provision of a functional healthcare system to accommodate the outbreak. It breaks societal barriers by promoting social dialogue for improved communities’ participation in development and execution of health programs.

Expected results

The expected results include building long lasting Trust towards the health authorities. It fosters a better understanding of the disease to prevent panic and rumors. It improves Community mobilization and encourages better understanding of key practices during an outbreak. It will also give the community members confidence to deal with the outbreak and report to the appropriate government authorities. Social capacity building will go a long way in preventing the spread and new infections of the virus due to an educated public. I

b) Decentralization of public health management;

This strategy includes:

Establishment of fully functional emergency operation centers and Training epidemiologists to effectively trace and detect the outbreak around the country. It also calls for Advocacy and policy dialogue with key government sectors to undertake reforms that would operationalize public health management at county level.

Decentralization requires Support development of policies and planning frameworks of public the public health management system. It requires high quality surveillance system and a complete and rapid case finding. The government and policy makers need to contribute to the execution of health sector reforms on decentralization of public health management. They also need to provide technical assistance to the Ministry of Health on development, financing and implementation programmes at county level. Support for the national and local authorities is encouraged to inform the public in a timely and transparent manner during and before an outbreak. The ministry of health and concerned partners should provide training in leadership and implementation of programs to restore trust in the government. They should also Support the involvement of the community in controlling and preventing an outbreak, to empower citizens to trust the government

Expected results

A decentralized public health system is supposed to strengthening governance at national and sub national levels. It should also improve the ability of the health sector to handle an outbreak at the county levels. It will ensure Availability of proper resources to handle the outbreak and proper leadership and management during a crisis. It will also ensure there is proper communication from the media to prevent panic and rumors and will foster better handling of the cases to prevent the virus from spreading on a national scale.

c) Capacity building systems for human resource.

Training and building capacity for all health cadres such as clinicians and nurses should be an essential area of focus. The ministry of public health should also establishing interventions that ensure health workers have access to adequate security measures to protect them from infections. The government should have an ample budget to ensure timely payment of salaries and hazard pay when appropriate. The medical personnel that have been identified to deal with Ebola related cases should have proper training on IPC and proper use of PPE’s. The government together with concerned partners should coordinate to ensure employment of skilled personnel from the particular region to prevent cross border control to neighboring countries. Capacity building also involves having adequate supply of medical equipments and appropriate wear especially personal protective equipments for the health personnel. Screening at all the ports of entry and major land crossings to prevent cross border transmission. Surveillance, infection control and case management systems are other areas of capacity building that demand proper attention.

Expected results

Implementation of capacity building systems for human management will enable health personnel to identify and handle suspects. Proper training will also lead to effective adoption of hygiene practices while handling patients. It will also ensure proper sanitation procedures are carried out when dealing with a case’s household. It will also halt the virus from spreading to newer areas and proper and quick burial of victims

d) Institutional improvements

Strengthening of the public health systems will prepare the country for emergency and rapid response when there is an outbreak. The sub regional and national institutions should be upgraded to ensure effective management the epidemic .This project aims at working with the government to strengthen coordination, leadership and public order. It calls for creating a strong coordination at the national, regional and local levels. Cross border relations between countries should be implemented using a joint framework especially at the sub regional Ebola outbreak coordinating center. The local and international NGO’S and civil societies should work together with the weak governments to provide assistance to the poor people in remote and rural areas. When regional institutions are supported, they tend to play a major role in the implementation and coordination process of Ebola response. The government should use proper channels to support and maintaining public order and a proactive preparedness promotion in neighboring countries through training and social mobilization.

Expected results

We expect to get improving coordination of regional and national institutions. If the proper frameworks are implemented, the ability of the government to manage the outbreak at the national and county level. It will also ensure availability of better healthcare facilities to accommodate future outbreaks. and better response to future emergencies. The government will be able to foster Proper leadership and public order to handle the virus effectively. The ministry of health and public health will ensure better management of gaps that allow the virus to spread. People in remote areas will no longer be locked out from receiving healthcare services.

e) Research, knowledge management and Policy dialogue;

Contribution to evidence based policy and programming will entail some of the following activities: Support the Ministry of health to conduct surveys, studies and operational researches. It will also provide technical assistance to the Ministry on development on research agendas, knowledge management and analyses of research findings to inform decision making. It will function to build partnerships and support academia to conduct quality research and reviews for the health sector.

Expected results

Research is important because it provides the ministry of health with new methods of effectively managing future outbreaks. It also gives Better understanding of the virus for effective control and prevention.

Value addition of proposed intervention

The existing partnership with the Government of Liberia through the Ministry of Health and Social Welfare would be utilized to form a holistic Health restoration Program Steering task force with membership of other key sectors like Education, Gender/Social, Youth, Finance and Planning; development partners, civil society and the private sector. The steering task force will function through thematic areas on Policy and sectoral reforms, Institutional capacity building, Social capacity and Research and Knowledge management.

We will support the formation and functionality of these thematic area working groups to mobilize and leverage resources for the Health System strengthening, conduct overall coordination of all efforts on health system strengthening and provide technical oversight on execution and evaluation of the health system strengthening program.

It is important to note that there are on-going processes by the Health sector to rebuild the health system but these have been based on the need to raise funding and not on the basis of critical gap analysis. Support to the health sector through the proposed interventions will focus on streamlining these processes to rebuild the health system in a sustainable and strategic pattern that is cognizant of the country context and sectoral reform competency in the country.

In partnership with the health sector we will influence the principle and outlook of the on-going Health system restoration process to be strategic and inclusive versus intention of only resource mobilization.

References
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