COVID-19 in Sierra Leone: a situation of once bitten, twice shy

The transition of coronavirus disease 2019 (COVID-19) from a local outbreak to a global pandemic has brought an unprecedented challenges on humanity. The pandemic novelty pose serious challenges in high income countries (HICs) and soon overwhelmed the health systems of these countries.1 Italy, the US and Spain experienced an unmatched strain on their health systems leading to loss of lives including healthcare workers. The impact of the virus was felt rapidly in low- and middle-income countries as it proves to be transcontinental. Disquiet has been raised among African countries as they battle the pandemic due to the challenges that are inherent in most of Africa's health systems.2

The first case of COVID-19 in the World Health Organization Africa region was reported in February 2020 in Egypt. Following this, more cases have been reported in the continent across different countries and the total reported cases of COVID-19 in Africa as at 27th of November is over 1 million.3 Sierra Leone, a low-income and post-conflict country with over 7 million population declared a state of emergency on 24th March, 2020.1, 2 This paper seeks to highlight the current situation of COVID-19 in relation to the health system and past outbreak experience in the country.

Sierra Leone, situated at the coast of West Africa, was one of the countries that experienced the Ebola virus disease (EVD) outbreak and had had a first-hand knowledge of how unprecedented a virus infection could be.1, 3 Even though over 4,000 people who were infected with EVD recovered, out of over 8,000 confirmed cases over 3,500 people lost their lives to the virus by 2016.1, 2 The country has learnt some important lessons in fighting infectious diseases. Shortage of human resources for health (HRH) is not uncommon in most African countries, but the advent of EVD in Sierra Leone exacerbated the challenging situation of HRH.2 The EVD outbreak claimed the life of over 90 health care professionals and this accounts for about 7% HRH workforce in the country.2 In a country of about 7.4 million people, there are 1.4 doctors, nurses and midwives per 10,000 population with over 30,000 projected as HRH shortage.1, 2 Despite this challenge, approximately 30 graduates pass out yearly from the only medical school in the country.2

Nevertheless, EVD has some sort prepared the country for the rainy days. Some of which includes, the importance of community engagement in curbing the outbreak, use of radio jingles to spread accurate information about outbreak, partnership and collaboration between religious leaders to create awareness amongst others. The news of the overwhelming impact of COVID-19 in HICs and the past experience of EVD in Sierra Leone has increased risk perception among Sierra Leoners.1, 4 It is imperative to acknowledge the influence of this past outbreak experience in the current COVID-19 responses in the country.

The government has prepared itself immediately after cases of COVID-19 were reported in neighbouring countries.5 The President of Sierra Leone addressed the country early before the first case emphasizing all precautionary measures that has been put in place, some of which includes; implementation of strict entry port surveillance measures at the international airport and the two major land borders in the country, three testing laboratories were set-up and isolation centres were equipped.5 The country reported the first case of COVID-19 at the end of March 2020 and the government acted swiftly in early April by effecting a lockdown.4, 5 With an increased perception of risk, the citizens were quite responsive to the stated measures though it led to the social issue of stigmatization towards those infected with COVID-19.1, 4 International organisations such as UNICEF, worked with the government and civil society organisations to help communities access accurate information to prevent and manage COVID-19. Information was shared via local religious and traditional arrangements, the media and also via mobile devices.5

There was a robust community sensitization and mobilization to improve on the knowledge on prevention, transmission and management of COVID-19.6 One of the innovative ways used to address the issue of misinformation was by tapping into the strength of local footballers to create awareness and sensitisation in communities. Also, the government launched an e-pass policies and procedures, targeted towards the movement of people during the lockdowns and restrictions; though transporters of essential goods such as medicine and food were excluded.5 The government set-up the National COVID-19 Emergency Response Centre with specialized pillars of the response being surveillance, case management, laboratory testing, risk communications, food and nutrition and coordination.6 Citizens were encouraged to make use of the toll-free line to make enquiries and also report cases of flu. In most African countries, COVID-19 responses took a while before getting to rural communities,7 and even as such, evidence suggests that rural people in Sierra Leone respond to infection risks in sensible and attuned conducts owing to the EVD experience.4 Though most responses were militarised to ensure compliance. The Ministry of Health ensured a decentralization of the COVID-19 response with various teams headed by a district coordinator to enhance fidelity across the 14 districts of Sierra Leone.6 There was an Inter-District Lockdown to limit spread of community transmission. The country seems to be in total control and COVID-19 is well-managed; better than some HICs. As at 16th December 2020, Sierra Leone had reported 2,460 confirmed cases, 75 deaths, 1854 recovered cases, 531 isolated cases, 9 new cases, 148 cases in quarantine and 12,250 cases out of quarantine.8 This statistics indicate a case fatality rate of 3.0%. In order to measure and monitor the impact of various responses by the government, a COVID-19 intra action review workshop was initiated to assess and review progress, identify and address challenges and share best practices.6

The COVID-19 pandemic did not only affect the health systems of the world, its impact on the economies of most countries have been highly felt.9, 10 Even though Sierra Leone government has been able to mitigate the spread of COVID-19 through enforcing lockdown and restrictions, the negative impact of lockdown on the livelihood of the citizens cannot be ignored.10, 11 Citizens who live in rural settings and those selling goods in minor markets had about 51%–100% decrease in their incomes.11 Studies has highlighted that rural settlers in Africa are most affected with both social and economic consequences of the lockdown.7 Sierra Leone being one of the countries which implemented early lockdowns may have increased the economic hardship on its over 6 million citizens who live in rural settings.2, 10, 11

In moving forward, there are predictions of a second wave of COVID-19 and there is a need for Sierra Leone government to brace up to improve its economy to cushion the impact. The quick and swift responses done by the government to the detriment of the economy of the country may not achieve its aims if a second wave of the pandemic should hit Africa. Information dissemination with language support initiatives should be encouraged to keep uneducated citizens informed. Conditional relief funds should be set-up to assist rural dwellers and local entrepreneurs. Government should foster solid partnership with global health organisations so as to motivate health students and increase HRH in the country. Policy responses should be tailored to address specific inherent conditions such as an investment in HRH and increased number of medical schools in the country.