Ebola vaccine impact depends on a strong health system

By Samuel Kargbo 19 October 2015

A study participant receives a candidate Ebola vaccine. How can vaccinations be better implemented in the fight against Ebola? Photo by: NIAID / CC BY

As a medical doctor responsible for the health of mothers and children in the nation of Sierra Leone, there is one job I never expected to have: chief undertaker.

For five months last year, I led the national team responsible for the safe burials of victims of Ebola, which was being transmitted as family members cared for the sick or grieved the dead. At the height of the epidemic, about one hundred people a week succumbed to the disease and it was hard to see the future or remember the past.

Fast forward 15 months. The first week of October marked the third consecutive week in Sierra Leone with no confirmed cases and all contacts of people previously diagnosed with Ebola have cleared as disease free. However, the risk of new cases remains, particularly in Guinea, where public health workers are following 509 contacts.

Meanwhile, the clinical trial of a promising new Ebola vaccine, rVSV-ZEBOV, has been underway in the three most affected countries of Guinea, Liberia and Sierra Leone. It offers the vaccine to all contacts — and contacts of contacts — associated with confirmed cases. Interim results of the trial had already indicated the vaccine was 100 percent effective in preventing Ebola disease.

Although the data is still preliminary, it grows stronger by the day and offers what seemed like impossible hope just six months ago. A safe, effective vaccine will be an invaluable tool to combat Ebola wherever and whenever it emerges next.

But even once a vaccine is approved for widespread use, it will be no silver bullet. The gaps in our health care system that allowed Ebola to advance so quickly must be filled if this new vaccine — or any vaccines — are to realize their life-saving potential.

When Ebola hit Sierra Leone, we had fewer than 500 doctors for a population of 6 million. We had five ambulances, and 16 specialized obstetric care centers for the whole country. Perhaps most telling, life expectancy at birth was a mere 45 years, a number brought down by high rates of maternal and infant mortality.

But when Ebola hit, we also had vision of a better health system. In 2010, President Ernest Koroma and the government had put in place a health care initiative that provided free treatment and medicine to pregnant women, lactating mothers and children under the age of 5. Alongside this initiative, doctors and nurses received a pay rise from 200 to 400 percent.

We had begun to experience the benefits of these monumental reforms. In one district, the number of births in the local health facility rose from 197 in 2010 to 468 in 2013. The number of new mothers bringing in their infants for follow-up care tripled. This meant the babies were being immunized. They were receiving lifesaving vaccines that protect against diarrhea, pneumonia, tuberculosis, polio and other diseases. Our national coverage rate for measles reached 99 percent — second to none. We were on the road to better health for all our citizens, starting with mothers and children.

Ebola set back the clock. A total of 304 health workers became infected with the disease and the country also lost 11 physicians and 221 nurses and nurse aides to the virus.

Nearly every resource at our disposal became focused against this new threat. Vaccination campaigns were suspended, as they required large numbers of people to congregate, raising the specter of contagion. Within months, the vaccination rate for measles dropped to 76 percent.

The cost of Ebola was mothers who died in childbirth, falling vaccination rates, and the emergence of old diseases — including outbreaks of measles in all three West African countries most affected by Ebola. To date, an estimated 600,000 children have missed out on routine immunization services in the three countries.

Equally troubling has been the loss of trust by our citizens in our health care centers and health care providers. Expectant mothers and others did all they could to avoid health care facilities, regardless of whether or not they were designated Ebola treatment centers.

Thankfully, this has begun to change, and as we work to repair the loss in trust, we must reprioritize the vaccination of infants and children against preventable diseases. Vaccines are one of the best weapons we have against infectious diseases, and one of the surest ways to lower the rate of infant and child mortality.

In the aftermath of the Ebola crisis, we are rebuilding our health system — giving us the opportunity to do things better than before. This means taking stock of the weak points that still exist in our vaccine delivery and public health systems, and fixing them.

We need good roads that reach all 1,300 of our peripheral health units, the “last-mile” outposts that provide primary medical care to remote rural communities. We need stronger cold chains and refrigeration systems to keep vaccines and medicines stable. An improved cold chain will be essential for the new Ebola vaccine. In its current formulation, the vaccine must be kept at -60 degrees Celsius, a temperature so low it must be shipped with dry ice. We need hundreds of new health workers trained, at every level of the medical system.

Other changes would also help. One simple example is vaccine packaging. Most standard childhood vaccines come in 10-dose packages. Rather than open a full 10-pack, health workers often tell parents and children to go home and come back when demand is higher, to ensure no vaccines are wasted.

Looked at one way, it might be cheaper to deliver vaccines in 10 vial packages, rather than as single doses, especially when there is a weak cold chain. Yet, what are the costs of disease treatment and of lives lost for parents and children who are sent home unvaccinated?

A commitment to childhood vaccination means, at its core, a commitment to rebuilding our health system with attention to both the big picture and the details that make quality health care available to every individual.

Especially now, when we are recovering from our most vulnerable state, we need to look closely at how to practically meet our basic health needs. As we continue the fight against Ebola, we must effectively use the vaccines we already have in hand, and ensure the survival of our youngest, most vulnerable children.

To read additional content on global health, go to Focus On: Global Health in partnership with Johnson & Johnson.

About the author

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Samuel Kargbo

Dr. Samuel Kargbo is the director of health systems, policy, planning and information in the Ministry of Health and Sanitation of Sierra Leone. His present responsibility is to oversee the planning, monitoring and implementation of the post Ebola recovery strategy and building of a resilient health system. He is a 2015 Aspen Institute New Voices Fellow.


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