After the Ebola outbreak was declared in Liberia in March 2014, early portrayal of Ebola as an incurable killer disease was met with intense mistrust, resistance and fear by many communities and early responders (The Guardian, 09/2014). As the outbreak spread, it was important to find appropriate ways to inform people how they could minimise the risk of catching the disease and what to do if it affected them and their families.
The way messages were developed and disseminated evolved with the epidemic. In Liberia the number of cases spread uncontrollably until September 2014, finally getting to zero in May 2015, before re-emerging twice on a very small scale. Communication remains a key aspect of community mobilisation efforts to address remaining Ebolarelated issues, such as survivor stigma and complacency towards prevention measures. This is the first of two reports that ACAPS is producing with the aim of identifying lessons learned and good practice in community-led communication processes. This report focuses on Liberia and the second covers Sierra Leone. The grey boxes indicate content that relates to communication in emergencies in general and is common to both reports. The report covers the changing behaviours of the affected population, the most effective channels for reaching communities, the most trusted actors for information delivery and the adaptation of messaging to the needs of affected populations. These insights suggest ways to better address communication needs in future outbreaks.
This report documents the secondary humanitarian problems and impacts of largescale Ebola outbreak on the different humanitarian sectors, to provide a non-exhaustive plan to help future responders. A large scale Ebola outbreak, in this document, refers to an epidemic with an unprecedented scale, geographical spread and duration.
At the beginning of the crisis, the international community perceived the outbreak as a purely public health emergency. The response was oriented towards the containment of the epidemic and treatment of the sick patients. The initial focus was on providing beds for patients and mobilising health practitioners. The livelihoods, education or protection needs of the affected communities, indirectly caused by the outbreak, were left unaddressed.
The secondary humanitarian problems and impacts of the epidemic were extensive, and threatened the lives and livelihoods of more than 22 million people in the three most affected countries, Guinea, Sierra Leone and Liberia. The disruption of public and private services created an “emergency within the emergency”. Humanitarian actors failed to activate their surge capacity, or set up emergency funding and coordination structures, as a result of this perception of the crisis. It took time for the humanitarian community to recognise the complexity of the crisis and respond to the secondary impacts on other sectors. One major lesson learned during this epidemic has been the need to broaden the scope of the humanitarian response during a large-scale Ebola outbreak.
On 20 November, a new Ebola virus disease case was confirmed in Monrovia, capital of Liberia. The latest case, depending on sources either a 10-year or 15-year-old boy, who lives in the eastern Paynesville district of the city, was admitted to a treatment centre in the outskirts of Monrovia on 19 November. Two direct family members tested positive as well on 20 November. As of 20 November, at least four other people, of whom two relatives, had been admitted to the Ebola treatment centre (ETC). At least 153 contacts have been identified and are being monitored. Food and water were delivered on 21 November to high risk contacts.
The boy was at school, the Living in Christ International Ministry School, and appears to have shown symptoms before being admitted to hospital, according to health officials. At least seven healthcare workers may have treated him without the protective equipment essential for Ebola cases (New York Times, 21/11/2015). According to media sources, the child’s family and school will be put into quarantine.
These are the first new Ebola cases in Liberia, since the country was declared free from the disease a second time on 3 September 2015.
Reintegrating those most affected by Ebola back into their communities is central to a country’s post-Ebola recovery. The reintegration process helps those affected to cope with the impact of the outbreak and to regain a sense of normality. It is also an essential part of increasing community preparedness and building resilience to possible future emergencies such as a new epidemic or a natural disaster.
Out of approximately 28,500 suspected, probable and confirmed cases, nearly 11,300 people have died since December 2013. With such a significant caseload, everyone living in Sierra Leone, Guinea and Liberia was affected by the Ebola outbreak in some way. Ebola survivors and their households, grieving families, orphans, quarantined people and frontline workers are among the most affected groups. This report outlines the key challenges these groups face as they reintegrate into their communities, and explores the main challenges for the response in supporting them through the process.
Since the Ebola epidemic started it has killed at least 11,295 people, out of at least 28,295 reported confirmed, probable, and suspected cases. It began in Guinea in December 2013 and rapidly spread to neighbouring Sierra Leone and Liberia.
All three countries were highly vulnerable to external shocks before the crisis, and still are today, due to a combination of low socioeconomic indicators, high risks of natural hazards, and a history of poor governance and political violence. Chronic poverty and weaknesses in public services greatly contributed to the rapid spread of the Ebola epidemic, its scale and severity. The epidemic not only caused severe health issues, including high levels of psychological trauma among communities, it also further weakened health systems, and impacted food security and livelihoods.
As of 5 October 2015, the transmission of the virus has been confined to several small areas in Guinea and Sierra Leone; reported incidence has remained below 10 cases per week since the end of July this year. While surveillance and treatment efforts to stop the transmission and re-emergence of Ebola continue, the response is moving away from its emergency phase towards longer-term recovery and building a more resilient health system.
In the complex environment of an epidemic, capacity to identify humanitarian needs is essential to inform and guide operations. Such capacity was challenged in the three countries most affected by the Ebola crisis, due mainly to problems of access and fear of the disease.
This report gathers lessons identified from assessments of the humanitarian situation in West Africa during the later stages of the Ebola crisis, between November 2014 and April 2015. It is based on conversations with individuals from different organisations who conducted assessments, as well as on ACAPS experiences of assessments conducted in Sierra Leone and Liberia during the Ebola Needs Analysis Project (ENAP).
The document provides a starting-point for organisations planning an assessment in this Ebola outbreak or in similar future situations. More general lessons, which have been covered in other publications, are repeated here because experience has indicated they need reinforcing. When considering these lessons, it is important to keep in mind that Liberia and Sierra Leone are developing countries whose public health systems were already weak pre-crisis.
There have been 26,339 cumulative Ebola cases as of 4 May 2015, with 10,895 deaths. However, the outbreak shows signs of subsiding. At the end of April, Guinea reported under 30 cases a week, Sierra Leone under 20, and Liberia declared the outbreak over on 9 May 2015. The crisis has highlighted the weaknesses of existing infrastructure and institutions, which have not been able to respond to the additional strain. Many, like the health system, have been weakened further.
The Ebola outbreak appears to have had a limited short-term impact on the WASH sector. Delivery of WASH services in Sierra Leone and Liberia were, for example, far more affected by civil war during the 1990s and 2000s. Despite WASH being addressed by the Ebola response , it necessarily remained secondary to the health sector. Assessments have been planned to scrutinise the impact of Ebola as a whole, at least in Liberia, but there are almost none completed to date. This, coupled with the limitations of available information, has led to a sporadic and an incomplete picture of the exact impact of Ebola on the WASH sector in all three countries.
Yet its impact must not be ignored. Pervasive unhygienic conditions and use of unsafe water have been identified as a key underlying factor in thousands of deaths prior and during the Ebola outbreak. In the medium to long-term, lack of development in the WASH sector is a constant burden to the three countries’ recovery and development. Addressing WASH development offers the opportunity to greatly increase the quality of life. In Liberia it has been estimated that improvements to the water supply could reduce diarrhoea morbidity by 21%, while improved sanitation facilities could reduce diarrhoea morbidity by 37.5%.
This document summarises the baseline data on WASH available for each country. It then provides an overview and analysis of the known and probable impacts of the Ebola outbreak on the WASH sector at both the community and facility level. Relevant aggravating factors not linked to Ebola are described, and WASH-related areas that present a possible risk to the people of Liberia, Sierra Leone, and Guinea are highlighted. Information gaps and lessons learned are outlined at the end.
At the beginning of April 2015, ACAPS conducted a phone based, multi-sectoral assessment of KIs in all 15 counties of Liberia. The objective of the assessment was to identify the main problems faced by communities, and how their needs differ from the pre-Ebola situation. The assessment intends to inform the ongoing discussions on early recovery and strategic decision making on sustainable development.
A multitude of needs assessments have been conducted to capture impacts of the Ebola outbreak on affected communities, since March 2014. This paper reviews all of the assessments on Liberia and Sierra Leone made available to the Ebola Needs Analysis Project (ENAP), between December 2014 and 20 March 2015. Several assessments have been conducted at a regional level. This report focuses only on those conducted on a national level or lower, to allow for disaggregation of results. The review aims to inform the humanitarian response and future assessments, by identifying what information exists and where information gaps remain.
Le nombre cumulé de cas d'Ebola signalés en Guinée, au Libéria et en Sierra Leone est de 23 694. Au 22 février, 9 589 personnes avaient succombé à la maladie. Il s'agit donc de la plus grande flambée d'Ebola de l'histoire. Depuis janvier 2015, le taux d'incidence de la maladie s'est stabilisé dans les trois pays et les opérations devraient progressivement céder la place aux activités de relèvement.
Le grand nombre de cas d’Ebola a ébranlé les systèmes de santé fragilisés et défaillants des trois pays les plus touchés. Les ressources (humaines et financières) limitées ont été redirigées vers les programmes de lutte contre Ebola et les établissements de santé ont soit fermé leurs portes pour une durée indéterminée, soit réduit leurs activités.
La défaillance des systèmes de suivi et de surveillance des maladies autres qu'Ebola ont entraîné d'importantes lacunes en matière d'information. Peu de données sont disponibles en ce qui concerne les autres problèmes de santé, y compris les flambées potentielles de maladies, l'accès au traitement contre le VIH/sida ou la tuberculose, l'incidence du paludisme et l'accès aux services de santé maternelle, aux campagnes d'immunisation et aux médicaments.
De nombreuses personnes hésitent à se faire soigner dans les établissements de santé de peur d'être contaminées et en raison d'une certaine méfiance à l'égard du système de santé, ce qui entraîne d'autres répercussions sur le secteur de la santé et risque d'augmenter les taux de mortalité et de morbidité liées à des maladies pourtant guérissables.
The reported cumulative number of Ebola cases across Guinea, Liberia and Sierra Leone is 23,694, including 9,589 deaths as of 22 February, making it the largest EVD outbreak ever recorded. Incidence has been stabilising in all three countries since January 2015, and the response is moving towards early recovery.
The large number of Ebola virus disease (EVD) cases has overwhelmed the weak and under-resourced health systems in the three most affected countries. Scarce resources have been diverted to the Ebola response, and health facilities have been temporarily closed or reduced operations.
The lack of monitoring and surveillance for diseases other than Ebola has led to big gaps in information. Little information is available on other health problems, including potential disease outbreaks, access to treatment for HIV/AIDS or tuberculosis, the burden of malaria, and access to maternal health services, immunisations and medication.
Fear of contracting EVD and mistrust of the health system has made people reluctant to seek treatment from health facilities, further impacting the health sector and increasing the risk of mortality and morbidity from otherwise treatable diseases.
Around 22 million people are estimated to live in the three countries most affected by the Ebola epidemic, Guinea, Liberia, and Sierra Leone. As of 3-4 November, the estimated cumulative number of confirmed Ebola virus disease (EVD) cases reported by WHO in the three most affected countries is 13,241 including 4,950 deaths. However, the numbers of registered cases and deaths seem to underestimate the real magnitude of the outbreak.
If not addressed in the coming weeks, the consequences of the outbreak will lead to long-lasting impacts on farmers' food livelihoods and household economies, resulting in a major food security crisis by March 2015. The most affected areas within each country are also the most agriculturally productive. Reduced food trade and rising prices, as well as expected reductions in domestic harvests, are all undermining a fragile food security situation.
Control measures implemented to contain the outbreak, such as border closures, quarantine, movement restrictions, curfews, have curtailed the movement and availability of food, goods, and services in the region, leading to panic buying, food shortages and increased basic food and commodity prices. Higher food prices and the loss of purchasing power mean an increasing number of vulnerable households are resorting to negative coping strategies in order to access food.
Food insecurity and lack of access to markets have been increasing community tensions. Lack of food in quarantined areas has led to violence.
A multidimensional and multi-sector approach is required to contain the outbreak and stabilise affected areas while safeguarding against a long-term food security crisis.
As of 21 September, the estimated cumulative number of confirmed Ebola virus disease (EVD) cases reported by WHO in the three most affected countries (Guinea, Liberia, and Sierra Leone) is 6,242, including 2,909 deaths. The ‘hidden caseload’, however, is unprecedentedly large, and these figures are believed to include only a fraction of all cases in this rapidly spreading epidemic.
According to a WHO projection, the aggregate caseload of EVD could exceed 20,000 by early November. Other agencies project the possibility of more than ten times as many cases, use different assumptions such as transmission to other countries, and evolution of the virus towards easier transmission between people.
The humanitarian community is already overwhelmed with the management of the epidemic and is greatly challenged in facing all the implications of this unprecedented and complex regional crisis. The current outbreak in West Africa is by far the largest ever recorded, and already numbers more cases than all past Ebola epidemics combined. 26 million people are estimated to live in the three most-affected countries. The epidemic started in Guinea in December 2013 but was only identified in March, and spread to Liberia, Sierra Leone, Senegal and Nigeria.