Sierra Leone - Ebola cases have been falling sharply since the start of the year, but the decline has now stalled in Sierra Leone. Although cases are confined to three districts - Port Loko, Kambia and Western Area Urban, including the capital - the past two weeks have seen 21 new confirmed cases, with 15 in the low income coastal community of Magazine Wharf, Freetown.

One of the key challenges in stopping the spread of Ebola is the high mobility of populations and cross-border movement of infected travellers.

Recognizing the need to strengthen cross border collaboration, a team of doctors and public health specialists from IOM’s HQ and regional office and the US Centers for Disease Control (CDC)’s National Center for Emerging and Zoonotic Infectious Diseases (NCEZID) arrived in Sierra Leone on 10 July as part of a two-week long mission to review IOM’s health and humanitarian border management (HHBM) programming, including response activities in Magazine Wharf. A UN World Health Organization (WHO) Sierra Leone field team subsequently joined the mission.

Since 23 June, IOM has been leading infection prevention and control (IPC) training efforts in Sierra Leone and has mobilized personnel to respond to the outbreak in Magazine Wharf in what is being called the “Western Area Surge”.

Fifteen IOM trainers are now providing support, in partnership with the Ebola Response Consortium, a grouping of seven INGOs, to eight peripheral health units in the area and regular activities have been postponed. IOM staffers are responsible for mentoring local health care workers on advanced health screening and IPC protocols to ensure patients who may be symptomatic are picked up immediately, while maintaining staff safety. 

IOM Training Coordinator Jasmine Riley sees the backstopping of smaller in-community facilities as essential to the success of surge operations. “The long term goal is to bring the number of cases down to zero and maintain zero for a period of 42 days past the last confirmed case,” she says.

In early May, Sierra Leone was down to only two confirmed cases, but a resilient zero has continued to prove elusive. As of 13 July, the National Ebola Response Center has called for all surge operations to be maintained to the end of September in a concerted effort to rid the country of Ebola once and for all.

The second and perhaps most essential component of IOM’s response in Freetown is community engagement and social mobilization. Community ownership has proved to be a critical success factor in the Ebola response and IOM is placing an increased focus on deepening community engagement.

Since January, IOM’s 32 community social mobilizers have been active in eight low income coastal communities in Freetown, including Magazine Wharf. For the past two weeks the regular deployment of four has been increased to 12 at the request of the Government of Sierra Leone's Social Mobilization Pillar.

IOM staff work in mixed ‘task forces’ with UNICEF, the Red Cross, and the Social Mobilization Action Consortium (SMAC), a grouping of agencies working with CDC and the Sierra Leonean Ministry of Health and Sanitation.

Fatamata Sesay, IOM social mobilizer in Suzan’s Bay says that even after eight months on the job and in spite of obvious dangers, there are still significant challenges in conveying potentially lifesaving messages to community members. “Some people simply refuse to cooperate no matter what approach we take,” she says.

IOM’s HHBM teams are also present in the area. Two teams of seven health screening monitors operate handwashing stations and temperature checks in the area and have recently established a flow monitoring point (FMP) at the Guinea Wharf in Suzan’s Bay. The teams work in eight hour shifts around the clock to ensure comprehensive monitoring and data collection.

The FMP system is being rolled out in Kambia, Port Loko, Freetown and Bombali. Monitoring teams positioned at prioritized checkpoints on the international border with Guinea, inter-district borders and Freetown seaports collect headcounts and information from travellers on their point of origin and departure, as well as asking multiple health-related questions. This information is collected in a centralized database that will be shared with the government and will act as an invaluable resource in ongoing surveillance and contact tracing efforts on the ground.

Dr. Teresa Zakaria, who is leading the IOM HQ team, noted: “It is essential to properly articulate population flows on the border and ensure interventions are multi-sectoral, so that mobility becomes an integrated component of the Ebola emergency response. It is only natural that when you tell someone no, they will seek an alternative place to dock a boat or to enter a community. So it is equally important to be sensitive to local realities and tap into local knowledge.”

Out of 17 total wharfs in Western Area Urban, 16 have been identified under a social mobilization team security review as having a high to medium threat rating. This is based on the number of boats operating at these wharfs, their links to other districts, especially Kambia and Port Loko, as well as the Republic of Guinea, ongoing fishing and transportation activities, and the absence of adequate surveillance and social mobilization in those areas.

After reviewing IOM operations in Kambia and Freetown, CDC migrant health specialist Dr. Alphonso Rodriguez said: “IOM field staff are highly trained and motivated, despite incredibly challenging working conditions.” IOM and CDC maintain an inter-agency cross border working group that meets every two weeks to share information and expertise on border management related issues.

The IOM team will return to IOM’s Geneva HQ at the end of the month after stops in Mali, Conakry, Monrovia and Dakar. In close collaboration with CDC and WHO, a final mission report will be issued with concrete action points to take forward their findings in the form of a more comprehensive and integrated HHBM strategy around the region. This will include enhanced data collection activities aimed at establishing a clearer understanding of where people move and why.

Tracking these mobile populations and generating a clearer picture of regional mobility will go far in strengthening outbreak response and preparedness measures, while impacting the ongoing epidemic in affected communities like Magazine Wharf.

For further information, please contact Nicholas Bishop at IOM Sierra Leone, Tel: (+232) 076 466 942, Email: nbishop@iom.int