NATIONAL EBOLA RESPONSE CENTRE GETTING TO A RESILIENT ZERO. July 2015

Transcription

1 NATIONAL EBOLA RESPONSE CENTRE GETTING TO A RESILIENT ZERO July 2015

2 EXECUTIVE SUMMARY Sierra Leone is one of three countries in the Mano River Union experiencing the most prolonged and devastating outbreak of Ebola Virus Disease (EVD) ever recorded. As of July 2015, an estimated 8,700 probable and confirmed cases and over 3,500 deaths have been recorded Sierra Leone alone. The National Ebola Response Centre ( NERC ) was established in October 2014 to provide strategic leadership to the Ebola response working in close collaboration with the Ministry of Health and Sanitation ( MOHS ) ), other Government bodies and with international partners. In mid- March 2015, NERC launched the strategic vision for Getting to Zero through the execution of three elements: (i) (ii) (iii) Achieving operational excellence and closing implementation gaps in the 7 Critical Interventions of the Ebola response Delivering effective and robust management of each EVD Event; and National Campaigns - the Zero Ebola Campaign (implemented at the end of March 2015) and the National Day of Remembrance (scheduled for one month after Sierra Leone is declared Ebola- free) The national epidemiological context in Sierra Leone in July 2015 is very different to the context in March 2015 and the strategic approach has been revised to take this into consideration. As at mid- July 2015, only 3 districts in Sierra Leone were recording confirmed cases and on 16 th July 2015 there were a total of 11 confirmed cases in Ebola Treatment Centres ( ETCs ) nationally. Within the 3 active transmission districts there were 4 transmission chains confined to a small number of chiefdoms and wards. The remaining 11 districts (the Silent Districts) had recorded zero Ebola cases for more than 75 days with 3 districts not having reported a confirmed case for over 200 days. Thus although there is a common national strategic direction, there is a different emphasis for Active Transmission Districts and for the Silent Districts that reflects the different epidemiological contexts. The strategic objective of the response continues to be to stop the transmission of EVD in Sierra Leone in the shortest possible timeframe and to achieve this in a manner that builds resilience and minimises the risk of the reoccurrence of an EVD outbreak on the scale of the current epidemic Building on lessons learnt and within the context of continuous improvement, the overall strategy for Getting to a Resilient Zero is to: (i) Adopt a Systematic Focus on Community Ownership in all Districts; (ii) Achieve Operational Excellence in the delivery of the Critical Interventions in all Districts; and (iii) Ensure Effective EVD Event Management in Active Transmission Districts and Resilient EVD Event Management Preparedness and Response Mechanisms in the Silent Districts. Community ownership has proved to be the critical success factor in the Ebola response - there must be a systematic focus on deepening community engagement in all aspects of the response in order to foster greater ownership Although Deepening Community Engagement is one of the 7 Critical Interventions, it is imperative to ensure meaningful engagement with affected communities in the delivery of all the critical interventions in a manner that solicits and enhances positive collaboration for effective containment of the outbreak. Based on the current epidemiology, the planning horizon for the containment of the outbreak and the declaration that Sierra Leone is Ebola- free is between 3 to 6 months from July NERC Planning Directorate Page 2 24 th July 2015

3 TABLE OF CONTENTS 1 INTRODUCTION BACKGROUND AND CONTEXT... 4 STRATEGIC OBJECTIVE UPDATED STRATEGY FOR GETTING TO A RESILIENT ZERO OVERALL STRATEGY... 6 SYSTEMATIC FOCUS ON ENGENDERING COMMUNITY OWNERSHIP... 7 OPERATIONAL EXCELLENCE IN THE DELIVERY OF THE CRITICAL INTERVENTIONS... 9 EVD EVENT MANAGEMENT RISKS TO IMPLEMENTING THE GETTING TO A RESILIENT ZERO STRATEGY WITHDRAWAL OF PARTNER SUPPORT POOR COORDINATION OF PARTNERS MAINTAINING TECHNICAL EXPERTISE APPENDICES APPENDIX 1 CRITICAL INTERVENTIONS MONITORING AND EVALUATION MATRIX NERC Planning Directorate Page 3 24 th July 2015

4 1 INTRODUCTION 1.1 BACKGROUND AND CONTEXT Sierra Leone is one of three countries in the Mano River Union experiencing the most prolonged and devastating outbreak of Ebola Virus Disease (EVD) ever recorded. As of July 2015, an estimated 8,700 probable and confirmed cases and over 3,500 deaths have been recorded Sierra Leone alone. The National Ebola Response Centre ( NERC ) was established in October 2014 to provide strategic leadership to the Ebola response working in close collaboration with the Ministry of Health and Sanitation ( MOHS ) ), other Government bodies and with international partners. Under the leadership of the NERC Chief Executive and the NERC Chief Operating Officer, with technical input and guidance delivered through seven pillars 1, and supported by international partners, the core functions of the NERC are executed through a Situation Room Directorate, a Planning Directorate and an Operations Directorate. There is also a Donor Aid Coordinator to ensure accountability, transparency and financial coordination, as well as Fiduciary Agents to ensure financial probity. At district level, District Ebola Response Centres ( DERC ) led by a District Coordinator report to the NERC Executive. The core functions of the DERCs are executed through command centres with technical input from the seven pillars and international partners at district level. NERC and its partners have pursued an approach to the Ebola response that has been district- led and centrally supported. There was an initial emphasis on ensuring that the requisite physical infrastructure and human capacity for the response were available whilst building a sense of community ownership and confidence in the response. Following the successful execution of the Western Area Surge and the completion and delivery of the District Plans in January 2015, confirmed cases in Sierra Leone fell from a peak of 550 per week in November 2014 to 80 cases a week by the end of January The downward trend in case numbers stalled during February 2015, potentially as a result of the onset of complacency and fatigue and confused public perceptions as certain Ebola emergency measures were lifted and discussions about transition (e.g. the re- opening of schools) began. In mid- March 2015, NERC launched its strategic vision for Getting to Zero through the execution of three elements: (i) Achieving operational excellence and closing implementation gaps in the 7 Critical Interventions of the Ebola response 1. Quality Surveillance and Comprehensive Contact Tracing 2. Infection Prevention and Control 3. Safe and Dignified Burials 4. Deepening Community Engagement 5. Cross Border Collaboration Cross- cutting Interventions 6. Psychosocial Support Services 7. Improving Operational Effectiveness 1 The seven pillars are; Case Management (co- chairs MOHS and WHO); Surveillance (co- chairs MOHS and WHO); Burials (MOHS and IFRC) ; Social Mobilisation (MOHS and UNICEF); Psychosocial( MSWGCW and UNICEF); Logistics (MOHS and UNICEF); and Communications (MOHS and CJAITF). NERC Planning Directorate Page 4 24 th July 2015

5 (ii) Delivering effective and robust management of each EVD Event; and (iii) National Campaigns - the Zero Ebola Campaign (implemented at the end of March 2015) and the National Day of Remembrance (scheduled for one month after Sierra Leone is declared Ebola- free) In the ensuing period, the focus of all the participants in the response on achieving operational excellence in the delivery of Critical Interventions, the treatment of each EVD case/cluster as a specific EVD Event with more targeted and focused management and the massive nationwide awareness Zero Ebola campaign yielded tangible results. Weekly case numbers reduced sharply from mid- March hitting single digits in April In early May zero cases were recorded nationally for 8 consecutive days. However, the emergence of a new outbreak cluster in 3 districts in June 2015 with the sharpest upward weekly trend for the first time in several months are clear reminders that although bumps in the road to zero Ebola are to be expected, there can be no complacency and the response must remain focused. Moving forward with the intensified strategy for getting to a resilient zero requires an adapted strategy that takes into consideration the epidemiological landscape (3 districts with active transmissions and 11 silent districts); the drivers of transmission that include fear, inadequate trust and collaboration from the communities and communities tendencies to seek healthcare through informal structures that include traditional healers and traditional birth attendants; an understanding of community behaviours and engagement with them to address their concerns in the delivery of the Critical Interventions; and the coordination and provision of support for the medical and non- medical needs of survivors in a manner that helps mitigate the potential resurgence of the disease through survivor sexual transmission. 1.2 STRATEGIC OBJECTIVE As of mid- July 2015, the three districts of Western Urban, Port Loko and Kambia continued to register confirmed EVD cases on a weekly basis, with transmission localised in certain geographical locations. Given the high volume of population movements within the country and across national geographic boundaries, and the high numbers of survivors country wide, the remaining 11 Silent Districts still remain at risk of EVD resurgence. Until the country, and the sub- region is declared free of Ebola, it is imperative to maintain a heightened sense of alert and rapid response capabilities countrywide to be able to manage and resolve a potential resurgence swiftly and efficiently. The strategic objective for this phase in Sierra Leone s response continues to be to stop the transmission of EVD and get to a resilient zero Guided by the current disease epidemiology countrywide, the specific objectives are: a) To rapidly identify, interrupt and stop further transmission of EVD in Active Transmission Districts in Sierra Leone in the shortest possible timeframe; and b) To ensure that systems and structures are in place to rapidly detect and manage the potential resurgence of EVD in Silent Districts thereby building resilience and minimising the risk of the reoccurrence of an EVD outbreak on the scale of the current epidemic. Based on the current epidemiology, the planning horizon for the containment of the outbreak and the declaration that Sierra Leone is Ebola- free is between 3 to 6 months from July NERC Planning Directorate Page 5 24 th July 2015

6 2 UPDATED STRATEGY FOR GETTING TO A RESILIENT ZERO 2.1 OVERALL STRATEGY As of 16 th July 2015 there were a total of 11 confirmed cases in Ebola Treatment Centres ( ETCs ) nationally. Within the 3 Active Transmission Districts there were only 4 transmission chains confined to a small number of chiefdoms and wards. The remaining 11 Silent Districts had recorded zero Ebola cases for more than 75 days with 3 districts not having reported a confirmed case for over 200 days. Thus although there is a common national strategic direction, there is a different emphasis for Active Transmission Districts and for the Silent Districts that reflects the different epidemiological contexts. Building on lessons learnt and within the context of continuous improvement, the overall strategy for Getting to a Resilient Zero is to: (i) Adopt a Systematic Focus on Community Ownership in all Districts; (ii) Achieve Operational Excellence in the delivery of the Critical Interventions in all Districts; and (iii) Ensure Effective EVD Event Management in Active Transmission Districts and Resilient EVD Event Management Preparedness and Response Mechanisms in the Silent Districts. Community ownership has proved to be the critical success factor in the Ebola response - there must be a systematic focus on deepening community engagement in all aspects of the response in order to foster enduring community ownership Although Deepening Community Engagement is one of the 7 Critical Interventions, it is imperative to ensure meaningful engagement with affected communities in the delivery of all the critical interventions in a manner that solicits and enhances positive collaboration for effective containment of the outbreak. Community engagement needs to better integrated in all aspects of the response (e.g. in surveillance, contact tracing, burials). All community- based interventions should involve meaningful partnerships with community members, with clarity about roles and responsibilities and a framework for mutual accountability that is implemented in a manner that reinforces community ownership. The Critical Interventions are not new and include the fundamentals elements of the response (e.g. surveillance and contact tracing) employed in EVD Event Management. There must be an effective feedback loop between achieving operational excellence in the delivery of the Critical Interventions and EVD Event Management to ensure that there is a process of continuous improvement in the response. A central element to ensure the success of the overall strategy is a robust system for reporting, monitoring and evaluating the delivery of the Critical Lessons learnt from the event and fed back into the critical interventions Respond to EVD event management Develop and implement actions for critical interventions Interventions and EVD Event Management. Given the significant numbers of participants in the response and although operational elements of the response are delivered at district level, it is essential that the impact of the delivery of the Critical Interventions and EVD Event Management be monitored against agreed key performance indicators at both national and district levels. The co- operation of all response partners in this is essential. NERC Planning Directorate Page 6 24 th July 2015

7 2.2 SYSTEMATIC FOCUS ON ENGENDERING COMMUNITY OWNERSHIP Community ownership is the critical success factor for Getting to a Resilient Zero and must now be central to all aspects of the response. Community ownership is a pre- requisite for the comprehensive identification of all contacts, for calling in sick and death alerts so that the former are appropriately assessed and isolated and the latter safely buried, for compliance with quarantine restrictions, for the adoption of preventative measures to stop the spread of EVD and for acceptance of survivors back into their communities. Anthropological investigations of the current transmission chains in the country suggest that drivers of transmission are linked to a failure by the response to effectively engage elements of the affected communities and engender a sense of understanding, ownership and responsibility. The above not withstanding, significant progress has been made by the response with regards community engagement and ownership. The three Qualitative Studies of Public Knowledge, Attitudes and Practices ( KAP Studies ) published in September 2014, December 2014 and January demonstrate that social mobilisation efforts have resulted in increased comprehensive knowledge and decreased misconceptions, decreased stigmatization of survivors, decreased resistance to shifting traditional burial practices and Increased avoidance of participating in traditional burials. The KAP studies issued in January 2015 highlighted the need for Intensified social mobilization in order to sustain the gains made thus far. More recent anthropological studies confirm that EVD sensitization 2 The qualitative studies on public knowledge, attitudes, and practices (KAP) relating to Ebola Virus Disease (EVD) in Sierra Leone was carried out by Focus 1000 with support and partnership with the Centres for Disease Control and Prevention (CDC). NERC Planning Directorate Page 7 24 th July 2015

8 messages still sweep the surface and do not adequately address the core issues that alienate some communities from the response 3. Engendering community ownership will require a systematic effort, informed by anthropologists and community leaders, to: (i) (ii) (iii) (iv) Engage predominantly at the grassroots level building and strengthening community- led and owned response structures, supporting village chiefs and key community stakeholders such as religious leaders, traditional leaders, women and youth groups, to take responsibility for the response within their communities. This includes embedding early warning and alert systems at village level in rural areas and ward level in urban areas and operationalizing Community Action Plans (CAP) in a participatory manner with existing community structures. Existing community structures include Village Taskforces, Village Development Committees ( VDCs ), Neighbourhood Watch Groups, Ward Committees, Community Event Based Surveillance ( CEBS ), Community Level IDSR Structures and DHMT Community Structures. There is also a need to emphasize and engage with the level of household where transmission can be pinned down and transmission chains broken. Target specific community groups who have the potential to be drivers of the disease but who could also potentially have a disproportionate impact in helping to break the chains of transmission. The key groups being; (i) Traditional Healers; (ii) Okada Riders and Taxi Drivers; (ii) Border and Wharf Communities; and (iv) Survivors. Additionally, there are resistant elements of communities that have always been present, but whose resistance is more evident as the landscape of resistance narrows. Pre- identification of these resistant elements is not possible; they are evidenced as a result of outcomes and actions, making it difficult to single them out for targeted engagement. They are therefore addressed through influencers and broader community engagements. Adjust the focus of the response so that the best messengers are consistently used to deliver the right message, recognising that the beliefs and traditions that the response requires communities to set- aside during the Ebola outbreak are deeply held phenomena. This reinforces the need to continue to target and bring into the response community opinion leaders and influencers through close consultation with paramount chiefs, section and village level chiefs, religious leaders, traditional leaders, women leaders and youth groups. Conscious efforts should be made to create opportunities for dialogue, reflection, participation and collaboration with communities through simple and participatory approaches. More emphasis should also be placed on learning from survivors, persons who have gone through quarantine, and community leaders who have taken a strong leadership role in their communities. Continue to identify and address the core issues that create barriers between communities and the response. These include but are not limited to: (i) failures in service delivery by the response such as lack of timely feedback about relatives taken to ETCs or off- site quarantine facilities, delays in death alert responses resulting in corpses remaining uncollected for unacceptable periods of time and lack of respect and cultural sensitivity demonstrated by 3 WHO Anthropological report Of love, familial obligations and beliefs Port Loko, 26 th June 2015 NERC Planning Directorate Page 8 24 th July 2015

9 response workers ranging from ambulance drivers to social mobilisers; (ii) inconsistent application of SOPs and differential enforcement of Ebola bylaws that risk sending the message that poor and marginal people do not matter, thereby fuelling resistance, resentment and conspiracy theories. There is a need to constantly review and reflect on issues pertaining to the implementation of the by- laws in totality in order to avoid a situation wherein communities are alienated because of fear rather than engaged; and (iii) failure to deliver basic non- Ebola healthcare to the sick who present to the response but are tested negative for Ebola as well as non- access to non- Ebola healthcare by communities due to a lack of trust in the health system or the resources to access care. It is imperative trust between the health system and communities is restored. Failure to deliver livelihood support for households in quarantine has also been a barrier to the response. It should be noted that attempts to address some of these issues are being made by elements of the response (e.g. the livelihood support programmes recently implemented for quarantine households in Kambia) but a more systematic delivery of solutions across the response is essential to success. (v) 2.3 Use the media to reinforce positive messages; it is important to continue to support local radio stations to produce programmes that are interactive and that can create a platform for local leaders and key influencers such as religious leaders and traditional healers to engage their audiences as trusted voices. Survivors may be encouraged and supported on radio and TV to share their testimonies and dispel fears, rumours and misconceptions especially about ambulances, health workers, quarantine and treatment centres. OPERATIONAL EXCELLENCE IN THE DELIVERY OF THE CRITICAL INTERVENTIONS The Critical Interventions are not new and are the fundamentals of the response, required to break the EVD transmission chains and get to zero. 1. Quality Surveillance and Comprehensive Contact Tracing 2. Infection Prevention and Control 3. Safe and Dignified Burials 4. Deepening Community Engagement 5. Cross Border Collaboration Cross- cutting Interventions 6. Psychosocial Support Services 7. Improving Operational Effectiveness With the reduced numbers of confirmed cases now in Sierra Leone, achieving operational excellence in delivering the key objectives of each of the Critical Interventions will translate into success in getting to a resilient zero. Achieving operational excellence in the response involves introducing innovation, improving the quality of delivery as well as closing the gaps between stated policies and procedures and operational delivery. A significant lesson learnt from the response to date is that gaps between the documented Standard Operating Procedures ( SOPs) or policy decisions in respect of the Critical Interventions, and the actual delivery and implementation of those SOPs or policies on the ground, have a detrimental impact on breaking the chains of transmission. For example, although the Contact Tracing SOP states that contacts must be monitored twice a day, if contact tracers operating in the field do not adhere to the SOP and skip the stipulated monitoring visits, identified contacts may be lost to follow up and may become symptomatic within or outside NERC Planning Directorate Page 9 24 th July 2015

10 their home environment and expose other people to EVD thereby perpetuating the EVD transmission chain. Similarly, there is a policy in place that requires healthcare facilities staff to adopt IPC procedures and training and supervision has/is being delivered to enable this to happen nationwide. However, if due to supply chain deficiencies the requisite IPC materials are not delivered to healthcare facilities, staff will not be able to effectively implement IPC procedures and this could result in the perpetuation or even amplification of transmission chains in the event of an EVD exposure at the healthcare facility. In order to consistently and in a timely manner identify and resolve challenges to achieving operational excellence in the delivery of the Critical Interventions, there must be clarity with regards accountability, delivery mechanisms, timelines and indicators of success that measure impact rather than output A Critical Interventions Working Group comprising the technical leads for each Critical Intervention has been established and will work with the pillars, technical partners, implementing agencies and the DERCs to constantly monitor and evaluate the delivery of the Critical Interventions using agreed quality indicators and monitoring mechanisms. The co- operation of all response partners is required. (See Appendix 1 for Critical Interventions Monitoring and Evaluation Matrix) The table below details the Critical Interventions and a sample of Key Performance Indicators and Targets that are to be reported and monitored. NERC Planning Directorate Page th July 2015

11 Critical Interventions 1. Quality Surveillance and Comprehensive Contact Tracing comprehensive investigations of cases and identification of contacts, and consistent and efficient contact tracing 2. Infection Protection and Control Effective IPC procedures and processes in place at all ETCs, health facilities, and at key gathering points, such as school entry Effective triage and isolation facilities at health care facilities and effective IPC procedures and processes in place Effective screening at schools, border crossing points, checkpoints etc 3. Safe and Dignified Burials 4. Deepened Community Engagement 5. Cross Border Collaboration create Effective working relationship, ensure response teams share information and resources in a timely and predictable manner Border communities take proactive measures to prevent cross border infection (linked in with above 6. Psychosocial Support Services 7. Improving Operational Effectiveness Current Key Performance Indicators and Targets (Non- exhaustive) 100% of new cases should come from contact lists, preferably those identified as High Risk Early identification and timely referral of suspects and probables to ETCs to increase survival Zero cases of nosocomial and health care associated infections Zero cases of infections in health care workers Adherence to IPC standards and practices (100%) Zero report of a breach in IPC practices zero reports of illegal or unsafe burials, 100% of reported deaths buried safely Increased community ownership leading to increase in sick and death alerts, preventative measures being adopted and own messaging being delivered. zero reports of community resistance /evading of interventions Zero reports of cross border infection 100% effective and cross border collaborative management of cross border events (cases and/or contacts) Adequate support given to the vulnerable, Ebola survivors, contacts and immediate associates, and those in quarantine ensuring dignity and respect. Reduction in stigmatisation and tangible support to deal with impact of being affected/infected Improving the quality of the response service delivery. Key areas include the laboratory process, quarantine process, 117 responses, fleet management and rainy season preparedness NERC Planning Directorate Page th July 2015

12 2.4 EVD EVENT MANAGEMENT Active Transmission Districts EVD Event Management underpinned by Community Ownership Getting to zero requires the targeted and effective management of each EVD Event as every event is a bump in the road and that could prolong the road to zero. The national epidemiological context that pertained in March 2015 and the reduced and manageable numbers of confirmed cases enabled the adoption of EVD Event management guided by a comprehensive investigation of all events. Notable performance indicators of concern included: EVD deaths in quarantined homes Healthcare worker infections New cases in a district representing an introduction of infection in new geographical locations New chains of transmission, or unexplained exposure history In the current epidemiological context, every confirmed case is an EVD Event and must be responded to as such. The EVD Event Management approach aims to deliver a targeted, comprehensive and tailored response to EVD Events with the objective of minimising the length and magnitude of the event, breaking the chain of transmission by isolating all the sick and identifying and monitoring all contacts. The use of Multi- disciplinary rapid response teams is now standard practice for EVD Event Management. The teams include: epidemiologists, surveillance officers, anthropologists as deemed feasible, and social mobilisers who quickly investigate confirmed cases and transmission chains related to the event, recommend and work with key implementers including community members, to institute tailor made solutions and actions aimed at interrupting and stopping the transmission chains. The core members of the multi- disciplinary teams are based in the DERCs. However, the EVD Event Management framework also facilitates and enables the deployment of external technical teams (e.g. additional DSOs and epidemiologists), physical assets (e.g. additional vehicles and tents) and financial support for specific response activities as required. EVD Event Management has been characterised by innovation that then feeds into improvements in the Critical Interventions. Examples of this include: (a) the use and application of gene sequencing to establish linkages and potential exposures to inform epidemiological updates and guide operational interventions; (b) the establishment of the Hastings Voluntary Quarantine Facility in response to the Crab Town EVD Event in an urban slum setting. This reflected lessons learnt from the use of the same concept in Rosanda, Bombali District in response to an EVD Event in a rural setting; and (c) the recent establishment of Incident Control Points in Port Loko and Kambia that build on the concept of the sub- DERC used in the Aberdeen and Hagan Street EVD Events earlier in the outbreak In districts with on- going active transmission chains, there will be an emphasis on the development and implementation of EVD Event Management plans to break existing chains of transmission. Guiding principles 4 for EVD Event Management include: Use outbreak control methods, not programmatic approaches 4 CDC Freetown June 2015 NERC Planning Directorate Page th July 2015

13 Prioritise of known problems first, look for unknown problems second Use intelligent strategies based on data Use performance management tools for every aspect of response Reduce time from case identification to identification of contacts Address laboratory and decision making errors to avoid them in the future Use assets and technical expertise wisely; more is not always better EVD Event Management in Active Transmission Districts must continue to have the communities at the heart of the response. Community ownership interventions should continue to occur alongside the EVD Event Management. The reporting on and monitoring of Critical Interventions will support EVD Event Management through the proactive identification and resolution of issues that adversely impact on achieving operational excellence in delivery Silent Districts Ensuring EVD Management Preparedness and Robust Response Mechanisms and Reinforcing Community Ownership The overall strategy for Getting to a Resilient Zero is applicable across all the districts. Achieving operational excellence in the delivery of the Critical Interventions and an Increased Systematic Focus on Community Engagement are core elements of the strategy. However in the Silent Districts, it is particularly important that: (i) The DERCs, in collaboration with the DHMTs, should retain the capacity and ability for rapid response and effective EVD Event Management in the event of confirmation of an EVD Event. The key features of the EVD Management framework must be in place the ability to plan, the ability to stand- up and deploy Rapid Response Teams and ready access to additional technical expertise and physical resources should these be required. It is also necessary to have a small and managed capability for temporary isolation to provide initial isolation and patient management should it become necessary. A process for regularly testing the level of EVD Event Management preparedness of the Silent Districts, which includes running simulation exercises, is also required. (ii) Vigilance is maintained for sustained alerts and rapid verification processes are in place. Active surveillance, high levels of alerts and real time verification mechanisms, coupled with public education and community engagement should be heightened and maintained. This is critical to maintaining high levels of sick and death alerts, and the reciprocal desired rapid verification process that should lead to the trigger of comprehensive event management response interventions in the event of confirmation of an EVD case. Given the low coverage of health facilities, and the tendency for a significant proportion of the population to seek initial health care in the informal systems (e.g. traditional healers, traditional birth attendants) the need to maintain vigilance and a high level of alerts will require systematic engagement with communities. There is a need to implement community based surveillance systems that link up with the primary health care facilities or directly with 117 for notification and rapid verification. Integrated disease surveillance and response systems will need to be rolled out to the health facilities. Additionally, capabilities for rapid verification and investigation of alerts in all districts should be established to support such a system. It is also recommended that swabbing of all deaths to rule out EVD be maintained and that safe and dignified burials be practiced for all deaths at least until the outbreak is declared over in the sub- region. NERC Planning Directorate Page th July 2015

14 The DERCs must have requisite capability in terms of human capacity, physical infrastructure, logistical and financial resources to maintain their core functions until Sierra Leone is declared Ebola- free. Additional challenges, particularly during the rainy season, require articulation and maintenance of additional resources to keep the core capacities functional. Any gaps in their capabilities and resources should be identified and adequately addressed. (iii) (iv) Notwithstanding that there has been a strong sense of community ownership in these districts, it is critical that the response in the Silent Districts continues to systematically engage with communities to reinforce community ownership. There must be certainty that silence does not reflect a fragile peace but a true victory in the fight against Ebola. Community ownership should translate into maintaining high levels of sick and death alerts this is currently not the case for a number of the Silent Districts as evidenced by alerts reported through 117. Community response structures must be supported and strengthened and early warning and alerts systems reactivated and embedded within communities. Given their knowledge of community linkages and relationships, community- owned local responses should be given full responsibility and accountability for ensuring all contacts are identified, missing contacts are recovered, quarantined households are properly managed and active surveillance is properly targeted Improved Survivor Engagement and Support is established: recognizing the substantial medical, psycho- social, livelihood and other needs of survivors, as well as new knowledge on the prolonged persistence of the virus in the semen of male survivors, enhanced capacity must be established to support the medical and non medical needs of survivors 3 RISKS TO IMPLEMENTING THE GETTING TO A RESILIENT ZERO STRATEGY 3.1 WITHDRAWAL OF PARTNER SUPPORT Partners and donors form a core and essential part of the response. Ensuring that partners are aligned with the response strategy and willing to support it financially and with other resources, is critical to getting to a resilient zero. Exit strategies of partners and donors must be predicated on first achieving resilient zero status before diverting response resources to recovery programmes. There should be further strengthening of national ownership to minimise the eventual impact of partner withdrawal. 3.2 POOR COORDINATION OF PARTNERS In a complex response, coordination is always a significant challenge. Throughout the response, partner coordination has been a necessary and critical role to ensure that the response has the resources required to implement the strategy. Partners are encouraged to continue to be engaged through the coordination platforms: pillar meetings at national and district level, development partner meetings, implementing partner meetings. It is vital that DERCs continue to be empowered to aid coordination on the ground at district level. 3.3 MAINTAINING TECHNICAL EXPERTISE As Sierra Leone gets closer to zero there will be a temptation for experienced EVD technical expertise to see the job as complete and leave the country. This is counter to received advice where defeating NERC Planning Directorate Page th July 2015

15 EVD and keeping it at zero requires forensic attention to detail. Ensuring that sufficient technical expertise with an understanding of the local environment remains in country until after Sierra Leone is declared Ebola- free is critical. NERC Planning Directorate Page th July 2015

16 4 Appendices Appendix 1 Critical Interventions Monitoring and Evaluation Matrix NERC Planning Directorate Page th July 2015