Liberia’s COVID-19 Trajectory: Experts’ Advice on How to Halt the Outbreak

By: Sara Beysolow Nyanti, MPA; Tolbert Nyenswah, LLB, MPH; Dougbeh Chris Nyan, MD; and Mardia Stone, MD, MPH

Fighting the Coronavirus disease (COVID-19) pandemic: Employing lessons from the Ebola Virus Disease response.

This is a summary of a full paper with recommendations that will be presented to the Government of Liberia.

Since the COVID-19 outbreak was declared a Public Health Emergency of International Concern (PHEIC) by the World Health Organization (WHO), there are over 183 million COVID-19 confirmed cases and a staggering 4 million deaths worldwide. To date, this global COVID-19 death toll almost totals the entire population of Liberia.

The Global North (a specific reference to countries in Europe and North America) is making progress in vaccinating its populations, while the Global South (countries in Africa, Asia, Latin America, and Oceania, often referred to as ‘least developed’ or ‘developing’) is disproportionally affected. With more fragile health systems, sub-Saharan Africa will very likely become home to the next COVID-19 hotspots.

In Liberia it is presumed that the situation is not as bad as it is in some other countries. Unfortunately, this perception may be misleading. In a little over a year (March 2020 to April 20201), Liberia recorded 2099 confirmed cases, with 85 confirmed deaths. However, in May to June 2021 alone, Liberia recorded 2205 cases and 44 confirmed deaths (NPHIL daily situation reports). The cases and deaths in 2 months are more than what we experienced in over a year.  

The identification of COVID-19 cases has primarily been conducted using reverse transcription polymerase chain reaction (RT-PCR), commonly referred to as “PCR.” Availability of testing has been very minimal across the country. Even where testing has been conducted, the results are alarming. Test positivity rates are now at a record high in Liberia at over 20 to 25%(NPHIL/MOH) from May to June 2021. Moreover, a test positivity rate above 5% to 10%, is deemed as an outbreak that is out of control (WHO).

Voluntary testing has not been a service that Liberians have enjoyed like others around the world. Testing for the most part has been largely for travel at cost. However, voluntary testing for COVID-19 is now being offered to those who are symptomatic and require clinical confirmation. Unfortunately, even when tests are conducted, those who get tested sometimes do not receive their test results, have no follow up, and their contacts are not traced. 

Beyond testing, countries that have been successful in managing COVID-19 disseminate socially and culturally appropriate public health awareness messages and ensure engagement with communities. They actively trace those who have been exposed to the virus and follow available scientific data and experiences of other public health emergencies.  Cross-border movements of populations are controlled, as well as crowds and gatherings in public spaces (schools included),

Vaccination campaigns are an important strategy implemented during an epidemic. However, vaccination is one of the major challenges with COVID-19. Around 77% of COVID vaccines being produced have already been bought by only 10 countries in the Global North (WHO). So where does Liberia stand with vaccines? Liberia has only relied on donations of vaccines from COVAX which has allocated 384,000 doses of the AstraZeneca vaccine. Of this allocation, 96,000 doses were received in March 2021. So far, 85,132 people (18,921 health workers and 66,211 others) have received the first dose of the vaccine, according to the Ministry of Health. In addition, 6,439 people have received the second dose of the vaccines. However, this has largely been in Montserrado country. What of the other 14 counties? We do not have sufficient vaccines for the population, and even with what Liberia has received, management of the vaccines has not been optimal. Countries around the world are now procuring vaccines and are not relying on donations. Liberia needs to vaccinate at least 3.5 million people. Donations will never be enough for the entire country. Countries procuring now are expecting vaccines in quarters 1 and 2 of 2022. When will Liberia enter this global procurement cue?

There is no substitute for political leadership and strategic management in any outbreak response. The 2014-2016 Ebola outbreak in Liberia, Guinea, Sierra Leone and Nigeria taught that very well.  Liberia has been down this road before and has gained the knowledge and skills to manage epidemics. By establishing the National Public Health Institute of Liberia (NPHIL) and the emergency operation centers in all 15 counties, as well as training field epidemiologists for community-based events surveillance, the government resolved to build a more resilient health system, capable of responding to public health emergencies such as COVID-19. That system plus the over 2,000 personnel trained in various aspects of public health during and after the 2014 Ebola epidemic should be mobilized.  

In the recent weeks of the COVID third wave in Liberia, scores of Liberians have died from what has been probably inaccurately diagnosed as malaria, typhoid, kidney failure and stomach ulcers, due to the lack of differential diagnostic capabilities in infectious diseases. Most are dying without ever being tested. Where testing is conducted, results are very rarely available on time. Anecdotal evidence suggests that waiting time for voluntary testing for COVID-19 is over 1-2 weeks in many instances. Some do not get results until after they have recovered. Nationwide testing, timely results and contact tracing are non-negotiables for dealing with COVID-19; and the private sector is needed.

Worst of all, misconception, misinformation, and incorrect information continue to pervade the population. Average Liberians still doubt the existence of COVID-19 or its presence in the country. Unlike Ebola, COVID-19 positive patients can be asymptomatic. This is an unfamiliar perspective in a country with high illiteracy and poverty rates.

With all of the issues raised herein taken into consideration, we advise the following in summary:

1. Demonstrate strong political and technical leadership going forward. A whole-of-government and whole-of-country approach is necessary, down to the household level.
2. The Minister of Health of Liberia officially should declare a “National Public Health Emergency” in keeping with Title 33, Chapter 14 of the Liberia code of Laws Revised, known as: The Public Health Law of Liberia.
3. The President should restructure and ensure a more efficient Incident Management System (IMS) by appointing a non-political and professional Incident Manager who will be directly accountable to him.
4. Mobilize all human and institutional resources and structures used for the Ebola response; as well as allocating the financial resources required – create the fiscal space.
5. Ensure adequate risk communication and community engagement that focuses on the uniqueness of COVID-19, such as asymptomatic presentation, as well as vaccine hesitancy.
6. Liberian leaders should lead by example: implement public health measures/ practices, regarding testing, vaccinations, social distancing, mask wearing to boost public confidence and suffer consequences when they do not lead by example.
7. Ensure that health care and other frontline workers are paid well and on time, given appropriate incentives and provided personal protective gears to facilitate their work.
8. Commission experts to develop Liberia’s COVID-19 test kits and scientific research for vaccine production.
9. Forge public-private partnerships for a whole-of-country approach including leveraging private clinics and hospitals to scale up testing and care services across the country.
10. Partner with the United Nations System, bilateral as well as multilateral development banks (MDBs) and International Financing Institutions (IFIs), to leverage multilateral financing options for procurement (especially of vaccines, oxygen plants etc.), technical assistance and administrative advice, setting up field hospitals and mobile clinics.
11. Develop a testing plan that involves scaling up rapid testing at private clinics as well as developing a dynamic database for contact-tracing.
12. Establish alternate care sites (ACS) for management of COVID critical cases in all 15 counties, building on the Ebola experience.
13. Establish at least two additional sub-reference laboratories in the Northeastern and Southeastern part of the country to augment the functions of the National Reference Laboratory.
14. Population management – ensure a comprehensive review of population movement and put in place mechanisms to manage spreader occurrences, including an analysis of risks to students, teachers, marketeers, shoppers etc.
15. Focus on land border entry points and ensure testing, contact tracing and follow-up at those points and establish health desks, using rapid testing at all points of entry.

About the authors:

Sara Beysolow Nyanti is a Liberian who was a key figure in the Ebola Virus Disease outbreak response in Nigeria. She was Leader of the Management and Coordination team of the Incident Management System. She is currently leading an international response to COVID in a global hotspot of the Delta variant.

Tolbert Nyenswah is Liberia’s first Incident Manager for the Ebola Virus Disease outbreak in Liberia and led the Incident Management System in Liberia. He is one of the architects and founding member of the National Public Health Institute of Liberia.

Dr. Dougbeh Chris Nyan is an expert in infectious disease research. He is the inventor of the US-patented rapid multiplex pathogens diagnostic test (the Nyan-Test). Dr. Nyan testified before the US Congress on the Ebola epidemic in West Africa and served as member of the Data Safety Monitoring Board of the PREVAIL Ebola vaccine trials.

Dr. Mardia Stone played a critical role in Liberia’s National Ebola Response serving as Senior and Technical Advisor, to the Incident Manager and Liberia’s Deputy Minister of Health for Disease Surveillance and Epidemic Response. She later served as Advisor to the Director General, NPHIL.