1. Liberia Field Epidemiology Training Programme (LFETP)Liberia Field Epidemiology Training Programme LFETP) FIELD WORK 2 -Expanded Surveillance Report- -Case Investigation Report- Moses B. Fomba County Surveillance Officer Bomi County

2. Liberia Field Epidemiology Training Programme (LFETP) 2 Expanded Surveillance Report

3. Liberia Field Epidemiology Training Programme (LFETP) Bomi County is located in western Liberia Population: 97, 291 residents Has four health districts – Senjeh, – Klay, – Dewoin – Suehn Mecca Health facilities: 23 (one referral hospital) Introduction 3

4. Liberia Field Epidemiology Training Programme (LFETP) Communication Flow Community Health Facility District Surveillance Office NATIONAL SURVEILLANCE OFFICE County Surveillance Office 4

5. Liberia Field Epidemiology Training Programme (LFETP) Disease Summary 1/2 5 Summary of reported key notifiable diseases, Bomi County, 2015 C = Cases; D = Deaths; CFR = Case Fatality Rate Diseases week 31-42YTD Cumulative CDCFRCD Acute Flaccid Paralysis 000200 Acute Watery diarrhea 23008100 Cholera 000000 Diarrhea with blood (Shigella) 000000 Lassa Fever 000000 Measles 6117%1716% Meningitis 000000 Yellow Fever 000100 Human Rabies (susp) 000000 Guinea Worms 000000 Suspected VHF (incl. Ebola) 3713810%81317822% Neonatal Death Neonatal 2 2 Maternal Death 3 6

6. Liberia Field Epidemiology Training Programme (LFETP) Disease Summary 2/2 Week 31-42 had 405 suspected cases with 44 deaths – All suspected EVD cases were negative and reclassified as non-cases – Zero reporting requirement was met by all reporting districts. – Measles cases were investigated and control measures implemented. 6

7. Liberia Field Epidemiology Training Programme (LFETP) Timeliness and completeness of reporting by district, Bomi County-Liberia, 2015. Legend District BEFORE FETP (Week 19 – 30)DURING FETP (Week 31-42) % Timeliness% Completeness% Timeliness% Completeness Senjeh 58%100% Klay 50%91% 97% Dewoin 50%91% 95% Suehn/Mecca 50%91%75%92% Timeliness and completeness of reporting has increased during the FETP % Cumulative >=80% on time/Complete>=50-79.9% on time/Complete<50% on time/Complete 7

8. Liberia Field Epidemiology Training Programme (LFETP) Trend of suspected Measles cases and death, Bomi County-Liberia, Epi WK31-42, 2015 8

9. Liberia Field Epidemiology Training Programme (LFETP) Trend of AWD cases, Bomi County-Liberia, 2015 9

10. Liberia Field Epidemiology Training Programme (LFETP) Maternal case investigation in Dewoin and Senjeh Districts Roll out of IDSR training for health workers in the county Roll out of SQS training for health worker in the county Review meeting for re-establishment of HERC in the county Performance feedback to districts and health facilities Activities carried out between week 31-42 10

11. Liberia Field Epidemiology Training Programme (LFETP) Challenges Lack of network coverage at some facilities High Staff attrition Bad road condition 11

12. Liberia Field Epidemiology Training Programme (LFETP) 12 Case Investigation Report Maternal Death

13. Liberia Field Epidemiology Training Programme (LFETP) Introduction Globally, approximately 800 women die daily from preventable causes related to pregnancy and childbirth Maternal death is one of the leading causes Maternal death: –Death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and the site of pregnancy, from any cause related to or aggravated by the pregnancy or its management but not from accidental or incidental causes 13 Ref: Maternal death, WHO Fact sheet N°348, May, 2014

14. Liberia Field Epidemiology Training Programme (LFETP) Introduction In 2008,millennium Development goal aimed to reduce maternal mortality rate by 75% in 2015. Maternal death is one of the immediately reportable diseases in Liberia due to increased reported cases A case of maternal death of a 43 year old from Dagweh’s Town occurred in Liberia government hospital on October 09, 2015 14 Ref: Maternal death, WHO Fact sheet N°348, May, 2014

15. Liberia Field Epidemiology Training Programme (LFETP) Introduction Investigation conducted on October 10, 2015 – County Surveillance Officer (CSO), – District Health Officer (DHO) – County diagnostic officer (CDO) Objectives: – Assess the cause of death – institute public health action based on findings. 15

16. Liberia Field Epidemiology Training Programme (LFETP) Methods Review of medical records Interviewed family members, medical staff and referral hospital staff ( Trained traditional midwife(TTM) inclusive ) Assess the health delivery system in the facilities. Recommendation public health actions based on findings 16

17. Liberia Field Epidemiology Training Programme (LFETP) Results 1/2 17 Home -Complained of stomach ache - Midwife: Impressed false labour. - Patient allowed to go home. 1 st visit to clinic LGH 2 nd visit to clinic Death 45 mins walk -Home delivery assisted by TTM -Excessive bleeding with retained placenta 8:30 am Sent to clinic 4: 45 pm -Examined by midwife and referred to LGH -No response by ambulance. -Private vehicle utilized No resuscitation Certified midwife and the nurses couldn’t access the IV line because all veins had collapsed 55 mins Delay 5: 45 pm -Patient expired 1 hour Series of events:

18. Liberia Field Epidemiology Training Programme (LFETP) Results 2/2 Patient was a high risk G12 P11: Poor assessment done by certified Midwife (CM) No response from ambulance due to fuel shortage Delay in transporting patient with no professional escort No resuscitation: certified midwife and nurses couldn’t access the IV line because all veins had collapsed. 18

19. Liberia Field Epidemiology Training Programme (LFETP) Discussion Probable causes of death: Hypovolemic Shock and Postpartum hemorrhage Contributing factors: – negligence of certified midwife – lack of skills and required resources to manage such complications at home by a TTM. – negligence of ambulance team in responding to the call – delay in transporting patient to referral hospital 19

20. Liberia Field Epidemiology Training Programme (LFETP) Recommendations That moderate to severe high risk pregnant women visiting the health facility should stay around the facilities toward their delivery period. Refresher training for health workers on management of high risk pregnancies. Need for clear guideline on ambulance deployment and assess to logistics. That MOH through the government of Liberia should build maternal waiting homes at facilities more than 10 to 20 km from county referral hospitals. 20

21. Liberia Field Epidemiology Training Programme (LFETP) Public Health Action Following our recommendation, residents of the community decided to build maternal waiting homes at every health facility in the districts with local materials to prevent home delivery 21

22. Liberia Field Epidemiology Training Programme (LFETP) Acknowledgement Field Epidemiology Training Programme, Liberia Ministry of Health, Liberia Emory University AFENET Centers for Disease Control and Prevention World Health Organization My Mentors – Stephen and Joseph 22