The Covid-19 pandemic has ravaged every country and has exposed the fragility of most countries’ health care systems. With all the strict Covid-19 measures, ranging from lockdowns, hand washing, social distancing, and some emerging therapeutics, we are left only with one option of becoming highly dependent on vaccines, which seemed to be our only saviour to contain the disease. The social and economic impact of the pandemic has demonstrated the importance of strengthening some of the core functions of our health care systems which include – health finance, health governance, human resource for health, health information and availability of essential drugs and quality services. I still insist that we be considered so lucky that Sierra Leone has not been affected as severely by Covid-19 as other places like Europe.
Impact of Covid-19 on essential health services
The Ministry of Health and Sanitation (MOHS), including all stakeholders involved, have tried their best to manage the pandemic; however, if we had thousands of moderate to severe cases of Covid-19 infections, our weak health care system would not have been able to handle it. Notwithstanding this, the pandemic impacted essential health services. The most significant drops were observed in child immunizations between March-May 2020, by 17.9% in April and 13.9% in May, with continued effect in the following months at least till July 2020. Community outreach services, such as growth monitoring for children under five years of age, were reduced by 13.4% in March and 22.9% in April. Other essential maternal and child health services were severely affected: the percentage of pregnant women receiving their first antenatal care was dropped by 5.1% in April and by 12.7% in May; postnatal care was declined by 10.7% in April and by 7.5% in May, and skilled birth attendance was dropped by 13.1% in April and by 6.6% in May. Disruptions in vaccination, antenatal care, and postnatal care were highest in the Western Area Urban district, which has the highest Covid-19 burden. 1 As a result of these disruptions, it is expected that maternal and child mortality in Sierra Leone could increase by 33% and 30%, respectively. This would mean 270,500 children are left without Diphtheria, Pertussis, and Tetanus (DPT) vaccinations, 209,500 children without oral antibiotics for pneumonia, while 48,700 women would be left without access to facility-based delivery. 2
Less than 5 out of 54 countries in the African continent complied with the Abuja Declaration, which states that African countries should invest at least 15% of their annual budget to improve the health sector! It might not be surprising that Sierra Leone is not one of those countries. Low government expenditure on health exposes the poor or marginalised communities to extreme poverty, having to pay out of pocket for their health. This is the time, like no other, to prioritize health and to use our current investments wisely to build up a resilient health system to prevent future shocks.
Ministry of Health and Sanitation’s Covid-19 vaccine Deployment Plan
The Pharmacy Board of Sierra Leone (PBSL) is the regulatory body that ensures that drugs, therapeutics and vaccines that reach the country are safe. At these unprecedented times, PBSL had to fast-track the regulatory processes to ensure that the Covid-19 vaccines get to the population on time. PBSL is supposed to be an independent body to provide updates to the people about the safety of the vaccines and to do press releases in case there are any safety concerns regarding any drug, vaccine or therapeutics. During this time of the Covid-19 pandemic, PBSL wasn’t given the opportunity to do so. It had to go through the Ministry of Health and Sanitation (MOHS). I found this rather unfortunate and it appeared as if it had been stripped off of its independence as a regulatory body.
Before the roll-out of Covid-19 vaccines, the MOHS created and swiftly activated a Covid-19 Vaccine Technical Working Group (COVID-19 Vac TWG) to provide technical support, enabling efficient and prompt decision-making in all aspects of the Covid-19 vaccine deployment. The country’s adoption of a differential strategy for vaccine administration based on each target group’s peculiar characteristics was a good move to minimise disruption of essential health services. The expanded program on immunization (EPI) is the existing body that ensures that monitoring and supervisory structures are strengthened to support a seamless implementation of the Covid-19 vaccination programme. Capacity building for all human resources needed for the campaign has been done, including implementing a risk communication plan to keep community leaders and communities well informed.
Covid-19 situational report
As of 3rd April 2021, there were 3,987 confirmed Covid-19 cases and 79 documented deaths in Sierra Leone (Sierra Leone Situational Report No.3689). The total Covid-19 tests conducted so far is 141,420 (18.45/1,000), and the overall case fatality rate (CFR) is 2.0%. The CFR is disproportionately higher after 40 years of age, with the average age of Covid-19 death is 58 years, and Covid-19 cases above 60 years have the highest CFR. Healthcare workers account for 8.8% of confirmed Covid-19 cases in Sierra Leone, making it the single most affected profession in the country by the pandemic.
Covid-19 vaccination eligibility criteria and vaccine hesitancy
The Covid-19 vaccine eligibility criteria include priority groups like healthcare workers at any age above 18 years, females who are not pregnant, people who have not been infected with Covid-19 for the past 6 months, and people above 70 social workers and civil servants above 40 years.
Vaccine hesitancy could potentially undermine the public health benefit of Covid-19 vaccination. In 2019, the World Health Organisation (WHO) considered vaccine hesitancy a global health threat. Provision of consistent and scientifically accurate information can help mitigate vaccine hesitancy among populations, but vaccine confidence may not improve unless efforts are made to increase public trust in vaccine effectiveness and safety in public health response. Vaccine hesitancy is not something new and has been in existence since the 18th century. Apart from misinformation which led to vaccine hesitancy, vaccine disinformation has an impact as well, defined as intentionally spreading false information or conspiracy theories either for political, economic or social gain; remains the most significant challenge globally and in Sierra Leone. These types of information stereotypically thrive during these times of uncertainty via social media, lowering the likelihood of adopting public health measures like vaccination.
Vaccination sites and adverse effects following immunization (AEFI)
Despite the issues surrounding vaccine hesitancy, the turnout of Sierra Leoneans in Freetown is a bit encouraging, depending on the vaccination site. Few challenges include inadequate vaccination sites, which could potentially hinder people leaving far away from respective vaccination sites to show up for vaccination. Freetown has five vaccination sites (three static, one mobile) and each district has three vaccination sites (two static and one mobile). In the near future, vaccination is supposed to take place at each chiefdom.
To put Sierra Leoneans’ mind at ease, so far with the ongoing successful implementation of the Covid-19 vaccination campaign, the most common speculated AEFI associated with both AstraZeneca (AZ) vaccine and Sinopharm vaccine include normal vaccine reactions like injection site pain, fever, headache, diarrhoea, with generalised body pain and swelling around the eyes, more associated with the AZ vaccine. Pure analysis and causality assessment shall be done soon by the competent pharmacists of the PBSL, to ascertain whether reported AEFI, are related to each deployed vaccine and to be able to pinpoint which of the two vaccines are more associated with AEFI or serious AEFI.
Other countries reported blood clots associated with AZ vaccine, however, the WHO, the European Medicines Agency (EMA) and UK Medicines and Healthcare products Regulatory Agency (MHRA) consider the vaccine benefits outweigh the risk. Up to 20 million people worldwide have been vaccinated with the AZ vaccine and very few people presented with blood clots. European and UK reviews find no proven link with blood clots. Covid-19 infections are highly associated with blood clots, and people generally may have predisposing risk factors associated with blood clots and it coincides at the time of vaccination. Anaphylaxis (severe allergic reaction) is a very rare side effect that can occur with any vaccine. An independent expert review has concluded that there is no increased risk of anaphylaxis associated with the vaccine above the expected rate for any other vaccine.
Where are we with Covid-19 vaccines and the new variants?
As the Covid-19 virus continues to evolve, drug makers are in a continuous race to develop vaccines that will be effective against the new troublesome variants. So far, no vaccine has been proven to be effective against the South African (SA) variant, which is known to be more problematic. Studies have shown that the AZ vaccine was 86 times less effective against the SA strain and the mRNA (Pfizer/BioNTech and Moderna) vaccines being 6-to-8 fold less effective against this strain. The British Kent variant (B.1.1.7) is another variant of concern, and studies have shown that the mRNA vaccines, as well as the Novavax vaccine, remain highly effective against this strain. However, the mRNA vaccines are 4-to 7- fold less effective against the Brazil variant, though it provides some amount of protection against disease prevention, says Anthony Fauci, MD, Director of the US National Institute of Allergy and Infectious Diseases. Could it be that we already have all these variants in Sierra Leone? This calls for the importance of strengthening our health care system by developing a high-tech Research and Development Institute, which not only saves lives but also creates cost savings, drives economic growth and enhances global security.
We are now living in a world that is full of surprises with emerging, remerging infectious diseases and natural disasters, if we do not invest in health, the challenges that we are about to face will become catastrophic!
- Global Financing Facility and World Bank. 2020. Monitoring essential health services in times of COVID-19. Sierra Leone July update.
- Global Financing Facility. 2020. Preserve essential health services during the COVID-19 pandemic. Sierra Leone.