Liberia: Country Profile
Liberia is a coastal West African country with a population of 5 million people. In July 2016, Liberia conducted the International Health Regulations (IHR) self-assessment, followed by the voluntary Joint External Evaluation (JEE) core capacities, in September of the same year. The Government of Liberia also completed a JEE of the IHR core capacities and conducted a self-assessment using JEE 2.0 tool in 2019. JEE findings showed although there has been significant progress, gaps still exist in key core technical areas. Out of 48 indicators assessed, 11 (22.9%) were rated GREEN (demonstrated/sustainable Capacity); 26 (54.2%) YELLOW (limited/developed capacity); and 11 (22.9%) RED (no capacity). Liberia scored less than 5, with 5 being the highest for sustainable capacity, which most scores fell between limited to developed capacity. A comparison of core capacity for risk communication between 2016 and 2019 remarkably indicates a decrease in scores for R.5.1: risk communication systems, and R.5.5: addressing perceptions, risky behaviors, and misinformation. Addressing this, the National Action Plan for Health Security was developed (NAPHS), which the GHSA activity is supporting the One Health platform through a multi-sectoral approach to strengthen risk communication and community engagement activities at both the national and subnational levels.
Liberia has major borders with three countries, Sierra Leone, Guinea and Côte d’Ivoire, several recognized port of entries, as well as several other illegal entry points. Due to porous borders, and the risk of people living along the borderlines, including common languages widely spoken between both people, and understanding the cultural context along the borders, plus inter-marriages, and shared forest resources, there is an immediate threat and risk of a potential spillover once there is an outbreak of disease in neighboring countries. A case in point is the outbreak of Ebola, which first case was announced in neighboring Guinea, while announcement of anthrax too was first announced in Sierra Leone recently. These has led to surveillance and disease monitoring here in Liberia, by the One Health platform, with support from partners. This led to a One Health response, bringing on board all One Health stakeholders and partners.
Priority Zoonotic Diseases
Liberia has 12 immediately reportable epidemic-prone diseases. Conditions or events under animal health disease surveillance, but the national one health message guide is focused on 10 of the PZDs listed, which are: Lassa fever, rabies, bovine TB, anthrax, Rift Valley fever, highly pathogenic avian influenza (HPAI), brucellosis, Ebola virus disease, monkeypox, and Marburg virus disease.
Anthrax is a bacterial infection that typically affects animals and can pass from animals and animal products to humans, with limited human-to-human transmission. In endemic settings, anthrax affects primarily cattle, goats, sheeps and the spores can remain in soil for years. It can spread to humans through open wounds on the skin, ingestion, or inhaling the spores. Recent outbreaks in 2020 and 2022 in Liberia or neighboring countries has elevated the importance of this disease in Liberia.
Avian influenza is an infection by an influenza virus that can affect almost all species of birds, wild or domestic. It can be highly contagious, especially in chickens and turkeys, and can lead to extremely high mortality, especially in factory farms. The avian influenza virus sometimes infects other animal species, including pigs.
Bovine tuberculosis is caused by the bacterial species Mycobacterium bovis and causes bovine tuberculosis in farm animals (and tuberculosis in other wild animals). In 2016, according to WHO estimates, 147,000 new cases of zoonotic TB were reported in humans, including 12,500 deaths.
Brucellosis is a bacterial infection with a global incidence of about 500,000 cases per year worldwide and a prevalence of more than 10 cases per 100,000 population in some countries. Humans become infected through contact with sick animals, ingestion of fresh unpasteurized or unboiled milk, or fresh cheese. Brucellosis has a significant impact on the health and productivity of livestock, thus greatly reducing their economic value and work performance.
Ebola and Marburg: Ebola virus disease (EVD) is an infection caused by a virus of the filovirus family to which the Marburg virus also belongs. Humans are infected either by direct contact with infected bats (a rare event), or by handling infected animals found dead or sick in forests (a more frequent event). Human-to-human transmission is also possible and occurs through direct contact with the blood, secretions, organs or biological fluids of infected individuals. The 2014-2016 Ebola outbreak in West Africa hit Liberia hard, and the country was declared Ebola-free in mid 2016.
Lassa fever: Lassa fever is a serious disease transmitted injection or inhalation of secretions (urine, feces, blood) of infected mice and rats (“multimammate” or Mastomys type). it is manifested by fever, muscle pain, generalized weakness, diarrhea, and bleeding from orifices. Lassa fever is endemic in Liberia.
Monkeypox is a viral disease that primarily affects animals such as rodents or non-human primates but can be transmitted to humans. The disease is transmitted through respiratory droplets, close contact with lesions or bodily fluids, or contaminated materials and causes a variety of symptoms including fever and rash. In the same family as smallpox, smallpox vaccines offer some protection against monkeypox. Monkeypox was first detected in Liberia in 2018, and an outbreak was recently declared in 2022 after an imported case was detected.
Rabies remains a widespread disease worldwide, responsible for tens of thousands of deaths each year. It is most often transmitted by dogs. Despite the existence of an effective post-exposure prophylaxis, it remains a concern.
Rift Valley Fever (RVF) is a viral infection that spreads most commonly to humans from livestock or wild animals via mosquitoes. It can also be spread through direct contact with blood or bodily fluids of animals such as sheep, goats, or camels. RVF can cause spontaneous abortion in animals, and assisting with abortions is a common exposure. Farmers, abattoir workers, and veterinary or laboratory staff are high risk groups. Mosquito control and wearing protective equipment when exposed to blood or bodily fluids of infected animals are the main prevention methods.
Visit the website of the National Public Health Institute of Liberia – NPHIL for more information on diseases in Liberia.
One Health Landscape
The One Health platform is an interdisciplinary, collaborative approach to attaining optimal health outcomes for people, animals, plants, and their shared environment. By working together, public health, veterinary medicine, and environmental science experts can better detect, prevent, and respond to disease events before they “spill over” to human populations and the environment. According to the One Health Governance Manual, the unprecedented Ebola Virus Disease (EVD) outbreak and now COVID-19 pandemic continues to remind us of the urgency to establish adequate capacities for preparedness, detection and response to public threats and events in line with the International Health Regulations (IHR 2005) requirements. These events – the document says – pose a great challenge to public health globally due to the attributable infectivity, morbidity, and mortality. It has further presented challenges in case management and Infection Prevention and Control (IPC), especially among health and veterinary care workers. Strengthening national health security and having a strong health system will protect lives and increase resilience of the Liberian population to threats of epidemics and disasters. WHO International Health Regulations Monitoring Evaluation Framework (IHRMEF) and the World Health for Animal Health (OIE) Performance of Veterinary Services (PVS), Pathway approaches have provided the ability for countries to determine strengths and weaknesses in their respective functions and activities, and promote prioritization and pathways for improvement. These efforts remain instrumental to the establishment of One Health approach in Liberia, with the intent of attaining relevant SDGs, improve global health security, and comply with the International Health Regulations. Given the importance, Liberia in 2017, established the National One Health Coordination Platform (N-OHCP), and in 2019, the County One Health Coordination Platform (C-OHCP) was also established. Its mission is to effectively coordinate “One Health” approach across the country ensuring multi-sector participation, resource mobilization, accountability and transparency with acceptable values. After its launch in 2017, the one health platform only existed on paper, and the 2019 JEE results exposed the poor coordination and collaboration between the One Health stakeholders. Hence, Breakthrough ACTION Liberia joined by other partners began leading interventions that strengthen collaboration and coordination amongst One Health RCCE stakeholders from ministries of health, agriculture, and the Environmental protection agency, including the national public health institute of Liberia at both the national and subnational levels. Thereafter, Breakthrough ACTION moved to mobilize all One Health RCCE partners such as FAO, REDISSE, IRC, Partners in Health, UNICEF, WHO, AIFO, AFROHUN-STOP Spillover and others, to formally join the One Health RCCE network and actively participate in all activities led by the RCCE TWG. The one health platform website (liberiaonehealth.org) is not active but is being worked on and may be active by the end of September 2022. However, most of the One Health documents are linked to the website of National Public Health Institute of Liberia’s (NPHIL). Previously there were COVID response pillar, and an Ebola response pillar (all standalone disease specific response pillars) involving the same group of partners. This created a lack of synergy and collaboration among partners, which confused messaging and response to the public. The need for a consolidated approach bringing together all partners to support various interventions directed through the One Health platform increased collaboration and reduced duplication of support to activities by partners. It also improved coordination among government stakeholders, as a means of ensuring everyone was at the same table discussing issues of relevance to the prevention and control of PZD from all fronts involving humans, animals and their shared environment.
At the end of the JEE and NAPHS midterm review meetings, risk communication score dropped due to lack of sectoral One Health approach. Recommendations highlighted the need for a sectoral risk communication system, to include animal health and the environment, headed by technicians from line ministries and agencies of the Liberian government. Immediately after the review, findings and recommendations brought forward included establishing a technical working group (TWG), couple with an updated term of reference to suit the situation. Initially, a justification called for the introduction of a TWG on Risk Communication and Community Engagement inclusive of key stakeholders, relevant to strengthening the platform on the environment, human health and animal health. This brought about the revision of the One Health governance manual. The One Health governance manual is a tool for government to comprehensively address the threats to public health security in Liberia, across the human, animal and environmental interfaces, and setting the pace for technical enabling environment, developed through a consultative and multi-sectoral engagement after the conduct of the Joint Risk Assessment (JRA), March 2021. Considering the review of the national systems to prioritized zoonotic diseases, inter-ministerial linkages and infrastructures, and existing national mechanisms for integrated collaboration, and agreement on terms of reference (ToR), for JRA led to steering committees.
In November 2023, the Liberia One Health platform launched its official website during the official celebration of World One Health Day.
Summary of existing Breakthrough ACTION research
In 2021, Breakthrough ACTION Liberia conducted a baseline survey on Lassa fever, rabies, and bovine TB to assess relevant indicators and inform the social behavior change strategy across several health areas and audiences. The objectives of the survey are to: 1) Identify key determinants of health behaviors in the areas of maternal health, maternal and child nutrition, malaria, COVID-19, 2) Set benchmarks for impact assessment of the integrated SBC Breakthrough ACTION Liberia program, 3) assess the roles of gender-equitable norms, social norms, couple communication, and decision-making in the adoption of health behaviors, 4) inform an SBC strategy across several health areas and audiences, and 5) establish baseline measures to assess the effects of project activities. A total of 2,433 households were sampled across three counties. The survey was conducted by BA Liberia through a research firm, and it was conducted between September and October 2021.
Participants were administered a series of questions about COVID-19 and several GHSA-related diseases (i.e., Lassa fever, rabies, and bovine TB) and their transmission. Among women, no differences in knowledge of Lassa fever were identified across the study sites; however, a higher percentage of men in the intervention counties (Bong & Bomi- 58%) correctly identified the source of Lassa fever than men living in Gbarpolu (41%). Correct identification of Lassa fever was the lowest among women in Bomi (15%), suggesting that they may be a priority group for intervention activities. With respect to rabies, men (51%) identified the correct source of rabies at the intervention sites (Bong and Bomi) more often than women (35%). Women in the intervention groups (35%) incorrectly stated the source of rabies more often than those in the control group (Gbarpolu, 50%). However, much of this general difference was influenced by the low identification rates in Bong. Among men, no difference was found between intervention and control counties. For bovine TB, the correct identification of bovine TB was low across all study sites. An interesting observation tied to this question in the study revealed that respondents tended to compare bovine TB with other, more common forms of TB (primarily pulmonary). For example, many respondents cited smoking (a pulmonary irritant) as a source of bovine TB. This finding highlights the importance of differentiating bovine TB from other forms of TB during future GHSA health communication interventions.
Find out more in the full baseline report.
Case study on SBC response
A photograph from the One Health RCCE TWG meeting held in Zwedru, to discuss issues associated with animals’ uncontrolled movement throughout the city.
Grand Gedeh County risk communication and community engagement technical working group (RCCE – TWG) has taken action to remove animals from the city, preventing spillover of priority zoonotic diseases caused by uncontrolled animal movement in the city, to humans and their shared environment.
After the review of the One health governance manual to include RCCE TWG, and holding the training of trainers’ workshop capturing RCCE, SBC, rumor management, and the One Health concept, in December 2021, Grand Gedeh was among the counties that rollout training and established RCCE TWG, in 2022. Approaches, strategies, and programming will continue to shift in light of the baseline research described above.
They have also made significant achievements to take steps and remove the free movement of animals from walking around the city. During its inaugural meeting with key RCCE stakeholders from line ministries and agencies the need to relocate animals from the city was raised by focal persons of the Environmental Protection Agency (EPA), Ministry of Agriculture (MoA), and the Ministry of Health (MoH) focal persons.
Grand Gedeh County located in the southeast of Liberia, is among 15 political subdivisions, bordering other counties including Nimba, River Gee, Sinoe, and the neighboring Ivory Coast.
The people of Grand Gedeh, Krahn, are known to be warriors, depending on the hunting of wide animals for livelihood.
The issue of larger parts of the city being left to uncontrolled animal movements, especially cattle living among the people, has been a longtime problem in Zwedru City, with animal feces spread across.
Based on consistent coordination meetings, and collaboration among One Health RCCE stakeholders, amplifying priority zoonotic diseases spillover caused Primarily by animals affecting humans, leading to an outbreak among the population, a decision was reached to remove from the city all animals, including cows, goats, sheep, pigs, etc…
The Environmental Protection Agency (EPA), Ministry of Agriculture, and health promotion focal persons then agreed that the issue has been a long-standing problem for many years without a solution, due to a lack of consolidated and collaborative effort.
Also, a team comprised of EPA, MoA, and EHT was set up to provide the public with radio awareness using talk shows on the potential risk of having animals uncontrolled throughout the city, which could transmit diseases associated with animals in the population.
The talk shows highlighted the spillover of priority zoonotic diseases (PZDs) from infected animals to humans especially when animals are living in proximity to the population.
The RCCE TWG also engaged relevant authorities on the issue, including the county superintendent, county inspector, joint security, and cattle owners.
The RCCE TWG also rallied the local city government to promote regular cleaning of the city and encouraged the distribution of waste bins to marketers.
However, Zwedru City Cooperation, through the RCCE TWG reached out to partners for the provision of waste bins, and Welthungerhilfe agreed to support the city’s cooperation with waste bins.
This is the first time that the One Health RCCE TWG has come together to engage partners to collaborate and solve problems, from the One Health perspective in the county, with key sectors like health, agriculture, and the environmental stakeholders being included, along with the joint security and Ministry of Internal Affairs.