Sierra Leone: Country Profile
Sierra Leone is a coastal West African country of around 7.5 million people based on the 2021 mid-term census. As a result of the country’s Ebola outbreak in 2014-2015, Sierra Leone approved the One Health concept in order to prepare for and control outbreaks of zoonotic diseases. The first One Health Zoonotic Disease Prioritization Workshop conducted in 2017 identified rabies, avian influenza, salmonellosis, anthrax, plague, and viral hemorrhagic fevers such as Ebola and Lassa Fever as endemic and emerging zoonotic diseases of significant concern in Sierra Leone.
Sierra Leone Map
Priority Zoonotic Diseases
Ebola: Ebola virus disease (EVD) is an infection caused by a virus of the filovirus family. Humans are infected either by direct contact with infected bats (a rare event), or by handling, including preparing and eating, 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. Sierra Leone experienced a significant outbreak of EVD that passed over the border from Guinea in 2014 and ultimately claimed almost 4,000 lives.
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.
Rabies remains a widespread disease across the globe, responsible for tens of thousands of deaths worldwide each year. It is a viral infection transmitted by contact with saliva of infected mammals, mainly through bites and scratches and in most places, commonly through dogs. Children are particularly vulnerable to rabies. Rabies is endemic in Sierra Leone; however, poor reporting and surveillance have resulted in gross underestimations of cases and mortality.
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.
Salmonellosis is an infection caused by the bacteria salmonella which typically spreads through contaminated food or contact with infected animals such as poultry, swine, cattle, rodents, or reptiles. Salmonellosis causes diarrhea, fever, and vomiting and is typically more severe in children or the elderly.
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, and sheep, 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. An outbreak in mid-2022 involved six confirmed or probable cases in humans and over 300 cases in animals.
One Health Landscape
Summary of selected existing research
In 2018, the Breakthrough ACTION Sierra Leone team conducted a literature review of zoonotic diseases in West Africa summarizing the available published literature on behavioral determinants and sociocultural systems and norms that influence specific priority zoonotic diseases. The search involved any articles that: (1) had a focus on any of anthrax, avian influenza, Brucella, Mycobacterium, plague, rabies, Salmonella, and viral hemorrhagic fever; (2) involved research in West Africa; (3) were published between 2008–2018; and (4) described individual, cultural, or social risk or prevention factors related to one of the zoonotic diseases. The literature search uncovered a total of 103 articles that met the inclusion criteria. Overall, excluding Ebola virus disease, avian influenza, and to some extent brucellosis, there were few publications on behavioral and community-level determinants of risk for the majority of priority zoonotic diseases included in the literature review. The majority of factors associated with risk were closely related to a lack of awareness and knowledge of zoonosis, strong cultural beliefs around food and burials, and poor hygiene and biosecurity measures. Common structural barriers identified that affect risk mitigation and prevention efforts included costs associated with vaccinations, quarantining, and biosecurity measures, as well as a lack of vaccines, and poor regulation of the farming and meat processing industry. With respect to Sierra Leone specifically, there was an abundance of information on behaviors, perceptions, and attitudes related to Ebola virus disease. However, there was very little information in the published literature about community-level perceptions and practices, and the sociocultural norms that influence transmission of many of the other priority zoonotic diseases. No published literature was found on the sociocultural norms, behaviors, and individual- or community-level perceptions related to the viral hemorrhagic fevers—yellow fever, dengue fever and Rift Valley fever, avian influenza, salmonellosis, anthrax, or plague in the Sierra Leone context.
Read more in the literature review.
To fill in gaps in the literature review on PZDs in Sierra Leone and to inform specific program interventions the Breakthrough ACTION Sierra Leone team conducted several research studies. The team used qualitative methods to collect baseline information on knowledge, perceptions, and behaviors related to zoonosis and rabies. The team conducted fifteen FGDs with 133 individuals. FGD groups for community members were stratified by gender and age, with three age categories for community members (children 10-17 years, young adults 18-29 years, and adults 30 years and older). Results showed that animal exposure was widespread, either through ownership or proximity. Participants described benefits of owning animals such as security, help with hunting, generating income, or providing food. There also were concerns about animal cruelty and unconfined or neglected animals. Awareness of rabies varied, but generally people had little knowledge about the causes or modes of transmission for rabies. As part of this baseline report and then at endline, the team collected two waves of survey data in June 2018 and July 2021 to monitor program outcome indicators that were related to individual- and community-level knowledge and behaviors for rabies. Specifically, the indicators included awareness and general knowledge of rabies, risk perception and risky interactions with animals, prevention of rabies in animals and humans, appropriate response to high-risk interactions with animals, appropriate reporting channels, and exposure to Breakthrough ACTION program activities. Outcomes monitoring data were collected using a rapid assessment survey among community members, with each wave including 1312 adult participants. The overall aim of the outcomes monitoring activity was to collect information about knowledge and behaviors from the target population to monitor the status of program indicators, inform campaign effectiveness, and at endline, assess campaign impact. The endline followed about six months of implementation of a campaign on living safely with animals, called Healthy Animals, Healthy People.
Read the baseline report and endline report which summarizes results of outcomes monitoring at baseline and endline, and in relation to exposure to the dog bites and rabies prevention campaign.
The team also developed several research briefs:
In 2021, in response to a case of Ebola in neighboring Guinea and reported concerns among survivors of EVD in Sierra Leone, Breakthrough ACTION-Sierra Leone collected data exploring the experiences and needs of EVD survivors in Kenema and Bombali districts, looking specifically at psychosocial needs, concerns around stigma, and relationship with others. The research team conducted 24 discussion groups, with 169 total across the two districts. Participants were all EVD survivors. They described concerns around their physical and mental health as well as interpersonal relationships as a result of having had EVD. They experienced lingering health concerns including deteriorating eyesight, muscle and joint pain, headaches, memory loss, and reproductive health issues. Anxiety and traumatic memories were common among participants with few coping skills. Community relationships varied, with some experiencing stigma or isolation, while others felt a sense of belonging. Participants also described negative experiences in health care settings and a lack of ongoing support either through free healthcare or economic or psychosocial support through government or other external channels. Knowledge and concern about the possibility of reinfection varied.
Read the formative research report on Adaptation, Experiences, and Support Needs of Survivors of Ebola Virus Disease in Bombali and Kenema Districts of Sierra Leone.
In July 2021, Breakthrough ACTION conducted a qualitative study to explore the context of Lassa fever in Tonkolili and Kenema districts of Sierra Leone, including norms and behaviors related to Lassa fever, experiences with rats, knowledge of the disease and its symptoms, and care-seeking behaviors. Adult community members (n=30) and health workers (n=15, all who had provided care in Kenema General Hospital’s Lassa ward) participated. The study found that exposure to rats was common in communities and rats were generally perceived to be destructive, though sometimes part of individuals’ diet when other food was scarce. Some participants were resistant to linking occurrence and experiences with Lassa fever to the practice of eating rats. Concern about Lassa fever was high among those who were aware and had some exposure to the disease; knowledge of the symptoms, causes, and mode of transmission varied among community members. Lack of knowledge about the signs and symptoms as well as an unwillingness to link a potential disease to rat exposure usually delayed care-seeking for symptoms of, and diagnosis of, Lassa fever. Participants were able to name some prevention methods such as keeping food covered, hand hygiene, and cleaning areas where food is stored or consumed.
Read the report on Environmental and Behavioral Determinants of Lassa Fever.
In 2021, the national AMR Structured Operational Research and Training Initiative (SORT IT) Program conducted research on AMR. These Plain Summaries of AMR Operational Research are available to understand more about antimicrobial management behaviors and outcomes in Sierra Leone.
- Clean hands, safe hospitals a call for action to improve hand hygiene practices in tertiary hospitals in Sierra Leone
- A Wake-Up Call to Improve Country-Wide Reporting of Adverse Drug
- Increased pesticides importation and use in Sierra Leone leads to a possible increase in antimicrobial resistance
- Inappropriate use of antibiotics in the management of COVID-19 patients in Sierra Leone
- Gaps on hand hygiene implementation in 13 public hospitals in Sierra Leone
- Infection Prevention and Control in 3 Tertiary Health Care Facilities in Freetown, Sierra Leone during the COVID-19 pandemic. More Needs to Be Done!
- High levels of resistance against critically important antibiotics from fresh poultry excreta in Sierra Leone
- Overuse of post-operative antibiotics at the Bo regional hospital in Sierra Leone a call for systematic monitoring and training to reduce the risk of antimicrobial
- Low Culture Requests and High Multi-Drug Resistance
- Significant gaps in infection prevention and control at points of entry in Sierra Leone, 2021 a wake-up call
- Critical levels of contamination in wells and standpipes at household water points in Freetown – A call to Action
- Livestock disease surveillance in Sierra Leone Significant improvement but gaps remain in data quality and use of antimicrobials
- Infection Prevention and Control in Sierra Leone Need for a Quantum Leap Forwards
Case study on SBC response
The Johns Hopkins Center for Communication Programs, through the USAID-funded Breakthrough ACTION program, worked with the Sierra Leone One Health sectors including Ministry of Health and Sanitation in Sierra Leone, Ministry of Agriculture, Environment Protection Agency, and other partners to develop and implement a high-quality communication campaign for dog bites and rabies prevention under the broader concept of Healthy Animals, Healthy People which promotes healthy behaviors for living safely with animals. The main objectives of the campaign were to increase awareness about the dangers of dog bites and rabies, how to prevent dog bites, and what to do if bitten, and to strengthen reporting channels within and between sectors for improved surveillance and response to dog bites. The baseline research on rabies that was conducted in 2018 was used to design this Dog Bites and Rabies Prevention Campaign in Bombali district. Community engagement and information dissemination via mass media activities were the fulcrum of the dog bites and rabies prevention campaign implemented in partnership with government and other local partners. Community engagement approaches, reinforced through a national- and community-level media campaign that included print and radio products were designed to promote community ownership of health outcomes and access to information about risks and prevention of dog bites and rabies.
