Out-of-school lessons learnt

    To date, immunisation against human papillomavirus (HPV), which helps prevent cervical cancer, has largely been conducted through school-based campaigns. But what about those who do not go to school? How do we reach communities where there is low school attendance? A new, more community- orientated approach being tested in Bong County, Liberia, may provide the answer to these questions.

    Ten-year-old Princess Ko waits patiently with the other girls until her name is called. As her parents watch on, she enters the small open hut that serves as a community health centre to receive her first shot of human papillomavirus (HPV) vaccine. There is a sense of anticipation in the air, yet as she feels the scratch of the needle in her upper arm she neither winces nor grimaces. Instead Princess looks down at the small pinprick and smiles with pride, and perhaps just a hint of relief. Having lived through the West African Ebola epidemic and the measles outbreaks that followed, she and her parents understand the importance of vaccination and how fortunate she is to be among the first in Liberia to receive this potentially life-saving vaccine.

    Princess is even more fortunate than she realises. This HPV demonstration project taking place in Bong County, just 200 km outside the capital, Monrovia, is part of a joint roll-out – with rotavirus vaccine. It is also one of the first HPV vaccination sessions that draws on lessons learnt from earlier introductions and targets girls both in and out of school.

    Since Gavi started supporting HPV vaccines, demand has been extremely high. While countries recognise the importance of HPV vaccination for reducing cervical cancer rates, the target population – girls aged between 9 and 13 years – is not easily reached through immunisation programmes more suited to vaccinating infants. The 21 countries that have already introduced the vaccine with Gavi support, including 6 in 2015, do so largely through school-based campaigns. While this approach has successfully reached many girls, it leaves open the question of how to access those who do not attend school.

    Princess is one of eight girls attending the vaccination session in Bong who do not go to school. That’s because the nearest school is a five-mile walk away, along a busy highway – a journey that most parents consider too dangerous for their child to make each day.

    In order to reach girls like Princess and her friends with HPV, Liberia is raising local awareness of cervical cancer prevention through face-to-face meetings with community leaders. This helps ensure high turnout for HPV vaccination sessions in community health centres, such as the one in Bong.

    Other countries are watching Liberia’s new approach to HPV roll-out with interest. Since most countries have only introduced HPV vaccines in districts with high levels of school attendance, we have very little evidence for what works when this is not the case. However, it is anticipated that when combined with school-based HPV vaccination sessions, social mobilisation projects like the Bong example will help to increase national coverage rates and reduce health inequity by reaching some of the more marginalised members of society. The Liberia experience will also help to inform efforts to use HPV vaccination as a platform for rolling out broader adolescent health and education interventions, such as nutrition, deworming, body literacy and menstrual hygiene.

    Finding ways to reach girls like Princess is vital if we want to stop the rise in cervical cancer deaths. Currently around 266,000 women die from this form of cancer every year, equating to roughly one every two minutes. The figure may already exceed the annual number of maternal deaths and, without intervention, is expected to reach nearly 416,000 by 2035.

    For Princess however the good news is that there is talk of building a school in her village, which means she won’t miss out on an education. As for the HPV vaccine, Princess beams as she holds up her vaccination card. She’s got that covered.

    Making numbers count

    At Kathmandu’s Patan hospital, Gavi is funding impact studies on two vaccines that protect children against the main causes of deadly pneumonia: Haemophilus influenzae type b (Hib) and pneumococcal disease. Three doctors who are leading these studies identify four ways in which Patan’s pioneering research is shaping Nepal’s immunisation policy.

    “Some countries are unaware of the burden of Hib and pneumococcal disease in young children,” says Dr Andrew J Pollard, Professor of Paediatric Infection and Immunity, University of Oxford, which partners with Gavi to support Patan’s vaccine impact studies. “Generating data which shows there is a burden, is essential to provide the key evidence governments need to drive the introduction of immunisation programmes that prevent the causes of pneumonia in young children.”


    When Nepal introduced pneumococcal vaccine in 2015, it became the first Gavi-supported country to use a 2+1 vaccination schedule – two primary doses plus a booster dose – as opposed to the more standard 3+0 schedule – three primary doses – that is administered in most countries. The decision was based on data generated at Patan hospital showing that immunity in the second year of a child’s life was better with a 2+1 schedule than with a 3+0.

    “Our study definitely helped the government make the final decision to use a 2+1 schedule for pneumococcal vaccination,” says Professor Shrijana Shrestha, Dean of the Academy of Health Science at Patan hospital. “Our experience could be very useful to our neighbouring countries as well.”


    Patan’s Chief Paediatrican, Dr Imran Ansari, estimates that prior to the addition of Haemophilus influenzae type b (Hib) vaccine into Nepal’s routine immunisation schedule, over a quarter of the 1,500–2,000 children admitted to his ward each year had pneumonia. “Even though the impact studies have not been published yet, it is my general impression that after the introduction of the Hib vaccine, the incidence of pneumonia has gone down,” says Dr Ansari.


    In addition to studying the effectiveness of the pneumococcal vaccine in reducing disease, Patan’s study is also assessing the long-term economic impact of preventing pneumonia, both for families and the government. “We’re looking at health economics,” says Dr Pollard, “By preventing disease, how have we changed the health of the population? What impact does that have economically, both for families who may no longer have to look after a sick child, and for the healthcare system?”


    Nearly one fifth of the world’s underimmunised children live in India. In 2015, with support from Gavi, the Indian Government launched Mission Rainbow – a nationwide drive to reach millions of “hidden” children living in urban slums and other hard-to-reach areas with life-saving vaccines.

    From an 11th floor window of an apartment block, the view of Agra’s city skyline is mesmerising. In the distant haze, beyond the rooftops that shimmer in the Indian heat, it is possible to make out the familiar ivory white dome and four minarets of the Taj Mahal. Such views are normally the preserve of India’s burgeoning middle-class who are wealthy enough to afford such apartments. Today, however, the only people enjoying this view are the migrant construction workers still working on the complex and who, ironically, have no homes of their own.

    The workers live in a slum at the foot of the tower block – temporary shacks that serve as home for hundreds of labourers and their families, at least until the building work is complete. Then, they will pack up and move on to wherever they can find work. Common throughout India, such settlements have become a focus for Mission Indradhanush – Mission Rainbow – a nationwide drive to improve access to childhood immunisation. Launched in 2015, this bold political initiative aims to ensure that all children under the age of two and pregnant women are fully immunised with the seven vaccines covered by India’s Universal Immunization Programme.

    Currently India is home to nearly one fifth of the world’s undervaccinated children. That translates into 3.2 million children who are not receiving a full course of even the most basic vaccines (three doses of the diphtheria- tetanus-pertussis vaccine). By concentrating efforts on its worst performing districts, the Government of India together with WHO, UNICEF and Gavi, hopes to turn things around; its target is to reach 90% of all infants within five years.

    Migrant populations, such as the one in Agra, represent some of the hardest to reach communities. With no permanent settlement, they often live “off-the-grid” hidden yet in full view of local administrators. Even if on the odd occasion they do come into contact with health services, continuity of provision is next to impossible to achieve, as they drift from one district to the next.

    For Mission Indradhanush to succeed, an essential first step is to generate demand for immunisation among migrant communities. This requires a dual track approach. Learning from its highly successful polio elimination programme, the Government of India has already mapped 256,000 migrant sites. Alongside other “high-risk” areas currently not being reached, these communities are being integrated into microplans for routine immunisation. At the same time, the Government is working with these “invisible” communities to raise awareness about the benefits of vaccines and overcome misconceptions about safety.

    The coming years will be critical, in part because of the ambitious targets India has set for itself. Not only does the Government plan to add a number of new vaccines to its Universal Immunization Programme, including rotavirus, rubella, pneumococcal and human papillomavirus (HPV) vaccines, but it hopes to transition out of Gavi support. India’s immunisation programmes are scheduled to become fully self-financing by 2021.

    To help with the process, in December the Gavi Board approved a new strategic partnership with India. This focuses on new vaccine support, health system strengthening and collaboration on vaccines supply and procurement. The new strategic partnership will build on the support that Gavi has already provided through the national scale-up of the pentavalent vaccine. Uttar Pradesh’s introduction of the five-in-one vaccine in December meant all Indian states have now introduced the vaccine.

    The rapid roll-out of pentavalent vaccine has added momentum to the Indian Government’s efforts to achieve more equitable and sustainable immunisation coverage. The view for Indian migrant workers in Agra and across the country is looking decidedly brighter and healthier.

    Connecting the dots

    Technology’s potential to collect immunisation- related data has never been greater. However, it’s not information alone that matters but how you use it – as Pakistan is fast learning.

    It would be easy to attribute Punjab Province’s dramatic increase in basic vaccine coverage in 2015 to modern technology. But while using smartphones to collect immunisation data undoubtedly played a critical role, the real reason behind this success story is the ability to use these data to build up a detailed picture of immunisation services – to connect the dots.

    Between October 2014 and April 2015, the 3,750 vaccinators working across the province were provided with a smartphone, known as an E-vacc. These devices are equipped with an app, which allows vaccinators to register at rural checkpoints. It now also collects more granular detail through electronic immunisation cards, which log details of the vaccinations administered to children at clinics and centres on a daily basis. Back in Lahore, a dedicated team of analysts mine this wealth of data, drawing on other technologies to create a continuous feed of immunisation-related data which can be used to monitor attendance, the number of children vaccinated, the number and type of vaccine administered, and all importantly, area coverage.

    Where the E-vacc package really excels is in its ability to identify areas of poor coverage and locate previously unreached communities and families by making use of satellite imagery and Google maps. This information is relayed back to vaccinators, who armed with exact locations of unimmunised children, are able to travel to these areas to offer vaccination services. On arrival, they register their location using the E-vacc and upload new data which allows the province’s Extended Programme for Immunization (EPI) to plot an up-to-date picture of coverage.

    “I think it’s technology done right”, said Dr Umar Saif, head of the Punjab IT Board, the organisation that has played a pivotal role in developing and rolling out the E-vacc package.

    In 2015, the data analysis started to pay off. Vaccinator attendance rose by an impressive 67%, and helped deliver an impressive increase in coverage with the five-in-one pentavalent vaccine from 64% to 86% in just 12 months – equivalent to an additional 500,000 immunised children. “We have worked very closely with everyone involved in immunisation in Punjab Province,” says Dr Saif, “from our partners all the way down to the vaccinators. They have been consulted, trained and their feedback has been incorporated.”

    There has also been political buy-in from the very top. “The oversight of the Chief Minister has been essential,” says Dr Saif. “Our monitoring data goes all the way to him, he looks at it personally to see where the gaps are. He makes sure that everyone continues to use the system.”

    Other provinces in Pakistan have recognised the benefits of data collection and analysis. Baluchistan, Khyber Pakhtunkhwa and Sindh have all formally requested help from the Punjab government to replicate its E-vacc approach.

    Khyber Pakhtunkhwa has progressed the furthest, and started deploying E-vaccs in 2015. “One of the challenges we’ve faced is ineffective outreach by vaccinators. Now, our EPI programme will train all vaccinators to develop outreach plans with support from WHO and Gavi,” says Dr Nasreen, training coordinator for the province’s EPI team. “District and provincial managers will then be able to check compliance using the E-vaccs. The approach will help managers to identify populated areas unreached by vaccinators.”

    Big data on a big scale

    Gavi’s ground-breaking full country evaluations (FCEs) gather high- quality, detailed data about national immunisation programmes while they are in progress. This is allowing countries like Uganda together with Vaccine Alliance partners to pinpoint problems as they arise and make near real-time improvements.

    Recognising and overcoming bottlenecks in service delivery is a key part of evaluating immunisation programmes. However, most programme evaluations are retroactive and take place after an immunisation campaign or a routine vaccine introduction has been completed. In contrast, Gavi-supported full country evaluations (FCEs) allow countries to identify obstacles to improving immunisation coverage and to make adjustments while the programmes are in progress.

    In 2015, when Uganda introduced human papillomavirus (HPV) vaccine to its routine schedule, a FCE revealed that some girls were missing out. By reviewing coverage at the district level, it quickly became clear that some areas had not introduced the vaccine because healthcare workers were not adequately trained.

    “The FCE process has given us an insight into where to put our effort to achieve better coverage,” says Dr Patrick Banura, a member of Uganda’s Expanded Programme for Immunization (EPI). “Thanks to this innovative approach, the next lifespan of health system strengthening will bring more focused interventions. Equity remains a bottleneck, and we have to use data to improve access.”

    The FCE in Uganda is not only making a difference to immunisation delivery at the local level. As part of the evaluation, the team developed an immunisation resource tracking tool, which monitors the allocation of funding for immunisation – both government and donor. When it emerged that government vaccine spending was declining, Uganda’s National Immunisation Technical Advisory Group (NITAG) used these data to advocate for changes in Uganda’s National Immunisation Bill; the Bill was passed in December 2015.

    “By using the FCE figures as evidence, we were able to ensure that two important issues were addressed: the government’s responsibility for funding basic immunisation services and the creation of a national immunisation fund,” says Celia Nalwadda, Secretary of the NITAG.

    Gilbert Asiimwe, a member of the FCE team in Uganda, believes the evaluation has even greater potential. “The FCE is extremely valuable for the immunisation system,” says Asiimwe. “Our Minister of Health has made it categorically clear: this kind of work is just the beginning, we‘re now looking at how we can make it better and broader in the coming years.”

    Laying the groundwork in Georgia

    In 2018, after 16 years of Gavi support, Georgia will take on full responsibility for financing all of its vaccines. The country is well prepared and firmly on the road to transition. In 2016, Georgia received Gavi support for just one vaccine, pneumococcal, and independently financed the introduction of a new hexavalent vaccine. Five individuals – all working at the frontline of immunisation – explain what lies behind Georgia’s success.


    Valeri Kvaratskhelia, Georgia’s Deputy Minister for Labour, Health and Social Affairs 

    Nothing underscores Georgia’s commitment to transitioning out of Gavi support more than its recent programme of healthcare reform. By the end of 2017, the government aims to be in a position to provide each of its citizens access to a primary healthcare centre.

    “Immunisation is effective in countries where the primary healthcare system works well,” says Valeri Kvaratskhelia, Deputy Minister for Labour, Health and Social Affairs, “In 2018, every little settlement, every village will have its own functioning primary healthcare centres.”

    Since 2013, Georgia’s public health budget has almost doubled, ensuring universal health coverage for all citizens. “Immunisation has been given a high priority by the Ministry of Health and by the Government,” says Kvaratskhelia, “Over the next two years, the state will continue to increase its share in purchasing vaccines so that by 2018 we are fully ready to cover all the costs.”


    Nana Jintcharadze, Regional immunisation manager, Adjara Region 

    Georgia’s commitment to immunisation stretches all the way to the tiny villages which lie deep into the mountainous region of Adjara. Nana Jintcharadze and her team are responsible for delivering vaccines across this large area, where heavy snowfall can make it difficult to reach communities for up to 6 months of the year.

    “When I started 18 years ago, there were many children around here who were unvaccinated,” says Jintcharadze, the regional immunisation manager. “I remember we had an outbreak of diphtheria, and we were bringing people in off the street to test them. Now we see no diphtheria at all.”

    The nation-wide introduction of a regional immunisation registry in September 2013 has helped transform coverage rates in Adjara and is the single biggest reason why Nana and her team can keep tabs on the immunisation status of almost every child in the region.

    “All family doctors were taught to fill in details about children – their name, surname, age, what type of vaccines they were given, when and in what dosage, as well as the doctor’s name,” she says.

    “I can check how many children were vaccinated and calculate how many vaccines were used in that day or month. I also come to clinics every month to double-check that the electronic data and the clinic journal match, so there is no risk of making any kind of mistakes. The system also allows us to see which doctors are having difficulties so we can help to solve them.”


    Ekaterine Kavtaradze, deputy general director of the National Center for Disease Control and Public Health 

    When Georgia announced its plan to introduce the inactivated polio vaccine, parents signalled their preference for the 6-in-1 hexavalent vaccine over a separate vaccine for administering the polio antigen to their children. Ekaterine Kavtaradze, the deputy general director of the National Center for Disease Control and Public Health (NCDC), helped the health ministry convince the government and parliament to increase the immunisation budget by 40% to ensure universal access to the multivalent vaccine.

    “It was a very big step for the budgeting process,” recalls Kavtaradze, “we collaborated very closely with the health ministry and the Georgian parliament, presenting evidence to demonstrate the importance of the hexavalent vaccine programme.” “When the Minister of Finance presented the budget to parliament, he agreed to allocate the amount that the health ministry requested. It was a huge collective achievement that we managed to convince all the decision-makers that we should always give priority to budgeting for the national immunisation programme.”


    Tamar Ugulava, Health specialist, UNICEF Georgia 

    In 2008, Georgian parents were alarmed by a series of misleading media reports that linked measles and rubella vaccines to unwelcome side-effects. Widespread vaccine hesitancy meant that a measles and rubella immunisation campaign only achieved a 50% coverage rate. This experience marked a turning point in the Georgian government’s approach to immunisation. “Following the events in 2008, we conducted several surveys showing that the most effective channel for communication with parents was doctors,” says Tamar Ugulava, a health specialist at UNICEF’s Georgia office.

    “We worked with the government to deliver training for health professionals to address the specific concerns of the population transferring knowledge, presenting case studies and helping them to do role play. As time has gone on, we really have seen commitment from the government in this field.”


    Amiran Gamkrelidze, director general of the National Center for Disease Control and Public Health 

    The 2008 vaccine hesitancy incident highlighted the need for public health education campaigns to reinforce the message about the benefits of routine immunisation.

    “The role of advocacy campaigns is huge. So speaking as much as possible in the media, on television and in newspapers, is very important,” says Amiran Gamkrelidze, director general of the National Center for Disease Control and Public Health, “We must explain to the population that vaccination is the most significant intervention ever in the history of public health.” In 2015, Georgia developed a mobile phone application to keep parents and other caregivers informed about vaccination schedules and track the vaccines that their child has received. The app also provides easy-to-access information about vaccines and the diseases they are intended to prevent.

    “Immediately after a baby is born, the mother receives this application free of charge,” says Gamkrelidze, “They will get an SMS reminding them when they should go for the next vaccine to their primary healthcare doctors.”

    A 'step' in the right direction

    United Parcel Service (UPS), a global logistics company whose business it is to deliver packages to the far flung corners of the world, offers some potentially life- saving lessons to immunisation supply chain managers in developing countries.

    When vaccines arrive in a developing country, their safe consignment to clinics and outreach centres – some of which are located in extremely remote areas – lies in the hands of a few dedicated health care workers. Specialised supply chain management training is rarely offered to staff responsible for the safe keeping and delivery of vaccines – that is until global logistics leader, United Parcel Service (UPS), offered a course at the recently opened Regional Centre of Excellence for Vaccines, Immunisation and Health Supply Chain Management in Kigali.

    “While hardware, infrastructure and technology are important, the successful implementation and management of the supply chain relies on strong managers,” says Kevin Etter, a UPS logistics executive. “Developing dedicated and competent leaders and skilled, motivated and empowered personnel at all levels of the health system is critical.”

    After introducing more than 100 new vaccines in the past five years, Africa’s supply chains are stretched to maximum capacity. Distribution managers – from large central depots and small local warehouses alike – need higher levels of expertise to hone their skills. Gavi’s partnership with UPS was set up in 2014 with the express purpose of drawing on the company’s 100 years of experience in logistics to help improve the efficiency of developing countries’ vaccine supply chains. “UPS has a long history of innovative management development programmes and we are honoured to share some of our best practices with Gavi,” says Etter.

    Between 2015 and 2020, Gavi and UPS expect to train 200 supply chain managers at the Centre of Excellence, which has the potential to become a regional hub for education and innovation. In addition to a traditional classroom experience and distance learning, course participants are paired up with mentors from UPS and AmerisourceBergen, a member firm of a second Gavi private sector partner, IFPW – see ‘Prospectus’ insert. With this expert guidance, they are able to put their new skills into practice, as well as build a network of co-leaders to share knowledge.

    “We presented a very non-traditional training experience,” says Etter. “Participants were very excited to learn in a new way and then to implement those learnings in their areas of responsibility.”

    One of STEP’s first graduates, Lucy Kanja, a vaccine depot manager at Dagoretti in Nairobi County in Kenya, is already applying what she has learned. “At Dagoretti, there’s a high turnover of workers and I used to wonder how we could keep everything going,” she says. “At STEP, I learnt about team building and how to attract and retain top talent. Today, I am mentoring three health workers. I teach them supply chain skills that help ensure effective vaccine management.”

    Operations director, Joshua Obel, has returned to his office at the Kenya Medical Supplies Authority (KEMSA) convinced that the training course is a “step” in the right direction toward countries’ long-term goal of building self-sustaining immunisation systems. “I have been to a lot of trainings during my career and this is the only one that I will really be able to put into practice,” he says.


    As the first country to be approved for Gavi’s new cold chain equipment optimisation platform support, Haiti is poised to improve immunisation coverage.

    Platon Malanga, in the west of Haiti, is at least 10 gruelling hours away from the nearest health centre by foot or on horseback.

    Haiti is extremely poor; it simply doesn’t have the money for new motorcycles or rough terrain vehicles which are what is needed to deliver vaccines to places like Platon Malanga. But when it comes to immunisation, by far the most pressing problem is not being able to pay for the propane gas that currently keeps the cold chain equipment running. This results in a considerable quantity of precious vaccines being wasted through temperature damage.

    As Francois Jeannot, manager for Haiti’s Expanded Programme for Immunization (EPI), puts it, “Because of this, vaccine coverage in the country is low. For example, if we consider delivering three doses of DTP or pentavalent vaccine as an indicator, the country never reaches 86%.”

    Having solar refrigerators would do away with the need for transporting expensive, heavy propane gas cylinders to hard-to-reach places like Platon Malanga, and would alleviate much of the pressure on Haiti’s cold chain.

    When Gavi’s cold chain equipment optimisation platform (CCE) support was announced in 2015, the Haitian Health Ministry, UNICEF, WHO and the US Centers for Disease Control were quick to take advantage of an opportunity to modernise the country’s ailing cold chain.

    Thanks to strong collaboration between the EPI team, technical partners and other stakeholders, Haiti became the first Gavi-supported country to be approved for CCE platform support, securing funds to cover the purchase of over 700 solar-powered refrigerators.

    “Haiti’s application ticked all the boxes,” says Homero Hernandez, Gavi’s focal point for Haiti. “It reflected a comprehensive approach to strengthening the efficiency and effectiveness of the cold chain and was fully aligned with overall national immunisation priorities. The application also demonstrated how support could complement existing investments in the supply chain.”

    To qualify for support, countries need to show that they have considered what would be the most appropriate type of cold chain equipment for a given health facility. Luckily, Haiti was able to draw on its 2013 effective vaccine management (EVM) survey, which included an assessment of the country’s cold chain management system – tracking vaccines from the time they arrive at Port-au-Prince through to the point of delivery in clinics.

    “The EVM gave us a bit of a head start,” says Jeannot, who coordinated the working group preparing the application. “We used this valuable data to help prepare our proposal, drafting an improvement plan that outlined our needs and what we had to do to reinforce the vaccine supply chain, including cold chain equipment.”

    Haiti was also able to provide a detailed budget for the long-term maintenance and sustainability of its entire cold chain. This included requests for over 1,000 spare part kits and more than 4,500 temperature monitoring devices. New solar-powered refrigerators and other pieces of cold chain equipment will not solve all of Haiti’s problems with vaccine storage and safety, but it’s an excellent place to start.

    “The CCE can be used as a way to strengthen the EPI as a whole and address other related issues like vaccine distribution and monitoring, data management and vaccine-preventable diseases surveillance,” says Jeannot, “Once we have the cold chain equipment working properly, it’s up to us to motivate people to be vaccinated and train our health workers properly, says Derline Mentor, a Haitian UNICEF cold chain and logistics officer. “In the next five years I hope we’ll be able achieve 90% coverage with life-saving vaccines.”


    Emmanuel Lasanah, outpatient supervisor at Monrovia’s Redemption Hospital, became one of the lead contact tracers during the recent Ebola outbreak, tracking down more than 900 potentially infected people. Given his high-risk status, he was also the first person in Liberia to receive the new vaccine against Ebola.

    This is his story.

    Fear was unavoidable. Fear was the hallmark. Always at the back of our minds. It was really tough, because the cases were too many. The cases overwhelmed the health facilities. People would call and you’d say there’s no space. So the families used to come and just drop them outside Redemption Hospital and then leave. Sometimes they would leave more than 15 dead bodies at once. They were dying in every home. It was quite terrible.

    At the peak of Ebola, Redemption Hospital suffered a heavy blow and health services collapsed. The medical director responsible for the hospital died of Ebola. We had nurses, physician assistants, nurse aids, medical doctors dying from Ebola. It was quite terrifying. Everyone was afraid and ran away. But I was still available. So I thought that the best thing I could do was to help my country; I had the knowledge for contact tracing. Let me use this, instead of sitting and being afraid. So I volunteered to take the lead.

    When someone came to the hospital with fever, vomiting, diarrhoea, sometimes bleeding we would immediately go to their home and complete the case- base investigation form. We would then submit this to the ministry. In that form we listed all those who had come into contact with the person. That included the name, the age, address and occupation of those people. So for a single case of Ebola we would have to trace a minimum of 15 contacts. In the zone I was assigned people lived in clusters. You have one house with five, six or even eight families. Each family has up to seven or eight members. So if there’s a house of that nature, then you sometimes have to trace up to 50 contacts.

    Tracing contacts was a very challenging task. We were afraid of getting Ebola and we didn’t want to enter the homes. In some communities, we were targeted, because people felt that we were trying to make up a story that their relative had Ebola. Many were in a state of denial. Sometimes we even had to contact the Liberian National Police, to prevent families from taking a body and burying it.

    I was really, really worried. And my team was worried. I had to encourage them. If we had got afraid and didn’t do anything about this and didn’t intervene, what would happen? We could also get infected, it might spread to our families, our friends and our relatives. My family didn’t want me to go out. I said no, I’m a health worker I have to go out, to save the population. Someone has to take the lead.

    The early symptoms of Ebola are like symptoms of malaria. So when one begins to experience fever, headache, joint pains, the first thing that comes to mind is “I must have malaria”. The introduction of the thermal scan helped us a lot. Before then, someone could be having fever and they say “No, I’m okay”, but you could see clinically this person is not okay. But then the thermometer was introduced and we started using it in the field. When people have fever, then you can start to tell them “You are not well, your temperature is high. You have been in contact with someone who has been admitted to the Ebola Treatment Unit (ETU) or someone who has died. So it’s very dangerous if you start developing symptoms and you hide the sickness, because you are exposing other family members. So the earlier you go to the ETU the better it is for you.”

    It was a strange disease for Liberia. We had not experienced Ebola before. We were not prepared to fight it. Whenever someone is sick in Liberia, everyone comes round and touches the person, and that’s one of the reasons why Ebola spread. When patients were brought to this hospital, health workers came into contact with these patients without protection. We were not used to wearing gloves, wearing gowns or boots in the hospital. That’s how a lot of our co-workers in the hospital died.

    Because our co-workers were dying the rest of us were afraid, nobody wanted to touch a patient again. You and a colleague work together today and then two or three days later he is dead. You are afraid, but the patients were still being brought to the hospital. Later we were trained in how to behave and given equipment to wear, masks, gowns and boots, things we never knew about before. Later partners came in and started constructing ETUs.

    The decision to be the first to take the Ebola study vaccine was made when suddenly I started thinking back on the number of family members, the number of friends, the number of health workers, the number of community persons that died from Ebola. I knew that I was exposed because I was doing contact tracing. I was afraid because I didn’t know what the effects of the vaccine would have been, but I decided that I needed to take part in this study to benefit. Seeing as I took the lead on contact tracing I also wanted to take the lead for the Ebola vaccine, even though this was a study. Since I took it I’ve been feeling very well. I am so grateful.

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