Strengthening laboratory biosafety in Liberia during the COVID-19 pandemic: Experience from the Global Laboratory Leadership Programme.

Background: The Global Laboratory Leadership Programme (GLLP) has biosafety and biosecurity as one of its core competencies and advocates for a One Health approach involving all relevant sectors across the human-animal-environment interface to empower national laboratory systems and strengthen health security. Decentralization of SARS-CoV-2 testing in Liberia coupled with an increase in the number of COVID-19 infections among laboratory professionals raised biosafety concerns. In response, a set of trainings on laboratory biosafety was launched for lab personnel across the country under the framework of the GLLP. The goal was to deliver a comprehensive package for laboratory biosafety in the context of SARS-CoV-2 through active learning. Methods: Three one-day workshops were conducted between September and October 2020, training personnel from human, animal and environmental laboratories through a One Health approach. Concepts critical to laboratory biosafety were delivered in an interactive engagement format to ensure effective learning and retention of concepts. Pre- and post-training assessments were performed, and a paired t-test was used to assess knowledge gain. Results: Of the 67 participants, 64 were from the human health sector, one from veterinary sector and two from environmental health sector. The average pre-test score was 41%. The main gaps identified were failure to acknowledge surgical antisepsis as a form of hand hygiene and recognition of PPE as the best risk control measure. The average post-test score was 75.5%. The mean difference of pre-test and post-test scores was statistically significant (p-value <0.001). Participants indicated satisfaction with the workshop content, mode of delivery and trainers' proficiency. Conclusions: The workshops were impactful as evidenced by significant improvement (34.5%) in the post-test scores and positive participant feedback. Repeated refresher trainings are vital to addressing the gaps, ensuring compliance, and promoting biosafety culture. GLLP's approach to cultivating multisectoral national laboratory leaders ready to take responsibility and ownership for capacity building provides a sustainable solution for attaining strong national laboratory systems better prepared for health emergencies and pandemics like COVID-19.

Laboratory capacity assessments in 25 African countries at high risk of yellow fever, August-December 2018.

INTRODUCTION: accurate and timely laboratory diagnosis of yellow fever (YF) is critical to the Eliminate Yellow Fever Epidemics (EYE) strategy. Gavi, the Vaccine Alliance recognized the need to support and build capacity in the national and regional laboratories in the Global YF Laboratory Network (GYFLN) as part of this strategy. METHODS: to better understand current capacity, gaps and needs of the GYFLN laboratories in Africa, assessments were carried out in national and regional reference laboratories in the 25 African countries at high risk for YF outbreaks that were eligible for new financial support from Gavi. RESULTS: the assessments found that the GYFLN in Africa has high capacity but 21% of specimens were not tested due to lack of testing kits or reagents and approximately 50% of presumptive YF cases were not confirmed at the regional reference laboratory due to problems with shipping. CONCLUSION: the laboratory assessments helped to document the baseline capacities of these laboratories prior to Gavi funding to support strengthening YF laboratories.

Improving dog bite victim survey and estimation of annual human deaths due to suspected rabies cases in three selected Liberian cities and environs, 2008-2017.

Rabies remains a public health challenge of unknown magnitude in Liberia in spite of the goal of ensuring that no human in the country dies of rabies by 2030. The annual prevalence of Dog Bite Victims (DBVs) and true load of Annual Human Deaths (AHDs) due to rabies were not known. We investigated three selected cities of Liberia for annual prevalence of DBVs and true load of AHD due to suspected rabies, using 10-year retrospective record, 2008-2017 obtained from Buchanan, Gbarnga, and Voinjama, three socio-economically important cities in post-conflict Liberia. Data were sourced at County Reference Hospitals and at the Liberia National Institute of Health for these cities and their local environs. In addition, household questionnaire survey was used to identify and audit data quality for unreported DBVs, and treatment received from traditional caregivers. The proportion was used to audit the 10-year data on unreported DBVs in the cities. Descriptive statistics was used to summarize annual DBVs over the 10-year period in the three cities, respectively. A standardized clinical decision tree model was used to estimate AHDs due to suspected rabies. Based on questionnaire survey, 140/365, 148/375 and 146/350 DBVs did not visit any orthodox health facility in Buchanan, Gbarnga and Voinjama cities, respectively in 2014. An estimated total of 559 DBVs died of suspected rabies in the three cities and their environs during the 10-year period. Mean yearly prevalence of DBVs was 179±106.82, 393±257.85 and 76.9±38.11 per 100,000 population, while mean AHDs due to suspected rabies was 14.3±8.47, 35.5±23.25, and 6.1±3.21 per 100,000 population in Buchanan, Gbarnga, and Voinjama cities, respectively. The present findings provide annual prevalence of suspected rabies cases, corrected for under-reporting in three selected cities of Liberia. The findings would be useful in planning for stepwise actions towards rabies elimination, ensuring that no human dies of rabies in Liberia by 2030.

Tuberculosis in Liberia: high multidrug-resistance burden, transmission and diversity modelled by multiple importation events.

Tuberculosis (TB) surveillance is scarce in most African countries, even though it is the continent with the greatest disease incidence according to the World Health Organization. Liberia is within the 30 countries with the highest TB burden, probably as a consequence of the long civil war and the recent Ebola outbreak, both crippling the health system and depreciating the TB prevention and control programmes. Due to difficulties working in the country, there is a lack of resistance surveys and bacillus characterization. Here, we use genome sequencing of Mycobacteriumtuberculosis clinical isolates to fill this gap. Our results highlight that the bacillus population structure is dominated by lineage 4 strains that harbour an outstanding genetic diversity, higher than in the rest of Africa as a whole. Coalescent analyses demonstrate that strains currently circulating in Liberia were introduced several times beginning in the early year 600 CE until very recently coinciding with migratory movements associated with the civil war and Ebola epidemics. A higher multidrug-resistant (MDR)-TB frequency (23.5 %) than current estimates was obtained together with non-catalogued drug-resistance mutations. Additionally, 39 % of strains were in genomic clusters revealing that ongoing transmission is a major contribution to the TB burden in the country. Our report emphasizes the importance of TB surveillance and control in African countries where bacillus diversity, MDR-TB prevalence and transmission are coalescing to jeopardize TB control programmes.

Development and application of affordable SNP typing approaches to genotype Mycobacterium tuberculosis complex strains in low and high burden countries.

The Mycobacterium tuberculosis complex (MTBC) comprises the species that causes tuberculosis (TB) which affects 10 million people every year. A robust classification of species, lineages, and sub-lineages is important to explore associations with drug resistance, epidemiological patterns or clinical outcomes. We present a rapid and easy-to-follow methodology to classify clinical TB samples into the main MTBC clades. Approaches are based on the identification of lineage and sub-lineage diagnostic SNP using a real-time PCR high resolution melting assay and classic Sanger sequencing from low-concentrated, low quality DNA. Thus, suitable for implementation in middle and low-income countries. Once we validated our molecular procedures, we characterized a total of 491 biological samples from human and cattle hosts, representing countries with different TB burden. Overall, we managed to genotype ~95% of all samples despite coming from unpurified and low-concentrated DNA. Our approach also allowed us to detect zoonotic cases in eight human samples from Nigeria. To conclude, the molecular techniques we have developed, are accurate, discriminative and reproducible. Furthermore, it costs less than other classic typing methods, resulting in an affordable alternative method in TB laboratories.

Lassa virus circulating in Liberia: a retrospective genomic characterisation.

BACKGROUND: An alarming rise in reported Lassa fever cases continues in west Africa. Liberia has the largest reported per capita incidence of Lassa fever cases in the region, but genomic information on the circulating strains is scarce. The aim of this study was to substantially increase the available pool of data to help foster the generation of targeted diagnostics and therapeutics. METHODS: Clinical serum samples collected from 17 positive Lassa fever cases originating from Liberia (16 cases) and Guinea (one case) within the past decade were processed at the Liberian Institute for Biomedical Research using a targeted-enrichment sequencing approach, producing 17 near-complete genomes. An additional 17 Lassa virus sequences (two from Guinea, seven from Liberia, four from Nigeria, and four from Sierra Leone) were generated from viral stocks at the US Centers for Disease Control and Prevention (Atlanta, GA) from samples originating from the Mano River Union (Guinea, Liberia, and Sierra Leone) region and Nigeria. Sequences were compared with existing Lassa virus genomes and published Lassa virus assays. FINDINGS: The 23 new Liberian Lassa virus genomes grouped within two clades (IV.A and IV.B) and were genetically divergent from those circulating elsewhere in west Africa. A time-calibrated phylogeographic analysis incorporating the new genomes suggests Liberia was the entry point of Lassa virus into the Mano River Union region and estimates the introduction to have occurred between 300-350 years ago. A high level of diversity exists between the Liberian Lassa virus genomes. Nucleotide percent difference between Liberian Lassa virus genomes ranged up to 27% in the L segment and 18% in the S segment. The commonly used Lassa Josiah-MGB assay was up to 25% divergent across the target sites when aligned to the Liberian Lassa virus genomes. INTERPRETATION: The large amount of novel genomic diversity of Lassa virus observed in the Liberian cases emphasises the need to match deployed diagnostic capabilities with locally circulating strains and underscores the importance of evaluating cross-lineage protection in the development of vaccines and therapeutics. FUNDING: Defense Biological Product Assurance Office of the US Department of Defense and the Armed Forces Health Surveillance Branch and its Global Emerging Infections Surveillance and Response Section.

Rubella transmission and the risk of congenital rubella syndrome in Liberia: a need to introduce rubella-containing vaccine in the routine immunization program.

BACKGROUND: Rubella is an RNA virus in the genus Rubivirus within the Matonaviridae family. Rubella remains a leading vaccine-preventable cause of birth defects. Most African countries including Liberia do not currently provide rubella-containing vaccine (RCV) in their immunization program. We analyzed the existing surveillance data to describe rubella cases and identify the at-risk population. METHODS: We conducted a retrospective descriptive statistics on the suspected-measles case-based surveillance data that obtained from the national database. Suspected-measles cases who were negative and indeterminate for measles IgM and tested for rubella IgM were extracted from the database. We used only rubella IgM positive cases to calculate trends and percentages by person, place and time. The cumulative-percent curve was used to visually describe the age distribution of rubella cases. RESULTS: During 2017-2018, a total of 2027 suspected-measles cases with known laboratory results were reported; of which, 1307 were tested for rubella IgM. Among tested cases, 472 (36%) were positive, 769 (59%) were negative and 66 (5%) were indeterminate for rubella IgM. Female contributed 269 (57%) of the confirmed rubella cases respectively. The median age was 7 years with an interquartile range of 5-10 years. From the total rubella cases, 6 (1%) were under 1 year, 109 (23%) were 1-4 years, 207 (44%) were 5-9 years, 87 (18%) were 10-14 years and 56 (12%) were more than or equal to 15 years. Women in their reproductive-age contributed 23 (5%) of rubella cases with 17% positivity rate. Two-thirds or 307 (65%) of the cases were reported from February to May which is dry season in Liberia. CONCLUSIONS: Our analysis revealed that rubella was widely circulating in Liberia. Majority of the cases were reported among children < 15 years. However, rubella was also reported among women of reproductive age and infants < 1 year with no report of congenital rubella syndrome (CRS). Detail investigation of rubella cases among infants of < 1 year and women of reproductive age is important to uncover CRS. Establishment of CRS surveillance and the introduction of RCV in the immunization program are crucial to prevent rubella infection and avert the risk of CRS.

Lesson learned from the investigation and response of Lassa fever outbreak, Margibi County, Liberia, 2018: case report.

BACKGROUND: Lassa fever (LF) is a viral hemorrhagic disease caused by the Lassa virus (LASV) and endemic in West African countries with an estimation of 300,000 to 500,000 cases and 5,000 deaths annually. The Margibi County Health Team of Liberia received a report of an unidentified febrile illness case from the Kakata district. We conducted the investigation to identify the causative agent and the source of infection to support treatment, control and prevention interventions. CASE PRESENTATION: We identified LASV in the blood specimens' of two patients by Reverse Transcriptase Polymerase Chain Reaction (RT-PCR). Both the confirmed cases have manifested respiratory distress, weakness, and difficulty of swallowing, muscle, joint and back pains, and vomiting with blood. The symptoms started with mild fever and gradually developed. Initially, the primary health facilities have miss-diagnosed the patients as malaria and respiratory tract infections. The primary health facilities have referred the patients to the referral hospital as the patients have failed to respond to antimalarial and antibiotics. The hospital suspected LF and sent blood specimens to the National Reference Laboratory while the patients were on supportive treatment in the isolation room. At the time when the laboratory result returned to the hospital, the patients died of LF illness before ribavirin administered. CONCLUSIONS: Our investigation revealed that the two hospitalized and deceased febrile cases were associated with LASV. The primary health facilities have failed to recognize the cases as suspected LF at the earliest time possible. The clinicians and health facilities, especially primary health facilities, need to consider LF as a differential diagnosis when the patient failed to respond to anti-malaria and broad-spectrum antibiotics.

Establishing National Multisectoral Coordination and collaboration mechanisms to prevent, detect, and respond to public health threats in Guinea, Liberia, and Sierra Leone 2016-2018.

BACKGROUND: The governments of Guinea, Liberia, and Sierra Leone have acknowledged that weak health systems and poor coordination of efforts hampered effectiveness of the 2014-2016 Ebola outbreak response. The bitter experience of the Ebola outbreak response served as an important catalyst for increased efforts to comply with World Health Organization (WHO) International Health Regulations (IHR 2005), Performance of Veterinary Services (PVS) Pathway capacities, and Global Health Security Agenda (GHSA) goals. In November 2016, an interministerial meeting held in Dakar, Senegal, resulted in formalized commitments from the three nations to strengthen resilience to health threats by establishing a Regional Strategic Roadmap to institutionalize the One Health approach. Since then, each country has made significant progress towards establishing National One Health Platforms to coordinate health security interventions, in collaboration with international partners. This paper outlines the methodology and results of these efforts for the period June 2016-January 2019, with a specific focus on activities supported by the US Agency for International Development (USAID)-funded Preparedness & Response (P&R) project. OBJECTIVES: In support of the West African Health Organization's November 2016 Regional Strategic Roadmap for institutionalization of the One Health approach, the Preparedness & Response (P&R) project worked in coordination with national partners in Guinea, Liberia, and Sierra Leone to establish multisectoral, One Health coordinating mechanisms. METHODOLOGY: The global USAID-funded P&R project was launched in 2014 to support the achievement of this objective, and began coordinating with partners in Guinea, Liberia, and Sierra Leone in 2016 to tailor its multi-step conceptual framework to fit the priorities and operating constraints of national stakeholders. Organized in phases of Collaboration (building key relationships), Formalization (defining and establishing a coordination structure), and Implementation (using newfound coordination to produce better health security outcomes), the framework features steps such as One Health sensitizations for multisectoral national stakeholders, development of One Health platform terms of reference and other operating guidelines, and application of these tools to coordination of technical assistance during outbreaks. RESULTS: In Guinea, Liberia, and Sierra Leone, in less than 3 yrs there has been a marked improvement in cross-sectoral coordination on health security actions. All three countries have passed legislation establishing permanent multisectoral coordination mechanisms referred to in this document as National One Health Platforms, or simply Platforms; instituted an annual mechanism for assessing capacity and performance of these platforms to lead health security actions; and have undertaken key steps towards developing and updating National Preparedness & Response Plans which truly reflect the multisectoral nature of emerging disease threats. However, multisectoral coordination is a work in progress: government stakeholders and their international partners continue to work together to further strengthen national ownership and investment in the newly established Platforms. CONCLUSION AND NEXT STEPS: Newly established Platforms in Guinea, Liberia, and Sierra Leone offer a long-term structure for coordinating health security actions. However, given the short period of time since their formalization, they depend on continued national, regional, and international resources to build from recent progress and further improve capacity and performance. Regional programs such as the World Bank Regional Disease Surveillance Systems Enhancement (REDISSE) project are of critical importance in keeping the momentum going. The highlighted progress and outputs to date provide reasons and motivation for continued, longer-term investment in the Platforms.

Pre-Ebola virus disease laboratory system and related challenges in Liberia.

Prior to the Ebola virus disease outbreak in Liberia, the laboratory system was duplicative, fragmented and minimally coordinated. The National Reference Laboratory was conceptualised to address the existing challenges by promoting the implementation of effective and sustainable laboratory services in Liberia. However, in a resource-limited environment such as Liberia, progress regarding the rebuilding of the health system can be relatively slow, while efforts to sustain the transient gains remain a key challenge for the Ministry of Health. In this paper, we describe the pre-Ebola virus disease laboratory system in Liberia and its prevailing efforts to address future emerging infectious diseases, as well as current Infectious diseases, all of which are exacerbated by poverty. We conclude that laboratory and diagnostic services in Liberia have encountered numerous challenges regarding its efforts to strengthen the healthcare delivery system. These challenges include limited trained human resource capacity, inadequate infrastructure, and a lack of coordination. As with most countries in sub-Saharan Africa, when comparing urban and rural settings, diagnostic and clinical services are generally skewed toward urban health facilities and private, faith-based health facilities. We recommend that structured policy be directed at these challenges for national institutions to develop guidelines to improve, strengthen and sustain diagnostic and curative laboratory services to effectively address current infectious diseases and prepare for future emerging and re-emerging infectious diseases.

The laboratory health system and its response to the Ebola virus disease outbreak in Liberia.

The laboratory system in Liberia has generally been fragmented and uncoordinated. Accordingly, the country's Ministry of Health established the National Reference Laboratory to strengthen and sustain laboratory services. However, diagnostic testing services were often limited to clinical tests performed in health facilities, with the functionality of the National Reference Laboratory restricted to performing testing services for a limited number of epidemic-prone diseases. The lack of testing capacity in-country for Lassa fever and other haemorrhagic fevers affected the response of the country's health system during the onset of the Ebola virus disease (EVD) outbreak. Based on the experiences of the EVD outbreak, efforts were initiated to strengthen the laboratory system and infrastructure, enhance human resource capacity, and invest in diagnostic services and public health surveillance to inform admittance, treatment, and discharge decisions. In this article, we briefly describe the pre-EVD laboratory capability in Liberia, and extensively explore the post-EVD strengthening initiatives to enhance capacity, mobilise resources and coordinate disaster response with international partners to rebuild the laboratory infrastructure in the country. Now that the EVD outbreak has ended, additional initiatives are needed to revise the laboratory strategic and operational plan for post-EVD relevance, promote continual human resource capacity, institute accreditation and validation programmes, and coordinate the investment strategy to strengthen and sustain the preparedness of the laboratory sector to mitigate future emerging and re-emerging infectious diseases.

The rubber plantation environment and Lassa fever epidemics in Liberia, 2008-2012: a spatial regression.

As Lassa fever continues to be a public health challenge in West Africa, it is critical to produce good maps of its risk pattern for use in active surveillance and control intervention. We identified eight spatial features related to the rubber plantation environment and used them as explanatory variables for Lassa fever (LF) outbreaks on the Uniroyal Liberian Agricultural Company (LAC) rubber plantation environment in Grand Bassa County, Liberia. We computed classical and spatial lag regression models on all spatial features, including proximity of residential camp to rubber tree-edge, main road in the plantation, LAC hospital, rice farmland, household refuse dump, human population density, post-harvest storage density of rice and density of rodent deterrent on rice storage. We found significant (p=0.0024) spatial autocorrelation between LF cases and the spatial features we have considered. We concluded that the rubber plantation environment influenced Mastomys species' breeding and transmission of Lassa virus along spatial scale to humans. The risk factors identified in this study offered a baseline for more effective surveillance and control of LF in the post-civil conflict Liberia.