The effects of COVID-19 in Sierra Leone are more complex than the disease itself. Patients and healthcare workers talk about fear of a new vaccine, fear of the coronavirus, reluctance among healthcare workers to touch patients, and critical child immunizations that were missed.
At seven in the morning, on a Monday, Nurse Aisha Kamara takes to the steep footpaths of Moiba Hills, in Kissy, on “defaulter tracing.” Nurse Kamara is a Maternal and Child Health (MCH) aide, on a mission to find children who skipped their life-saving immunization visits at the clinic.
Defaulters are common in the Western Area Urban (WAU). These are mothers who may want to get their children vaccinated, but the long and treacherous footpaths downhill, and the long waiting time at the clinic, discourage them.
And, since news of the COVID-19 pandemic reached Sierra Leone, the efforts to immunize children received an additional blow.
Dr Tom Sesay, Program Manager, Child Health/ Expanded Program on Immunization (EPI), said that hospitals and health clinics have seen a significant drop in the number of patients since February 2020.
“Even before we had our first [coronavirus] case in March, when we started having the anxiety with COVID-19, we started seeing a drop in immunization services uptake. It was only in January that we had figures similar to 2019, but by the month of February the figures started dropping, and it continued to drop in March. The lowest we saw in the figures for vaccinations was in the month of April,” he said.
The decline in immunizations coincided with a flood of rumors and misconceptions about the COVID-19 vaccines, Dr Sesay said. However, the immediate response of the healthcare delivery system and training of healthcare workers, community engagements and sensitization, helped improve immunization numbers by the end of the year, Dr Sesay said.
Ministry of Health and Sanitation (MoHS) data show that in April 2020, the number of total immunizations in children dropped by 17% when compared to the same period in 2019. The trend recovered slightly in the second half of 2020, but it never reached the levels of 2019.
COVID-19 scared people and healthcare staff equally
Community Health Worker (CHO), Betty Mbayo from Moyamba Junction Health Centre, two and a half hours by car from Freetown, said that the people’s main concern was fear of a COVID-19 vaccine.
“We told them that the vaccine being administered is not for COVID-19 [and] to continue the routine immunization of the children, and [that it] is safe. We gave them health advice on the antigen being administered, not only to children, but for pregnant women and those who are within the childbearing age,” Mbayo explained.
Lucy Brown (legal name withheld), a 28-year old mother of two, was six-month pregnant when the first confirmed case of COVID-19 was announced by authorities in Sierra Leone. She recalls vividly the surreal experience when a health provider refused to touch her during a routine pre-natal visit.
“My gynecologist told me that [she] will not be touching any patient physically, even after I paid the consultation fee, she told me that I will be doing the examination of my fetus myself… what do I know? -I asked myself.”
“When I ask her, what should I do if I go into labour, what will be my fate? She told me that I should pray that it is not too serious. I left her clinic with tears flowing down my cheeks,” the woman explained.
Lucy said she then tried to get pre-natal care at the Planned Parenthood Association Sierra Leone (PPASL) but discovered that PPASL did not have a resident doctor. She eventually found a gynecologist willing to perform the proper pre-natal consultations, but she recalls the terror of having to deal with a newborn during a national health emergency.
“It was really scary for me as a mother, as I was also thinking if I go into labour during lockdown what will happen? All of those fears were running through my mind,” she said.
According to official data from the National COVID-19 Emergency Response Centre (NACOVERC) at the end of January, 7.5% of all diagnosed cases of COVID-19 were among healthcare staff.
Under-5 mortality in Sierra Leone three times higher than the world average
Out of 16 districts, three had immunization numbers below 80% in the first half of 2020, which is 10% lower than the national target. These are Bombali, Karene and Western Area Urban.
Although WAU houses 15% of the country population, and having the highest concentration of health clinics, only 57% of all children under the age of five have been vaccinated against key diseases there. This means that an estimated 43% of all children under five in the WAU are vulnerable to developing serious diseases that could lead to death.
The vaccines currently administered to children in Sierra Leone have the role of protecting against polio, diphtheria, tetanus, whooping cough, hepatitis B, influenza, and rotavirus disease which can cause severe diarrhea.
According to the World Health Organization (WHO), the global under-5 mortality rate was 93 deaths per 1,000 live births in 1990. In Sierra Leone, in 1990, the under-5 mortality rate was almost 260, three times higher than the world average.
But while Sierra Leone made progress in vaccinations, the gap between our country and the world has never closed.
In 2019, the under-5 mortality rate was 38 deaths per 1,000 live births. In Sierra Leone, in 2019, the under-5 mortality was 109 deaths per 1,000 live births, which is still almost three times higher than the world average.
Nurse Kamara’s uphill battle
Nurse Kamara is in-charge of about 100 children at her clinic in Moiba but she spends a lot of her time on default tracing and outreach.
“When we visit the houses, we request for the under-five card. So, we look at the card, and if it is overdue and not gone too far, we give the child the vaccine. But if we are not with the vaccine that the child is required to have, they are being referred to the [health] centre,” she said.
The “under five cards” are immunization cards issued at birth on behalf of each child.
“Sometimes the children may have missed two or three vaccines, so we will give one, and get them another date to complete the others. We go up those hills and, as I speak to you, I am just coming from an outreach and my feet are killing me. Our catchment area is very big. It runs up to Leicester Peak and the boundary of Regent. We go to places like Up Water, and Garden Soja Town, which is the last hill,” nurse Kamara described.
Parents, she says, don’t always share the real reasons why they skip vaccination visits. When asked, they prefer to keep quiet, or they make up a small lie.
Dr Tom Sesay acknowledged that nurses face significant challenges trying to reach children up in the hills. But the single most important thing in helping fix the problem is to figure out why the parents skip their children from immunization visits.