National Public Health Institute of Liberia

Community health worker (CHW) programmes are central to primary healthcare (PHC) in sub-Saharan Africa (SSA). Yet who pays for them, how much, and whether funds favour vertical (single-disease) or horizontal (broader-focus) programmes remains unclear. This study examined trends in donor and government financing for CHW programmes across SSA. We conducted a secondary analysis of publicly available data. Organisation for Economic Co-operation and Development Creditor Reporting System (2002-2022) projects were screened and classified as vertical or horizontal through standard definitions and manual review. Government spending in 37 SSA countries (using WHO Global Health Expenditure Database (2016-2022) was estimated by applying maturity-based allocation percentages to preventive and outpatient curative functions. We described trends, donor composition, vertical-horizontal shares and the annual financing gap against published cost benchmarks. Between 2002 and 2022, global external assistance for CHW programmes totalled US$14.4 billion, SSA receiving 76% (US$11.0 billion). Of donor funds to SSA, 76.4% supported vertical programmes, although these made up fewer than 20% of projects; horizontal programmes received just 14.7%. Annual external assistance rose from ~US$0.28 billion (2016-2019) to ~US$1.83 billion (2020-2022), with over 90% directed to vertical or COVID-19-related efforts. Government spending across 37 SSA countries totalled ~US$1.4 billion (2016-2022). This represented less than 20% of total CHW funding but a greater share directed to horizontal services (54.6%). The annual financing gap remained between US$4.7 billion and US$4.3 billion. CHW financing in SSA is donor-dominant and vertically oriented; domestic allocations are limited but relatively more horizontal. Closing the funding gap will require larger, predictable government budgets for CHWs, better-aligned partner support and stronger expenditure tracking to sustain PHC and advance universal health coverage.

Liberia's health system, severely impacted by prolonged conflict and the 2014-2015 Ebola outbreak, suffered from critical gaps in laboratory governance, workforce capacity, and diagnostic infrastructure. To address these challenges, the Ministry of Health (MoH), in collaboration with international partners, launched a national reform initiative aimed at strengthening the laboratory system. This study assesses the implementation and outcomes of the revised National Laboratory Policy and Strategic Plan introduced in 2019. A situational analysis was conducted to identify systemic weaknesses. The MoH formed a Technical Working Group to develop and implement the revised policy and plan. Qualitative and quantitative data were gathered through stakeholder interviews, document reviews, and laboratory quality audits. The reform focused on five key areas: enhancing governance structures, expanding workforce development, implementing quality management systems (QMS), integrating private laboratories into the national network, and formalizing national laboratory policies and strategic guidelines. Substantial improvements were observed across intervention areas. Governance was enhanced through strengthened roles of the National Diagnostic Division and National Public Health Institute of Liberia. A Bachelor of Medical Laboratory Science program was launched, with its first cohort enrolled in 2023. Eighteen laboratories joined a structured QMS program, and three attained a one-star rating. Four private laboratories were integrated into national disease surveillance. Comprehensive policy documents and infrastructure, equipment, and quality assurance guidelines were developed and disseminated. Liberia has made measurable progress in laboratory governance, workforce development, and quality assurance. Sustained investment in policy implementation, training, and infrastructure is critical to preserving these gains and improving national health security.

Genomic analysis of parasites can deepen our understanding of their transmission, population structure, and important biological characteristics. Onchocerciasis (river blindness), caused by the parasitic nematode Onchocerca volvulus, involves adult worms residing in subcutaneous nodules that produce larval-stage microfilariae (mf), which are routinely detected in the skin for diagnosis. Whole-genome studies of mf are limited; most analyses have focused on the mitochondrial genome. We conducted a genome-wide analysis with 94% median nuclear genome coverage, analyzing 171, 37, and 98 mf from 16, 3, and 5 individuals from Ghana, Liberia, and the Democratic Republic of Congo, respectively. These data were used to investigate population differentiation, estimate the number of reproductive adult worms, and analyze genetic variation across chromosomes. Population genetic analyses across hosts and countries showed that nuclear genome diversity can reveal fine-scale genetic structure, even between geographically close countries, providing more resolution than mitochondrial haplotype data. By reconstructing maternal and paternal sibships, we estimated the number of reproductively active adult filariae. Comparisons between adult worm estimates from genetic data and nodule observations showed that genetics-based estimates were higher or equal to observed worm counts in 8 out of 9 hosts for female worms and 7 out of 9 hosts for male worms. Our analysis also revealed lower-than-expected X chromosome diversity, consistent with neo-X chromosome fusions in filarial species. This study represents an important step in using nuclear genome data from mf to support onchocerciasis elimination efforts and in developing genetic tools that could inform mass drug administration programs.

Background Lassa fever (LF) is an endemic and immediately notifiable disease in Liberia, and one laboratory confirmed case constitutes an outbreak. We described the epidemiological characteristics and hospital outcomes of LF cases hospitalized during the 2022-2023 outbreak in Liberia. Methods A retrospective cohort study was conducted using routine LF surveillance data from the 2022-2023 outbreak in Liberia. Descriptive statistics were used to summarize the data and log binomial regression to assess the association between epidemiological characteristics and mortality. Results A total of 439 suspected LF cases were reported. The median age was 22 (interquartile range (IQR): 10-33) years and 233 (53%) were females. The median number of days between symptom onset and admission was 4 (IQR 2-7). Of the 439 cases, 416 (95%) were tested for LF and 138 were confirmed with 33% positivity rate. The majority, 95 (69%), of confirmed cases were <30 years, 78 (57%) were females, and 81 (59%) were reported during the dry season (October – March). Contact with rodents, 95 (69%), was the commonest mode of exposure. Fever, 128 (93%), malaise, 121 (88%), headache, 114 (83%) and myalgia, 114 (83%) were the most common clinical presentations. There were 83 (19%) deaths among hospitalized suspected LF cases - 42 deaths (15%) among 278 individuals who tested negative and 41 among confirmed cases with 30% case fatality rate (CFR). Presenting CFR per age group, age 40-49 years accounted for 8/12 (67%) and those aged≥50 reported 5/8 (63%) of the deaths among the confirmed cases. There was no significant association between epidemiological characteristics and LF mortality. Conclusions The outbreak highlighted a high disease burden of LF with young adults disproportionately infected, and mortality, even among those who tested negative for the virus. This underscores the urgent need for preventive measures like vaccines and health education campaigns.

BackgroundLassa fever (LF) is an endemic and immediately notifiable disease in Liberia, and one laboratory confirmed case constitutes an outbreak. We described the epidemiological characteristics and hospital outcomes of LF cases hospitalized during the 2022-2023 outbreak in Liberia.MethodsA retrospective cohort study was conducted using routine LF surveillance data from the 2022-2023 outbreak in Liberia. Descriptive statistics were used to summarize the data and log binomial regression to assess the association between epidemiological characteristics and mortality.ResultsA total of 439 suspected LF cases were reported. The median age was 22 (interquartile range (IQR): 10-33) years and 233 (53%) were females. The median number of days between symptom onset and admission was 4 (IQR 2-7). Of the 439 cases, 416 (95%) were tested for LF and 138 were confirmed with 33% positivity rate. The majority, 95 (69%), of confirmed cases were <30 years, 78 (57%) were females, and 81 (59%) were reported during the dry season (October – March). Contact with rodents, 95 (69%), was the commonest mode of exposure. Fever, 128 (93%), malaise, 121 (88%), headache, 114 (83%) and myalgia, 114 (83%) were the most common clinical presentations. There were 83 (19%) deaths among hospitalized suspected LF cases - 42 deaths (15%) among 278 individuals who tested negative and 41 among confirmed cases with 30% case fatality rate (CFR). Presenting CFR per age group, age 40-49 years accounted for 8/12 (67%) and those aged≥50 reported 5/8 (63%) of the deaths among the confirmed cases. There was no significant association between epidemiological characteristics and LF mortality.ConclusionsThe outbreak highlighted a high disease burden of LF with young adults disproportionately infected, and mortality, even among those who tested negative for the virus. This underscores the urgent need for preventive measures like vaccines and health education campaigns.

Standardised forms for capturing clinical data promote consistency in data collection and analysis across study sites, enabling faster, higher-quality evidence generation. ISARIC and the World Health Organization have developed case report forms (CRFs) for the clinical characterisation of several infectious disease outbreaks. To improve the design and quality of future forms, we analysed the inclusion and completion rates of the 243 fields on the ISARIC-WHO COVID-19 CRF. Data from 42 diverse collaborations, covering 1,886 hospitals and 950,064 patients were analysed. A mean of 129.6 fields (53%) were included in the adapted CRFs implemented across the sites. Consistent patterns of field inclusion and completion aligned with globally recognised research priorities in outbreaks of novel infectious diseases. Outcome status was the most highly included (95.2%) and completed (89.8%) field, followed by admission demographics (79.1% and 91.6%), comorbidities (77.9% and 79.0%), signs &amp;amp;amp; symptoms (68.9% and 78.4%) and vitals (70.3% and 69.1%). Mean field completion was higher in severe patients (70.2%) than in all patients (61.6%). The results indicate that clinical characterisation CRFs can be streamlined to reduce data collection time, including the modularisation of CRFs to offer a choice of data volume collection and the separation of critical care interventions. This data-driven approach to designing CRFs enhances the efficiency of data collection to inform patient care and public health response.

The SARS-CoV-2 pandemic ignited global efforts to rapidly develop testing, therapeutics, and vaccines. However, the rewards of these efforts were slow to reach many low- to middle-income countries (LMIC) across the African continent and globally. Therefore, two bead-based multiplexed serological assays were developed to determine SARS-CoV-2 exposure across four counties in Liberia. This study was conducted during the summer of 2021 on 189 samples collected throughout Grand Bassa, Bong, Margibi, and Montserrado counties. Our multiplexed immunoassay (MIA) detected elevated exposure to SARS-CoV-2 and multiple variant antigens. Additionally, we detected evidence of exposure to Dengue virus serotype 2, Chikungunya virus, and the seasonal coronavirus NL63. Our multiplexed inhibition test (MINT) was developed from the MIA to observe antibody-mediated inhibition of SARS-CoV-2 spike protein binding to its cognate cellular receptor ACE-2. We detected inhibitory antibodies in the tested Liberian samples, which were collectively consistent with a convalescent serological profile. These complementary assays serve to supplement existing serological testing needs and may enhance the technical capacity of scientifically underrepresented regions globally.

IntroductionPerinatal mortality remains a pressing concern, especially in lower and middle-income nations. Globally, 1 in 72 babies are stillborn. Despite advancements, the 2030 targets are challenging, notably in sub-Saharan Africa. Post-war Liberia saw a 14% spike in perinatal mortality between 2013 and 2020, indicating the urgency for in-depth study.ObjectiveThe study aims to investigate the predictors of perinatal mortality in Liberia using 2013 and 2019–2020 Liberia Demographic and Health Survey datasets.MethodsIn a two-stage cluster design from the Liberia Demographic and Health Survey, 6572 and 5285 respondents were analysed for 2013 and 2019–2020, respectively. Data included women aged 15–49 with pregnancy histories. Descriptive statistics was used to analyse the sociodemographic characteristics, the exposure to media and the maternal health services. Bivariate and multivariate logistic regressions were used to examine the predictors of perinatal mortality at a significance level of p value ≤0.05 and 95% CI. The data analysis was conducted in STATA V.14.ResultsPerinatal mortality rates increased from 30.23 per 1000 births in 2013 to 42.05 in 2019–2020. In 2013, increasing age of respondents showed a reduced risk of perinatal mortality rate. In both years, having one to three children significantly reduced mortality risk (2013: adjusted OR (aOR) 0.30, 95% CI 0.14 to 0.64; 2019: aOR 0.24, 95% CI 0.11 to 0.54), compared with not having a child. Weekly radio listenership increased mortality risk (2013: aOR 1.36, 95% CI 0.99 to 1.89; 2019: aOR 1.86, 95% CI 1.35 to 2.57) compared with not listening at all. Longer pregnancy intervals (p<0.0001) and receiving 2+ tetanus injections (p=0.019) were protective across both periods. However, iron supplementation showed varied effects, reducing risk in 2013 (aOR 0.90, 95% CI 0.48 to 1.68) but increasing it in 2019 (aOR 2.10, 95% CI 0.90 to 4.92).ConclusionThe study reports an alarming increase in Liberia’s perinatal mortality from 2013 to 2019–2020. The findings show dynamic risk factors necessitating adaptable healthcare approaches, particularly during antenatal care. These adaptable approaches are crucial for refining health strategies in line with the Sustainable Development Goals, with emphasis on the integration of health, education, gender equality, sustainable livelihoods and global partnerships for effective health outcomes.

Suboptimal detection and response to recent outbreaks, including COVID-19 and mpox (formerly known as monkeypox), have shown that the world is insufficiently prepared for public health threats. Routine monitoring of detection and response performance of health emergency systems through timeliness metrics has been proposed to evaluate and improve outbreak preparedness and contain health threats early. We implemented 7-1-7 to measure the timeliness of detection (target of ≤7 days from emergence), notification (target of ≤1 day from detection), and completion of seven early response actions (target of ≤7 days from notification), and we identified bottlenecks to and enablers of system performance. In this retrospective, observational study, we conducted reviews of public health events in Brazil, Ethiopia, Liberia, Nigeria, and Uganda with staff from ministries of health and national public health institutes. For selected public health events occurring from Jan 1, 2018, to Dec 31, 2022, we calculated timeliness intervals for detection, notification, and early response actions, and synthesised identified bottlenecks and enablers. We mapped bottlenecks and enablers to Joint External Evaluation (second edition) indicators. Of 41 public health events assessed, 22 (54%) met a target of 7 days to detect (median 6 days [range 0-157]), 29 (71%) met a target of 1 day to notify (0 days [0-24]), and 20 (49%) met a target of 7 days to complete all early response actions (8 days [0-72]). 11 (27%) events met the complete 7-1-7 target, with variation among event types. 25 (61%) of 41 bottlenecks to and 27 (51%) of 53 enablers of detection were at the health facility level, with delays to notification (14 [44%] of 32 bottlenecks) and response (22 [39%] of 56 bottlenecks) most often at an intermediate public health (ie, municipal, district, county, state, or province) level. Rapid resource mobilisation for responses (six [9%] of 65 enablers) from the national level enabled faster responses. The 7-1-7 target is feasible to measure and to achieve, and assessment with this framework can identify areas for performance improvement and help prioritise national planning. Increased investments must be made at the health facility and intermediate public health levels for improved systems to detect, notify, and rapidly respond to emerging public health threats. Bill & Melinda Gates Foundation.

Liberia is a postwar, post-Ebola, and low-income nation in West Africa with minimal to no palliative care access. In 2017, Partners In Health in collaboration with the Liberian Ministry of Health invested in the development of a nurse-led, community-based palliative care team in southeastern Maryland County at JJ Dossen Memorial Hospital. Between 2017 and 2022, the 9-member team (8 nurses, 1 physician assistant) has enrolled 142 patients under their care. This is a qualitative process evaluation eliciting the experiences, perspectives, and attitudes of patients with cancer to inform future palliative care program delivery improvement and development. Using an exploratory design, n = 8 participants were interviewed using a semi-structured guide. The sample had a mean age of 48 years with an average palliative care clinic enrollment period of 22.5 weeks at the time of interview. The interdisciplinary coding team used an applied thematic text analysis approach and identified 5 themes: history and disease progression, follow-up clinic services, psychological distress and its sources, social support, and spiritual and cultural beliefs. Implications emphasize the need for increased community engagement, primary palliative care capacity development of clinical colleagues in the region, and the support of local and national decision-makers to prioritize palliative care service expansion.