Epidemic-Ready Primary Health Care and the Application of the 717 Metrics: A Case Study on a Measles Outbreak in Sierra Leone, January-March 2024
1ICAP Columbia University, Freetown, Sierra Leone
2ICAP Columbia University, New York, USA, Columbia University Mailman School of Public Health, New York, USA
3Resolve to Save Lives, Epidemic Ready Primary Health Care, Alexandria, Virgina, USA
4Minister of Health, National Public Health Association, Freetown, Sierra Leone
*Corresponding author: Oliver Eleeza, ICAP Columbia University, Freetown, Sierra Leone oe2160@cumc.columbia.edu, +232 78 855545Abstract
The COVID-19 pandemic exposed vulnerabilities in health systems’ abilities to detect, report, and respond to threats. Inadequate preparedness led to healthcare worker infections (HCW), essential service disruptions, and impacts on communities. Primary health care (PHC) is often overlooked in health security initiatives. Epidemic Ready Primary Health Care (ERPHC) is an initiative that strengthens PHC facilities to prevent, detect and respond to outbreaks, while maintaining essential services.
ICAP at Columbia University, the Ministry of Health of Sierra Leone, and Resolve to Save Lives is implementing a multi-year ERPHC project in Sierra Leone. A retrospective data review of 52 confirmed measles cases across four PHC facilities from January – March 2024 was conducted. Data is presented using an adapted 7-1-7 quality improvement approach for detection and notification to evaluate the key tenants of ERPHC: speed, safety, surge.
Out of 52 confirmed cases, 98% and 100% met the first “7” and “1” for detection and notification. Immediate case management and safety actions were completed for all 52 cases (100%). Zero facilities were able to implement two readiness parameters for surge: sufficient supplies and referral pathways. Key bottlenecks included late presentation to health facilities, delayed notification via the electronic case-based surveillance system, inadequate PPE, and no updated referral pathways.
These results underscore the need to scale and implement ERPHC, using adapted 7-1-7 metrics, in PHC facilities. HCW safety, increased community engagement, national supply chain mechanism strengthening, and established patient referral pathways need to be the foci of further health security investment in Sierra Leone.
Article notes
Competing Interest Statement
The authors have declared no competing interest.
Funding Statement
This work was funded #Startsmall. Funding was provided via Resolve to Save Lives.
Background information
How fast a health system detects and responds to a threat is a critical indicator of its emergency readiness and responsiveness [1, 2]. The COVID-19 pandemic and other recent outbreaks showcased vulnerabilities in health systems’ capacities to be resilient against emerging and re-emerging threats [3]. Healthcare worker (HCW) infections and essential service disruptions are consequences of health system vulnerabilities [4]. In low-resource settings, insufficient preparedness exacerbates existing challenges in fragile health systems, further compromising overall health security [4, 5]. Currently, most health security initiatives focus on national or immediate sub-national health system levels [6]. The role of primary healthcare (PHC) has been mostly overlooked in epidemic planning and preparedness initiatives: a critical oversight given that the entry points for most outbreaks are at the PHC level [6, 7]. Strengthening PHC, specifically the ability to detect, protect against, and respond to threats, can enhance early outbreak detection and response, thereby supporting health system resilience. The 7-1-7 targets were introduced to enable countries to assess and improve outbreak detection and response performance[8]. At the national and sub-national levels of the healthcare system, the approach assesses critical timeliness metrics for pathogens with outbreak potential, emphasizing detection (≤7 days from emergence), notification (target of ≤1 day from detection), and completion of relevant early response actions (target of ≤7 days from notification)[8]. A review of 7-1-7 implementation across five countries identified 61% of the bottlenecks to outbreak detection were at the PHC facility level, with low clinical suspicion among HCWs as the most frequently cited bottleneck[9].
Epidemic Ready Primary Health Care (ERPHC) strengthens PHC systems to effectively prevent, detect and respond to outbreaks, while maintaining essential services. Ensuring facilities can quickly identify cases (speed), manage them safely (safety), and handle increased patient volume (surge). The ERPHC approach builds HCW capacity to connect with communities, rapidly detect and report cases, protect themselves by applying infection prevention control (IPC) measures, and treat cases while maintaining essential services. Key interventions include continuous, real-time mentorship to increase HCW’s clinical index of suspicion for suspected cases of pathogens with outbreak potential, reviewing PHC facility data with HCWs, enhancing HCW IPC knowledge, and ensuring reporting mechanisms for alerts are established. Adapted from the national and sub-national approach, ERPHC uses a modified 7-1-7 tool tailored for the PHC level to assess epidemic readiness and drive improvements. It is applied to all confirmed cases at the facility, providing a broader understanding of performance and enhancing learning opportunities from real-life events. The tool looks at detection and notification timeliness to evaluate the speed of case detection and notification; immediate health facility case management actions to review the safety measures taken for both patients and HCWs; and health facility readiness for further cases to assess preparedness for potential surges in cases.
Current situation
Sierra Leone has faced many outbreaks, the most notable of these was the Ebola Viral Disease (EVD) outbreak in 2014 [10]. Since this time, there have been considerable investments in the country’s health system architecture to strengthen outbreak preparedness and response. The establishment of an electronic integrated disease surveillance and reporting system (IDSR) and a national IPC program are examples of health system improvements achieved since the end of the EVD outbreak [11–13]. Yet, despite these gains, significant challenges remain. In November 2019, an outbreak of Lassa Fever resulted in the infection of five HCWs [14]. While an epidemiologic link was established among all cases, it took 20 days to detect the index case [15]. After action reviews (AARs) identified gaps including delays in accessing local emergency funding, reporting delays via the electronic case-based surveillance (eCBDS) system, and electronic IDSR (eIDSR) systems, and late distribution of laboratory supplies and PPE [16].
Since January 2024, ICAP at Columbia University (ICAP), in partnership with Resolve to Save Lives (RTSL), the Ministry of Health (MOH), District Health Management Teams (DHMTs), and the National Public Health Agency has implemented the ERPHC model. This case study aims to provide a detailed analysis of the ERPHC model’s implementation in Sierra Leone’s PHC facilities during a measles outbreak utilizing an adapted version of the 7-1-7 metrics. By examining relevant findings and lessons learned, the study seeks to assess the effectiveness of the ERPHC model in enhancing outbreak preparedness and response within PHC facilities.
Methods
Design
The study used a retrospective design to assess a measles outbreak that occurred between January 1 and March 31, 2024. An adapted, standardized data collection tool based on the 7-1-7 metrics, incorporating both survey-based and open-ended questions was used to gather information from multiple sources, including IDSR case-based notification forms, the eCBDS system, PHC facility reports, and AAR discussions with HCWs who managed the measles cases. This design allowed for a comprehensive evaluation of outbreak management practices and timelines.
Setting
The ERPHC model is being implemented across 80 PHC facilities in five districts: Western Area Urban, Western Area Rural, Bombali, Port Loko, and Kenema. These districts collectively represent approximately 43% of Sierra Leone’s total population [17].
This case study examines the implementation of the ERPHC model in two of the ERPHC supported districts— Port Loko and Bombali —focusing on four PHC facilities that managed confirmed measles cases. Amongst these PHC facilities, there were 2 Community Health Centers (CHCs), which typically have 10-15 staff members and offer preventive and curative services with a population of 10,000 to 30,000 or more within 15 km, 2 Community Health Posts (CHPs), which offer basic maternal and child health services to 5,000 to 10,000 individuals within 8 km (5 miles) radius and has 1-3 staff members[18].
In Sierra Leone, PHC facilities utilize multiple channels to report suspected measles cases and other priority pathogens identified by HCWs. Alerts can be communicated via text message (SMS), WhatsApp, or phone calls to higher levels of the health system, such as the DHMT and the central MOH. Additionally, all suspected cases of priority pathogens can be directly entered into the eCBDS or weekly aggregate eIDSR systems.
Population
A total of 52 measles cases detected at four PHCs comprised the population. This case study focused on cases that met the following criteria:
Inclusion Criteria: Suspected measles cases that were subsequently confirmed and detected at PHC facility implementing the ERPHC model from January 1 – March 31, 2023.
Exclusion Criteria: Cases were excluded if they did not receive confirmation of measles or were outside the ERPHC facility catchment area.
Data collection Tool
A standardized data collection tool, adapted from the 7-1-7 outbreak assessment framework, was used in this case study to assess PHC facility readiness (see Annex 1). The tool was organized into four key sections: 1) background information; 2) timeliness metrics for detection and notification; 3) immediate case management and safety actions; and 4) facility readiness to manage a surge in cases, assessed through ten critical readiness actions. By identifying strengths, gaps, and areas for improvement, the tool provided actionable insights to enhance PHC preparedness and response capabilities.
Data collection Process
Data collection was conducted by a team of two ICAP staff, two DHMT IPC focal persons, and two IDSR focal persons. They used the data collection tool to extract information on measles cases from PHC facility registers, case-based notification forms, and the eCBDS system. Additionally, nine HCWs, including four facility managers and five nurses who managed suspected cases, were interviewed during an AAR using survey-based and open-ended questions. These focused on safety measures and surge capacity. Data were collected over five days at four PHC facilities, initially recorded on paper, and later entered into Microsoft Excel for analysis. Prior to data collection, ICAP and DHMT staff participated in a one-day orientation to ensure consistency in tool use, data abstraction, and interview techniques.
Data management
The dataset was reviewed to ensure completeness, accuracy, and logical consistency. At the PHC level, all required fields were populated according to predefined specifications, with no critical information omitted. The data collection team verified PHC facility records with the eCBDS system to minimize discrepancies. Transcription errors were identified and corrected, while analytical checks flagged and resolved inconsistencies and anomalies. No personally identifiable information was collected, and all data were anonymized, securely stored, and accessible only to authorized personnel.
Analysis
Descriptive statistics were used to calculate the number of cases meeting the targets for timely detection (Dd-Do ≤7 days) and notification (Dn – Dd ≤1 day) (see Box 1).
Definitions for measures of detection and notification (Speed)
To assess safety, descriptive statistics were used to calculate the number of cases that: 1.) were isolated at the PHC, 2.) had HCWs use the appropriate PPE for a suspected case of measles, and 3.) received correct actions for clinical case management (see Annex 1). Additionally, HCWs’ perceptions of safety requirements were analyzed using thematic analysis.
To assess surge readiness capacity, calculations on the proportion of PHC facilities that met each of the 10 requirements for PHC surge readiness during the measles outbreak were conducted (see Annex 1). Additionally, HCWs’ perceptions on surge requirements were analyzed using thematic analysis.
All data collected using the data collection tool for each PHC facility can be reviewed in Annexes 2-4.
Results
A total of 52 measles cases were detected in PHC facilities implementing ERPHC. Of the 80 PHCs implementing the ERPHC model, four PHC facilities received measles cases. One PHC facility detected 49 confirmed cases representing 94% of all 52 cases assessed, with an average volume of two cases per day [median: 1 (1-5)]. The remaining three PHC facilities had one confirmed case each (6%). Table 1 below provides details of PHC facilities performance on detection and notification metrics (speed).
Of the 52 confirmed cases, 51 (98%) met the target for the “first 7” of the 7-1-7 metrics for detection. (see Table 1). The PHC with the most cases (n=49) had a range for detection of 1-12 days. This PHC reported a single case on day 12, when the suspected case presented to the PHC and had already had symptoms for 12 days prior. The other 48 cases at this PHC facility were detected within the 7-day range, making the median time to detection for all four PHC facilities 3 days.
Of the 52 confirmed measles cases, 52 (100%) met the “the 1” of the 7-1-7 metrics for notification. All alerts were notified via SMS, WhatsApp message, or phone call to the DHMT. All alerts were eventually notified via the eCBDS system, though not within the targeted one-day timeframe. Only 44% (23/52) met “the 1” target using the eCBDS system, which directly notifies the national level of a threat. Reasons for these delays included HCW workload, technological challenges and limited connectivity.
Table 2: depicts the number of cases (n=52) where immediate case management actions to ensure HCW and patient safety were implemented. Specifically, HCWs placed measles cases into isolation (n=52, 100%)) donned the correct PPE (n=52, 100%), and provided initial treatment based on SOPs (n=52, 100%) (Table 2). The IPC job aides, SOPs, and HCWs’ training, and case management protocols were identified as enablers to successful implementation of case management safety actions.
Table 3 details the surge parameters for HF readiness at the four PHC facilities that detected measles cases.
All four (100%) PHC facilities were able to implement readiness parameters for surge requirements 1-8. None of the PHC facilities were able to implement readiness parameters for surge requirements 9 and 10. Supply chain issues, limited PPE availability, and no referral pathways were identified as key bottlenecks.
In discussion with HCWs during an AAR, HCWs stated that not having PPE supplies was the top bottleneck for keeping them safe. HCWs reported that not having adequate supplies, including PPE, as well as a lack of updated referral pathways at the PHC were key bottlenecks for surge capacity. HCWs identified IPC mentorship that allowed for an increase in clinical suspicion of a priority pathogen, SOPs/job aides, and case management protocols as implementation enablers.
Discussion
Primary healthcare facilities, implementing the ERPHC model, were largely successful in achieving the detection and notification targets of the 7-1-7 metrics adapted for PHCs. This achievement shows that with increased investment in continuous, real-time mentorship at the PHC level, HCWs can improve their clinical index of suspicion and rapidly identify and notify a suspected case of a pathogen of outbreak potential.
Regarding speed of detection (“first 7”), the health facility reporting the highest number of cases (49) had a detection range of 1–12 days. Notably, only one patient presented on day 12, reflecting a delay in seeking care following symptom onset. Despite this delay, HCWs at the facility promptly suspected measles upon the patient’s arrival and notified the case. The remaining 48 cases were detected within the critical window of 1–7 days, resulting in a median detection time of 3 days for the facility. All confirmed measles cases were successfully reported within 1 day using SMS, WhatsApp, or phone. However, only 44% percent of the alerts were notified within 1 day via the eCBDS or eIDSR platforms, which go directly to the national level - that can initiate rapid response teams (RRT), emergency funds, and declare an outbreak – for response initiation. Reasons for this lack of eCBDS utilization by HCWs was related to technological challenges, insufficient internet capacity, and the three other options (SMS, WhatsApp, phone) allow for reporting mechanisms to be returned to the HCW. Messages of receipt and dialogue with another individual at the DHMT may provide reassurance and encouragement to HCWs, compared to entering information into the electronic platforms, where the imported information is sent off and no information returned to the HCW. This lack of returned communication to HCWs using the eCBDS system, while reporting on the same pathogen over and again during an outbreak, may lead to report fatigue. Human-to-human communication may be the key to increase HCW reporting.
The safety actions were also achieved with great success in this case study, mostly likely attributed to the integrated interventions of the ERPHC model. The ERPHC approach integrates surveillance, IPC, and case management into mentoring to ensure that HCWs are equipped to detect and report cases, understand the necessary IPC measures to ensure their safety, and provide appropriate treatment to patients. These three areas: surveillance, IPC, and case management, are typically siloed and focused on independently of the other. Based on the results of this case study, integrating them together better equips HCWs at PHCs for outbreaks.
Regarding the two surge actions that no PHC facility successfully implemented—adequate supplies and a referral pathway for cases—these shortcomings may be linked to challenges in national supply chain mechanisms and the absence of SOPs during the early months of ERPHC implementation. During outbreaks, HCWs often lack sufficient PPE to ensure their own safety and that of their patients. While PHC facilities implementing the ERPHC model are not immune to these challenges, this should not be accepted as the norm.
Limitations
There were limitations to this case study. First, retrospective data collection may have led to recall bias by HCWs at the PHC facilities during the AAR. Second, the PHCs in this case study may not be reflective of PHCs in Sierra Leone, in that they received interventions that are not routine in other PHC facilities. Thus, these results may not be generalizable to other PHC facilities. Despite these limitations, the insight this case study provides can better prepare PHC facilities for outbreaks
Recommendations and Conclusions
This case study demonstrates the effective application of the adapted 7-1-7 metrics at the PHC level, showing that these metrics, traditionally employed at national and subnational levels, can be successfully modified and implemented at lower tiers of the health system to assess and enhance epidemic readiness. To strengthen preparedness for future outbreaks, the ERPHC model should be prioritized, scaled up, and adequately resourced as a fundamental health security intervention in Sierra Leone. Expanding this approach at the PHC level is essential for building resilient health systems and ensuring timely, effective outbreak responses.
Community engagement is a cornerstone of effective outbreak response. Delayed presentation to PHC facilities exacerbates transmission, highlighting the importance of ensuring that communities are promptly informed of outbreaks. Establishing direct links between communities and PHCs—through community health workers or focal points—enables the rapid dissemination of risk communication and educational materials at the onset of an outbreak. Reducing the time between symptom onset, case detection, and notification of epidemic-prone pathogens is crucial for expediting response actions, enhancing outbreak control efforts, and preventing further transmission.
Ensuring HCW safety through comprehensive interventions is also critical. This case study underscores the need to proactively address PHC infrastructural gaps and supply chain challenges ahead of outbreaks to mitigate their impact. PHCs must have reliable communication systems, internet connectivity, and functional technologies for the swift reporting of suspected cases. Beyond infrastructure, HCWs must feel supported by these systems, receiving timely, reliable guidance to manage suspected cases effectively, particularly under stressful conditions. To prevent overcrowding and minimize HCW exposure to high-risk environments, robust referral pathways should be established to appropriately direct patient care. Additionally, addressing supply chain issues is essential, as limited access to personal protective equipment (PPE) places HCWs at increased risk of infection. Prepositioning PPE at PHC facilities ensures that HCWs can protect themselves when managing suspected cases of epidemic-prone pathogens.
Prioritizing community engagement and HCW safety measures is vital for achieving strong outbreak preparedness and enhancing health security. The early results from the ERPHC model in Sierra Leone demonstrate its potential to drive significant improvements in preparedness actions at the PHC level. This case study illustrates the benefits of adapting and utilizing the 7-1-7 metrics at health facilities to better understand performance, readiness, and to drive improvements. By fostering timely, proactive interventions, the ERPHC model can further bolster health system resilience, address systemic vulnerabilities, and improve the capacity to manage outbreaks effectively. Ultimately, these early actions are crucial to ensuring that Sierra Leone protects its most valuable asset during outbreaks: its people.
Annexes
Acknowledgements
We thank the Ministry of Health and National Public Health Agency in Sierra Leone for their efforts in implementing this initiative. Our collaborative partner Resolve to Save Lives for co-implementation support.
Contributors
OE and AEBC conceived the paper and served as the primary authors. SMS and SM contributed to the conceptualization and provided substantial editorial input. OE, AN, RM, MT, AY contributed data to the manuscript. OE analyzed the data. All authors reviewed and edited the final draft of the manuscript. All authors were involved in the design and implementation of the ERPHC pilot.
Funding
This work was funded #Startsmall. Funding was provided via Resolve to Save Lives.
Competing interests
Not applicable
Ethics statements
This work was determined to be exempt human subjects research by the Columbia University Institutional Review Board and Resolve to Save Lives Research Committee. Approvals to disseminate findings or IRB review and approval was obtained as required in each country.
Patient consent for publication
Not applicable
Provenance and peer review
Not commissioned, external peer review
Data Availability Statement
All data relevant to the study are included in the article or uploaded as online supplemental information.