WATHI propose une sélection de documents sur le contexte économique, social et politique au Liberia. Chaque document est présenté sous forme d’extraits qui peuvent faire l’objet de légères modifications. Les notes de bas ou de fin de page ne sont pas reprises dans les versions de WATHI. Nous vous invitons à consulter les documents originaux pour toute citation et tout travail de recherche.
Maladie à virus Ebola, rapport de situation
Organisation mondiale de la santé
L’urgence de santé publique de portée internationale liée à Ebola en Afrique de l’Ouest a été déclarée terminée le 29 mars 2016. Au total, 28 616 cas confirmés, probables et suspects ont été notifiés en Guinée, au Libéria et en Sierra Leone, dont 11 310 décès.
Dans le dernier foyer de cas, sept cas confirmés et trois cas probables de maladie à virus Ebola ont été notifiés entre le 17 mars et le 6 avril par les préfectures de N’Zérékoré (neuf cas) et Macenta (un cas) dans le sud-est de la Guinée. Entre le 1er et le 5 avril, trois cas confirmés ont également été notifiés à Monrovia (Libéria) ; il s’agit de la femme et des deux enfants du cas de Macenta, qui se sont rendus à Monrovia. Au Libéria, le dernier cas a obtenu un deuxième résultat négatif le 28 avril 2016.
La résilience des femmes : Intégrant le genre dans la réponse à l’Ebola
Banque africaine de développement
Accès aux services de santé
Avec la fermeture de certaines installations médicales et la priorité donnée à la lutte contre le virus Ebola, l’accès des femmes aux services de santé pour le traitement d’affections non liées à Ebola s’est réduit sensiblement. L’utilisation des contraceptifs était relativement faible avant Ebola, en Guinée, au Liberia et en Sierra Leone ; qui plus est les femmes avaient un accès très limité au contrôle des naissances et aux services de planification familiale. En Sierra Leone, par exemple, la clinique obstétrique Marie Stopes, à Freetown, a signalé que les méthodes de planification familiale avaient reculé de 90 % rien qu’entre mai et août 2014. De même, les femmes enceintes et les mères allaitantes éprouvent de grandes difficultés pour accéder aux services de santé.
La maladie à virus Ebola a compromis les progrès réalisés dans la réduction de la mortalité maternelle et infantile dans les trois pays. En octobre, le Fonds des Nations Unies pour la population (FNUAP) a corroboré ces hypothèses, au vu des estimations selon lesquelles sur plus de 800 000 femmes donnant naissance en une année en Guinée, au Liberia et en Sierra Leone, 120 000 femmes connaîtraient de graves complications en cours de grossesse et au moment de l’accouchement.
Accès aux services de santé et aux infrastructures
L’épidémie de maladie à virus Ebola a mis au jour les graves problèmes que pose le manque d’infrastructures – routières et énergétiques, en particulier – pour les trois pays contaminés au début de l’épidémie et encore aujourd’hui dans des foyers reculés de la maladie. Le mauvais état de routes plutôt limitées dans la région complique fortement le déplacement d’équipes médicales et de matériel médical dans les zones reculées. Cela a retardé également le diagnostic de la maladie à virus Ebola, plusieurs jours étant nécessaires pour transporter les prélèvements sanguins vers les laboratoires.
Il s’en est suivi un retard pour relayer les informations critiques aux patients suspectés d’être contaminés, ce qui n’a fait qu’accroître l’anxiété et la frustration du personnel médical et des patients. Au nombre des problèmes d’infrastructures qui ont entravé la lutte contre la maladie à virus Ebola figurent le manque d’hébergement décent pour les équipes médicales et l’insuffisance de volontaires pour se rendre auprès des malades dans les zones reculées. Pour remédier à cela, une rotation coûteuse d’équipes médicales a été nécessaire sur de plus courtes périodes, pour permettre un temps de repos et de récupération.
D’après un rapport déposé par ActionAid Liberia, les femmes qui ont perdu un mari subvenant à leurs besoins à cause d’Ebola sont marquées de multiples façons. Christina Scotland, 33 ans, veuve enceinte déjà mère de quatre enfants, a été stigmatisée par ses voisins et a perdu sa maison. Aujourd’hui sans travail, elle déplore le décès tragique de son mari médecin, survenu en octobre, et le lourd tribut psychosocial que lui impose Ebola.
De même, pour reprendre les propos du Dr Wvannie-Mae Scott McDonald, administratrice en chef du centre médical John F. Kennedy, à Monrovia : « Soigner quelqu’un c’est aussi le réconforter et le consoler. Ebola nous a privés de tout réconfort. Il nous a pris notre humanité »36. La stigmatisation des familles des victimes, des survivants d’Ebola, des équipes d’inhumation et du personnel de santé a blessé psychologiquement des communautés entières dans la sous-région de l’Union du fleuve Mano, surtout les femmes, qui subviennent aux besoins de leur famille et soignent leur entourage.
En dehors de la stigmatisation, Ebola a pour conséquence inattendue une perturbation de l’ordre public pouvant exposer les femmes à une violence sexiste exacerbée et à l’exploitation sexuelle. Le déploiement de forces de sécurité et d’un dispositif militaire pour maintenir en quarantaine des communautés entières au Liberia et en Sierra Leone, par exemple, a fait revivre le traumatisme de la guerre et a probablement exposé les femmes à un traumatisme supplémentaire. Il y a lieu de mener des recherches et d’intervenir au niveau des politiques dans ce domaine, compte tenu du manque d’éléments factuels sur le sujet à l’heure actuelle. L’impact psychosocial d’Ebola sur les communautés de femmes dans les trois pays mérite que l’on y accorde une attention critique, surtout pour les femmes confrontées à de multiples pertes à plusieurs niveaux.
Par exemple, des jeunes femmes se sont retrouvées seules à s’occuper d’orphelins de leur entourage. C’est le cas de Siatta et de Famatta, deux sœurs âgées respectivement de 30 et 32 ans, qui vivent à Kakata, dans le comté de Margibi, au Liberia et élèvent aujourd’hui seules six enfants depuis le décès de leur mère, de leur père et de cinq autres membres de leur famille à cause de la maladie. Sans revenus stables ni filets de sécurité sociale pour les aider, ces deux jeunes Libériennes auront d’énormes difficultés à s’en sortir.
Ebola and Its Control in Liberia, 2014–2015
Centers for Disease Control and Prevention
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In Liberia, Ebola virus disease was first reported from Lofa County on March 30, 2014, a week after cases in Guinea had been reported. On August 4, 2014, the US ambassador to Liberia declared a disaster; on August 6, the president of Liberia declared a state of emergency; and on August 8, the World Health Organization (WHO) called Ebola in West Africa a public health emergency of international concern. However, on June 29, 2015, a postmortem diagnosis of Ebola was made for a 17-year-old boy, and 5 other cases were subsequently confirmed, but no further spread was noted. Liberia was again declared free of Ebola on September 3, 2015
Incident Management System and Coordination of the International Response, July–September 2014
The government of Liberia initially set up a diverse Ebola Task Force, whose large size and organizational challenges handicapped its effectiveness. In late July 2014, supported by the US Centers for Disease Control and Prevention (CDC), WHO, and other partners, the Liberia Ministry of Health and Social Welfare (MOHSW) implemented an Incident Management System (IMS) with an incident manager devoted exclusively to Ebola. Separately, the president convened the Presidential Advisory Committee on Ebola, a small group of senior officials and international partners who provided advice about sensitive matters and policy.
Surveillance, Epidemiology, and Laboratory Diagnosis, July 2014–May 2015
An early priority for directing the response was surveillance. Timely reconciliation of data from multiple sources proved challenging. Constraints included shortage of trained staff, lack of communication and information technology, poor internet and mobile phone coverage, and lack of transport from remote locations.
In July 2014, only 1 laboratory, at the Liberia Institute for Biomedical Research outside Monrovia, was able to conduct Ebola testing, with support from the US National Institutes of Health and the US Army Medical Research Institute of Infectious Diseases. By December 2014, real-time reverse transcription PCR testing for Ebola genomic RNA was available at 10 laboratories nationwide.
Patient Isolation, Case Management, and Epidemic Trends, July–November 2014
The IMS emphasized 4 pillars for interrupting Ebola transmission: 1) early detection, isolation, and treatment of cases; 2) safe transport of patients with suspected cases; 3) safe burial; and 4) infection prevention and control (IPC) in healthcare settings. Isolating persons with Ebola was an immediate, overriding objective. Initially, contact tracing was difficult because of the large number of cases and the urgent need to isolate patients and dispose of cadavers.
By November 2014, the epidemic was characterized by low numbers of cases overall, about half in Monrovia and the rest in small clusters in remote locations across the country, frequently initiated by infected travelers from the capital. Lower case counts and increased staff facilitated data reconciliation. Manual matching of laboratory results with ETU and burial data became logistically feasible. Although incomplete, verified laboratory data proved the most useful indicator of epidemic trends.
Management of Cadavers, July–December 2014
Ebola testing of postmortem blood or oral swab samples enabled detection of unrecognized Ebola cases and assessment of excess deaths resulting from Ebola. In Monrovia, swampy topography and heavy rains in early August 2014 led to resurfacing of recently buried bodies, causing public outrage. The president of Liberia decreed mandatory cremation, a taboo that was accepted reluctantly and incompletely.
Ebola virus–positive cadavers in Montserrado County peaked at 380 during the week of September 15, 2014. From October to December, the estimated proportion of Ebola virus–positive cadavers in Montserrado County declined from 35% to 5%. However, the proportion of all bodies collected by burial teams was estimated at <50%, even lower outside of Montserrado County.
Ebola in Healthcare Workers and IPC, July 2014–May 2015
Early investigations demonstrated greatly increased risk for Ebola among healthcare workers, who accounted for 97 (12%) of 810 cases reported by mid-August 2014. The greatest proportions of cases were in nurses and nurse aides (34/97; 35%) and physicians and physician assistants (17/97; 18%). Over the course of the epidemic in Liberia, 378 healthcare workers had confirmed cases of Ebola and 192 died (case-fatality rate 50.8%). These numbers represent 12% (378/3,157) of all confirmed cases and 4% (192/4,808) of all Ebola deaths.
Social Mobilization and Public Communication, August 2014–March 2015
Liberia has a strong tradition of oral communication; therefore, thousands of general community health volunteers were trained to share health messages locally. In October 2014, traditional leaders convened and resolved to support government interventions, opening another trusted channel of health information.
Novel methods were instituted, such as providing traditional chiefs with mobile phones to report suspected cases. The evidence-based “Ebola Must Go!” campaign defined 5 essentials in commonly used language: safe burial, rapid isolation of suspected cases, provision of treatment, identification and 21-day monitoring of contacts, and encouragement to speak out against concealment of illness.
Getting to Zero in a Declining Epidemic, Mid-November 2014–May 2015
Starting in mid-November 2014, several events heralded the waning of the epidemic in Liberia. About half of Ebola cases were now part of discrete rural outbreaks often affecting villages so remote that even motorcycles could not reach them. The IMS promoted the Rapid Isolation and Treatment of Ebola (RITE) strategy, which empowered county authorities, with support from partners, to respond quickly to remote hot spots. Essentials were engagement of community leaders, community education, active case finding and contact tracing, quarantine of high-risk contacts, isolation and care for patients, and safe burials.
Application of fundamental principles—suspect case isolation, rapid diagnosis, and contact tracing—yielded results but required different tactical approaches in varied settings. Ebola had become less widespread, enabling recognition of individual transmission chains in a way not possible earlier. By December 2014, <10 cases were being reported daily, and focus turned to case investigation and contact tracing around laboratory-confirmed cases.
Liberia was ready to be declared free of Ebola when on March 20, 2015, an Ebola diagnosis was confirmed for a 44-year-old woman in Monrovia, who died 1 week later. This patient represented the last Ebola case in the second phase of the Liberia epidemic. On June 29, 2015, a third epidemic phase began with 6 cases in Margibi and Montserrado Counties without further spread; the origin of infection in the index case-patient was uncertain. Liberia was again declared free of Ebola on September 3, 2015.
Essentials in Containing Ebola, July 2014–September 2015
No single factor explains Liberia’s control of Ebola, and at least 6 issues deserve mention: 1) government leadership and sense of urgency, 2) coordinated international assistance, 3) sound technical work, 4) flexibility guided by epidemiologic data, 5) transparency and communication, and 6) efforts by communities themselves.
Community engagement resulted in remarkable behavior change. Physical contact with others ceased; chlorinated handwashing stations sprang up everywhere; and in-country movement reduced. The presidential order for cremation of cadavers in Monrovia was generally respected. By contrast, forcible isolation of case-patients and quarantine of a slum community in Monrovia in August 2014 led to violence, to which the government responded, commendably, with dialogue.
The president and government communicated clearly and honestly. The “Ebola is Real” and “Ebola must Go!” campaigns transmitted critical information and may have contributed to community resistance being less extensive there than elsewhere. In retrospect, the response would have been enhanced by much greater investment early on in all aspects of data management, including selection of the most appropriate database.
Staying at Zero and Beyond, May 2015–September 2015
After the Ebola epidemic, the 2 priorities in Liberia are ensuring rapid recognition and containment of resurgent disease and restoring health services to prevent loss of life from traditional concerns such as vaccine-preventable diseases or malaria. The most likely sources of new cases will be importations from Sierra Leone or Guinea, unrecognized transmission chains within Liberia, or sexual transmission from survivors.
Healthcare facilities should maintain clinical suspicion for Ebola and surveillance among healthcare workers, a sentinel population. Simplifying and expanding Ebola testing without all tests triggering ETU admission and contact tracing will be necessary.
Investment is needed in surveillance, laboratory strengthening, emergency operations center support, epidemiology expertise, outbreak response capacity (including risk communication and health promotion), and the ability to base decisions on data. In retrospect, it was lack of such public health systems that enabled the Ebola epidemic to grow in West Africa with such devastating consequences.
Ebola survivors in West Africa, who number in the thousands, have suffered stigma and discrimination, now exacerbated by the possibility of sexual transmission. Many Ebola infections resulted from acts of compassion, such as assisting the sick or participating in funerals. Ostracism of survivors would be an unacceptable conclusion to this unique event in global health, the response to which has been a credit to the government and people of Liberia.
Added in Proof
Since acceptance and publication on-line of this report, a 15-year-old-boy in Montserrado county tested positive for Ebola on November 22, 2015 and died the next day. Two other family members subsequently tested positive and survived. Rapid response and containment were achieved using the containment strategies and procedures outlined in this report. The source of the cluster was believed to be viral re-emergence in a persistently infected survivor. Liberia was again declared Ebola-free on January 14, 2016.
Liberia, Demographic and Health Survey, 2013
Liberia Institute of Statistics and Geo-Information Services (LISGIS) Monrovia ; Liberia Ministry of Health and Social Welfare Monrovia, Liberia ; National AIDS Control Program Monrovia, Liberia ; ICF International Inc. Rockville, Maryland, USA
Marriage and sexual activity
Polygyny (the practice of having more than one wife) has implications for the frequency of exposure to sexual activity and, therefore, fertility. The percentage of currently married women who report that their husband has no other wives is higher than the figure reported in the 2007 LDHS (86 percent versus 78 percent, respectively). There is an inverse relationship between education and polygyny. Women with no education are less likely to report having no co-wives (82 percent) compared with women with at least some secondary education (91 percent). There is also an inverse relationship between wealth and polygyny. Although 83 percent of currently married women in the lowest two wealth quintiles report that they have no co-wives, 90 percent of women in the highest wealth quintile report no co-wives.
Age at first sexual intercourse
The median age at first intercourse among women age 25-49 is 16.2 years. Liberian men exhibit a slightly older median age at first intercourse compared with women. Among men age 25-49, the median age at first intercourse is 18.3 years.
The total fertility rate for Liberia is 4.7 children per woman. This represents a decrease since the 2007 LDHS, which reported 5.2 children per woman. The median age at first birth among women 20-49 is 18.9 years. Fertility among urban women (3.8 children per woman) is markedly lower than among rural women (6.1 children per woman).
Teenage pregnancy and motherhood
The issue of adolescent fertility is important for both health and social reasons. Children born to very young mothers are at increased risk of sickness and death. Overall, 31 percent of women age 15-19 have begun childbearing.
The ideal number of children is 4.8 for all women and 5.0 for all men. Overall, 69 percent of all births were wanted at the time of conception, 26 percent were reported as mistimed (wanted later), and 5 percent were unwanted. The total wanted fertility rate is 4.0 children per woman, compared with the actual fertility rate of 4.7 children per woman.
Women in rural areas have a larger gap between their actual and wanted fertility (1.0) than do women in urban areas (0.5). Women with higher levels of education as well as those in the higher wealth quintiles seem to be the most successful in achieving their fertility goals.
Knowledge of at least one method of contraception is nearly universal in Liberia: 98 percent of women and 95 percent of men have heard of at least one method. The contraceptive prevalence rate has increased to 20 percent among currently married women. In 2007, this rate was only 11 percent. A majority of modern contraceptive users obtain their contraceptives from the public sector (64 percent). Only 13 percent of women know that they are most fertile midway between two menstrual periods.
Thirty-one percent of currently married women have an unmet need for family planning services (22 percent for spacing and 9 percent for limiting births). Among currently married women, only 39 percent of the demand for family planning has been satisfied.
Infant and Child Mortality
The under-5 mortality rate in Liberia is 94 deaths per 1,000 live births. That is, about 1 in 11 Liberian children dies before they reach age 5. The infant mortality rate, or deaths before the first birthday, is 54 deaths per 1,000 live births. About half of these occur in the first month of life. Under-5 mortality has been cut in half over the 15 years prior to the 2013 LDHS; neonatal, postneonatal, infant, and child mortality all declined as well over this 15-year span.
Survey data show that spacing births farther apart could have an enormous impact on reducing under-5 mortality in Liberia.
High-risk fertility behaviour
Typically, infants and young children have a higher risk of dying if they are born to very young mothers or older mothers, if they are born after a short birth interval, or if their mothers have already had many children.
Maternal Health Care
Ninety-six percent of women age 15-49 who gave birth in the five years preceding the survey received prenatal care from a skilled provider during pregnancy for their most recent birth. Eighty-four percent of the women who gave birth in the five years preceding the survey received two or more tetanus toxoid injections during pregnancy, ensuring that their most recent live birth was protected against neonatal tetanus.
Fifty-six percent of live births in the five years preceding the survey took place in a health facility, and 61 percent of live births were delivered by a skilled provider. Among women who gave birth in the two years preceding the survey, 71 percent received a postnatal checkup within the first two days after birth, and 57 percent received the checkup from a skilled provider.
Among women who had a birth in the two years preceding the survey, 35 percent of their newborns received a postnatal check-up in the first two days after birth, and 30 percent received a check-up from a skilled provider. Forty-seven percent of women report that getting money for treatment is a problem in accessing health care when they are sick; 40 percent of women indicate that distance to a health facility is a problem.
Place of Delivery
There is a strong correlation between a mother’s education and place of delivery, and between household wealth and place of delivery. Births to mothers with secondary and higher education are much more likely to take place in a health facility than births to mothers with no education (72 percent compared with 45 percent).
Postnatal Care for the Mother
A large proportion of maternal and neonatal deaths occur during the first 48 hours after delivery. Safe motherhood programs recommend that all women receive a check of their health within two days after delivery. Women who deliver at home should go to a health facility for postnatal care services within 24 hours.
Problems in Accessing Health Care
The most common factor impeding women from accessing health care for themselves is getting money to pay for treatment; 47 percent of the women highlighted this concern. Distance to a health facility was cited by four in ten women as a big problem in accessing health care (40 percent). As expected, women residing in rural areas were more likely than those in urban areas to report distance as a big problem (63 percent compared with 26 percent). Eight percent of women reported getting permission to go and 25 percent reported not wanting to go alone as big problems in accessing health care. The percentage of women who reported each of these factors as big problems in seeking medical care generally decreased with increasing educational attainment and wealth quintile.
Health interventions undertaken to improve maternal health in Liberia include prenatal care, delivery, postnatal services, intermittent preventive treatment of malaria during pregnancy, family planning, and tetanus toxoid immunization. Other support interventions include the construction of maternal waiting homes to facilitate institutional and skilled delivery, procurement of ambulances for referrals, and provision of insecticide-treated nets and a “mama and baby kit” to stimulate institutional delivery and prenatal care visits. The mama and baby starter kit is a package of assorted items such as a baby towel, soap, baby powder, and blanket provided to mothers upon delivery to encourage institutional delivery.
By mothers’ estimates, 20 percent of all infants born alive in the five years preceding the survey were very small or smaller than average at birth. Among infants with a birth weight, 10 percent weighed less than 2.5 kg. Fifty-five percent of children ages12-23 months were fully vaccinated at the time of the survey; 48 percent of this age group had received all basic vaccinations by age 12 months.
Seven percent of children under 5 experienced symptoms of an acute respiratory infection (ARI) in the two weeks preceding the survey. Among those with symptoms, advice or treatment from a health facility or provider was sought for half (51 percent), and slightly more than half (56 percent) received antibiotics. Twenty-nine percent of children under 5 had a fever within the two weeks preceding the survey. Among those with a fever, 58 percent were taken to a health facility or provider for advice or treatment, 56 percent received antimalarial drugs, and 39 percent received antibiotics.
Twenty-two percent of children under 5 had diarrhea in the two weeks preceding the survey. Nearly one-half of the children with diarrhea (47 percent) were taken to a health facility or provider. Three in four (76 percent) of the children with diarrhea were treated with oral rehydration therapy (ORT) or increased fluids. Eight percent of children with diarrhea did not receive any type of treatment.
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