Food Hygiene and Safety Practices amongst Food Vendors in the Western Area, Sierra Leone

Food safety and hygiene practices require a multisectoral approach including food, water, sanitation, waste management, transport, education, trade, policies and programs that enable safe food preparation, storage and service. Unsafe food can cause illness keeping people from achieving their full potential and death. This was a descriptive study that uses a mixed method approach to derive insights into the characteristics of food vendors related to demography, knowledge, practices, infrastructure, compliance and recommendation for a policymaking framework. Using the Lemeshows’ sample size formula, 473 vendors from formal (restaurants) and informal (cookri-baffa/table top) sites were interviewed and observed. We found from discussions that respondents had a good understanding on how to keep food safe. However, observed practices were poor 93% handled food with their bare hands, 83% did not cover their hair, and 76% did not wear an apron whilst handling, preparing or serving food, 61% did not keep their finger nails clean or short and 57% did not wash their hand before preparing or serving food. Over half (51%) had access to a toilet but 32% reported their use required payment and emphasized their poor condition/inadequate management. Nearly half (47%) of the vending sites did not have a handwashing facility, with soap and water available. Only 7% reported having any authority oversight of food safety. Food safety and hygiene practices in most cookri shops and restaurants was ‘poor’ with very limited surveillance system in place by competent authorities for compliance of food operators. Hand washing, clean surroundings, and covered food were the most common and emphasized practices to mitigate the risks associated with unsafe food.

Environment and Awareness Influencing Food Safety in the Western Area, Sierra Leone

Food safety, nutrition, health and wellbeing are inextricably linked. This study investigated the environmental, awareness and practices amongst both food vendors and consumers in and around Freetown the capital of Sierra Leone. The population of the area has vastly out-grown the infrastructure laid down before and since independence. De-centralization of authority to local councils as recommended post-war has only been partial. The role of local versus central government in the planning and maintenance of water, sanitation and market-infrastructure and related policies was explored. This is a qualitative study that used semi-structured interviews with vendors, consumers and 29 key informants. Amongst an estimated population of 5386 actors in food services a sample size of 309 vendors, consumers in and around the 12 busiest market hubs in Western Area Urban and Rural Districts were sampled. Most of the respondents described “food safety” as “good-to-eat, well taken care-off, and free from germs”. The respondents cited that main causes to unsafe food are poor hygienic practices: 38%, contamination by flies: 28%, uncovered food/ improper handling/poor personal hygiene: 21%, and environmental factors, such as improper refuse disposal: 11%. Respondents expressed that consuming unsafe foods can lead to diarrhoea: 34%, food poisoning: 24%, vomiting: 17%, stomach ache/pain: 16%, or typhoid: 9%. Various measures to improve food safety were cited as hand washing: 60%, cleaning surroundings: 57%, covering food: 56%, washing utensils: 52%, covering hair: 42% and using a face mask: 32%. However almost 76% of food vendors interviewed were trading near gutters, where muddy/dirty water settled, with slippery floors, discarded plastic waste, flies and inadequate water, sanitation, and/or storage facilities. None of the food vendors had had any formal training on food safety. Despite progress recently made in solid and liquid waste management during the “Transform Freetown” agenda much more improvement in infrastructure and behaviour change is required. Similarly, despite improvements in formal market facilities the pattern of informal street trading remains the most prevalent especially for the poor. The link between “safe food” and good health was only partially understood, whilst the widespread application of recommended practices to reduce risks was lacking due in part to inadequate infrastructure. As the importance of food safety becomes better understood by administrators and the public the investments required in infrastructure and social and behavioural change will contribute towards a healthier environment and outcomes.

Changes in Rainfall and Temperature and Its Impact on Crop Production in Moyamba District, Southern Sierra Leone

Rainfall and temperature are the important variables that are often used to trace climate variability and change. A Perception study and analysis of climatic data were conducted to assess the changes in rainfall and temperature and their impact on crop production in Moyamba district, Sierra Leone. For the perception study, 400 farmers were randomly selected from Farmer-Based Organizations (FBOs) in 4 chiefdoms and 30 Agricultural Extension Workers (AWEs) in the Moyamba district were purposely selected as respondents. Descriptive statistics and Kendall’s test of concordance was used to analyze the data collected from the farmers and AEWs. Data for the analysis of variability and trends of rainfall and temperature from 1991 to 2020 were obtained from the Sierra Leone Meteorological Agency and Njala University and grouped into monthly, seasonal and annual time series. Regression analyses were used to determine the statistical values and trend lines for the seasonal and annual time series data. The Mann-Kendall test and Sen’s Slope Estimator were used to analyze the significance and magnitude of the trends respectively. The results of both studies show evidence of climate change in the Moyamba district. A substantial number of farmers and AEWs perceived a decrease in the annual rainfall amount, length of the rainy season, a late start and end of the rainy season, an increase in the temperature during the day and night, and a shortened harmattan period over the last 30 years. Analysis of the meteorological data shows evidence of variability in the seasonal and annual distribution of rainfall and temperature, a decreasing and non-significant trend in the rainy season and annual rainfall and an increasing and significant trend in seasonal and annual temperature from 1991 to 2020. However, the observed changes in rainfall and temperature by the farmers and AEWs partially agree with the results of the analyzed meteorological data. The majority of the farmers perceived that;adverse weather conditions have negatively affected crop production in the district. Droughts, high temperatures, and irregular rainfall are the three major adverse weather events that farmers perceived to have contributed to a substantial loss in the yields of the major crops cultivated in the district. In response to the negative effects of adverse weather events, a substantial number of farmers take no action due to their lack of knowledge, technical or financial capacity to implement climate-sensitive agricultural (CSA) practices. Even though few farmers are practicing some CSA practices on their farms, there is an urgent need to build the capacity of farmers and AEWs to adapt to and mitigate the negative impacts of climate change. The most priority support needed by farmers is the provision of climate-resilient crop varieties whilst the AEWs need training on CSA practices.

Radio Direction Finding Method to Mitigate Tsunami Risk in Sierra Leone

In this study,the Radio Direction Finding method is proposed for the detection of electromagnetic signals,in the VLF band,to try to anticipate the occurrence of potentially destructive geophysical events.The experimentation concerns the interception of electromagnetic anomalies in Sierra Leone,in the five-day time window,associated with seismic events that could potentially generate tsunamis.The area of investigation is Sierra Leone,whose coastline is subjected to tidal wave hazards triggered by earthquakes generated in the Mid-Atlantic Ridge.Although Sierra Leone is not affected by recurrent earthquakes,there is nevertheless a low probability,estimated at 2 percent,of the occurrence of destructive earthquakes in the next 50 years.Also in estimates,the risk of rogue and potentially damaging waves is estimated to strike the Sierra Leone coast at least once in the next 10 years.The Radio Direction Finding experiment carried out continuously 24/7,has shown a close relationship between increased radio-anomalies,in the frequencies of 6,000 Hz,a time window between electromagnetic anomaly detection and the imminence of an earthquake,and higher frequency times for the risk of earthquake occurrence in the Mid-Atlantic Ridge.

Strategies for Promoting Rice Self-sufficiency in Sierra Leone

Rice is the main food of Sierra Leoneans and an important source of employment and income for rural communities. According to the West African Rice Development Association report, annual consumption of rice is amongst the highest in SubSaharan Africa（SSA）, 104 kg. Mainly, small scale farmers who are resource poor on both the upland and various lowlands grow rice. Sierra Leone has not been able to produce enough rice to meet its local consumption demand for a very long time now. 530 000 MT of milled rice is the required consumption need of the Sierra Leonean population per annum. In 2007, national paddy rice production was projected at 638 000 MT. The level of rice self-sufficiency rose from 50.57% in 2002 to 62.15% in 2006 and then to 63.49% in 2007. The remainder must be imported at increasingly expensive prices in the current situation of high food prices, which includes rice. The price of rice has seen a steady increase in the entire country. What most affected by this, is the low-income urban and peri-urban households. The promotion of domestic rice production is therefore a key element in the strategies for improving rice self-sufficiency, stimulating economic growth and increasing rural income. Therefore, supporting rice production programme is the only solution to pull the country out of the worsening rice situation and maintain the present trend in rice self-sufficiency. Therefore, having an understanding of the strategic interventions in rice production in Sierra Leone is an important ingredient in the promotion and attainment of rice self-sufficiency.

Studies on the Genesis of Soils in Jong River Basin in the Northern Province of Sierra Leone

The soil resources of Sierra Leone remain an integral part of sustainable agricultural development but knowledge of the suitability of soils and their management requirements for a variety of land uses is still lacking to a greater extent. In this view, a detailed soil survey of three chiefdoms in Northern Sierra Leone was undertaken to evaluate the genesis of soils and interpret soil-landscape properties and their relationships using the toposequence and free style approach of soil survey. Three major soil types, viz, gravelly, gravel-free over gravel and gravel-free soils, formed either directly or indirectly from weathered and disintegrated parent materials of two geologic origins namely Rokel River Series (comprising of sandstone, shale and mudstone), and Granite and Acid Gneiss were identified. The gravelly soils are formed from sandstone and sandy shales of the Rokel River Series, which upon weathering released iron and hydrated oxides that hardened into plinthite upon drying. The gravel-free over gravel soils are formed from acid gneiss containing acid and intermediate igneous and metamorphic rocks, which upon weathering produced sandy clay textured soils whereas the gravel-free soils are derived from sedimentary rocks (shales and mudstones) of Rokel River Series, which upon weathering and action of organisms produced sandy clay loam and sandy clay textured soils. The gravel-free over gravel soils are mostly located in the summit and back slopes and show dark brown to dark yellowish-brown hue and moderate chroma, weak to moderate structure and absence of coarse fragments in the 0 - 40 cm layer, and a strong brown hue and high chroma, very weak fine angular blocky structure having abundance of coarse fragments from 40 cm and above. In these soils, the compactness of ironstone and sandstone gravels increases with depth. The gravel-free soils are found on three landscape positions, viz, back slopes, foot slopes and toe slopes. On the back and foot slopes, the soils are characterized by very dark brown to dark yellowish-brown hue and high chroma, sandy loam to sandy clay texture, coarse angular to moderate sub-angular blocky structure and absence of coarse fragments throughout the horizon. In these soils, the clay content and sand grain sizes were observed to increase with depth. On the toe slopes, the soils show black to greyish-brown hue and low chroma, silty loam to sandy loam, structureless and high water holding capacity.

Extent of Reduction of the Fallow Period and Its Impact on Upland Rice Production in the Nongowa Chiefdom of Kenema District in Eastern Sierra Leone

Slash-and-burn agriculture is the common practice for upland rice intercropping system in Sierra Leone and it has been blamed for the loss of forest vegetation across the country. Shortening of the fallow period in the Eastern region of Sierra Leone has implications on agricultural food production and the persistence of the remaining tropical rainforest. This study was therefore undertaken to assess: 1) the extent of reduction of the fallow period in the Nongowa Chiefdom of Kenema District;2) the causes of reduction in the fallow period;3) farmers’ perception of the relevance of fallow period and the implications of reduction of fallow period on crop production. The study revealed a drastic reduction of the fallow period in the chiefdom with a mean of 3.8 years which falls far below the country mean fallow period of 8.8 years as estimated by FAO. Farmers pointed out that the reduction of the fallow period was as a result of land scarcity due to competing land uses such as large scale commercial agriculture, logging, mining, charcoal burning and expansion of settlements. Farmers agreed that a fallow period of at least 10 years is necessary for upland rice production. Farmers were aware of the impact of reduction of the fallow period on upland rice production and were able to estimate rice yields based on the age of the fallow. Also, farmers have attempted to adapt to the constraints posed by shorter fallow periods by selection of rice varieties to suit the length of the fallow periods.

Assessing the Potential Contribution of Fisheries to Economic Development —The Case of Post-Ebola Sierra Leone

This paper examines the potential contribution of the fisheries sector to national economic development in Sierra Leone, following the cessation of the recent Ebola virus disease (EVD). The tragic deaths of some 4000 persons, as a direct result of this epidemic, have also been accompanied by serious economic disruption to one of the world’s poorest countries, amounting to a loss of over USD 1 billion (20 per cent of annual Gross Domestic Product, GDP). Based on recent work undertaken by the New Partnership for Africa’s Development (NEPAD), an assessment was made of the potential contribution of one of the country’s major natural resource sectors—fisheries—to future economic recovery. It was confirmed that the fish resources of Sierra Leone have an estimated capitalised economic value of USD 735 million, and could potentially make an increased contribution to GDP under suitable conditions, over and above the current estimated level of 10 per cent. However, our results also show that with an overall “readiness assessment” score of 41/100, the sector is unlikely to realise its full potential unless a number of specific areas are addressed (based on analysis valid up to January 2016). These include an improvement in fisheries economic assessment, the upgrading of the fisheries governance and management framework, and the establishment of a fisheries development strategy and implementation plan to channel future investments and interventions in an appropriate sequence. Particular attention should be given early on to an increase in the quality and capacity of both public and private sector organisations relevant to roles and functions within a general process of fisheries sector reform. Finally, the fisheries policy evaluation approach used here is novel. While it has been applied to Sierra Leone for the intrinsic interest of that case, this demonstration also shows that it could be applied elsewhere in the future when reviewing fisheries policy.

Reasons to pursue a career in medicine:a qualitative study in Sierra Leone

Background:Many low-income and crises-affected countries like Sierra Leone struggle with the recruitment and retention of their health professionals,particularly nurses and doctors.There are multiple factors that influence the‘recruitment to retention’pipeline.The first stage of an exploration into the issues influencing the availability of qualified health care workers may focus on the aspects which influence their entry into relevant educational programmes.This paper explores the reasons given by junior doctors in Sierra Leone for wanting to become a doctor.It also describes entry procedures into undergraduate medical education.Methods:In-depth interviews were conducted with purposively sampled junior doctors(n=15)from the only medical school in Sierra Leone in October 2013.Digital diaries and two follow-up interviews were used to explore their evolving career experiences and aspirations until November 2016.In addition,semi-structured interviews with key informants(n=20),including senior teaching staff at the medical school(n=7),were conducted.Thematic analysis was used to explore linkages and themes across cases.Results:Six themes were identified.The most commonly mentioned reasons for wanting to become a doctor were a desire to help(theme 4)and the influence of family and friends,via role modelling(theme 2)and verbal encouragement(theme 3).Other motives were an interest from a young age(theme 1),being attracted by the job prospects(theme 5),and having an intellectual and science capacity(theme 6).Junior doctors gave at least two and up to six reasons for applying to enter the medical profession.Doctors were allowed entry to the medical school largely based on their previous academic performance.Conclusions:This study showed that multiple reasons underlie the decision to apply for entrance to medical school and the decision to enter medicine is complex.These findings may inform the review of future admission procedures by the medical school in Sierra Leone and similar settings,which is a crucial step in addressing the human resource needs for healthcare that currently exist.

Soil-transmitted helminth infection in school age children in Sierra Leone after a decade of preventive chemotherapy interventions

Background:Baseline mapping of soil-transmitted helminth(STH)infections among school age children(SAC)in 2008-2009 found high or moderate prevalence in 13 of the 14 districts in Sierra Leone.Following these surveys,mass drug administration(MDA)of mebendazole/albendazole was conducted biannually at national level targeting pre-school children(PSC)aged 12-59 months and intermittently at sub-national level targeting SAC.In addition,MDA with ivermectin and albendazole for eliminating lymphatic filariasis(LF)has been conducted nationwide since 2010 targeting individuals over 5 years of age.Each MDA achieved high coverage,except in 2014 when all but one round of MDA for PSC was cancelled due to the Ebola emergency.The objective of the current study was to determine the prevalence and intensity of STH infections among SAC after a decade of these deworming campaigns.Methods:Seventy-three schools in 14 districts were purposefully selected,including 39 schools from the baseline surveys,with approximately two sites from each of low,moderate and high prevalence categories at baseline per district.Fresh stool samples were collected from 3632 children aged 9-14 years(male 51%,female 49%)and examined using the Kato Katz technique.Results:The prevalence of STH infections in Sierra Leone decreased in 2016 compared to 2008:Ascaris lumbricoides 4.4%(95%confidence interval[CI]:3.7-5.1%)versus 6.6%(95%CI:0-25%),Trichuris trichiura 0.7%(95%CI:0.5-1.1%)versus 1.8%(95%CI:0-30.2%),hookworm 14.9%(95%CI:13.8-16.1)versus 38.5%(95%CI:5.4-95.1%),and any STH 18.3%(95%CI:17.0-19.5%)versus 48.3%(CI:5.4-96.3%),respectively.In 2016,no district had high hookworm prevalence and four districts had moderate prevalence,compared with eight and four districts respectively in 2008.In 2016,the arithmetic mean hookworm egg count in all children examined was light:45.5 eggs per gram(EPG)of faeces,(95%CI:\35.96-55.07 EPG);three(0.08%)children had heavy infections and nine(0.25%)children had moderate infections.Conclusions:Sierra Leone has made considerable progress toward controlling STH as a public health problem among SAC.As LF MDA phases out(between 2017 and 2021),transition of deworming to other platforms and water and sanitation strategies need to be strengthened to maintain STH control and ultimately interrupt transmission.

Rapid assessment of knowledge,attitudes,practices,and risk perception related to the prevention and control of Ebola virus disease in three communities of Sierra Leone

Background:The recent outbreak of the Ebola virus disease(EVD)in Sierra Leone has been characterized by the World Health Organization as one of the most challenging EVD outbreaks to date.The first confirmed case in Sierra Leone was a young woman who was admitted to a government hospital in Kenema following a miscarriage on 24 May 2014.On 5 January 2015,intensified training for an EVD response project was initiated at the medical university of Sierra Leone in Jui.To understand the knowledge,attitudes,practices,and perceived risk of EVD among the public,especially after this training,a rapid assessment was conducted from 10 to 16 March 2015.Methods:Interviews were conducted with 466 participants based on questionnaires that were distributed from 10 to 16 March 2015 by cluster sampling in three adjacent communities,namely Jui,Grafton,and Kossoh Town,in the Western Area Rural District of Sierra Leone.Results:It was found that knowledge about EVD was comprehensive and high.Positive attitude towards prevention was found to be satisfactory.Nearly all participants knew the reporting phone number 117 and had reported some change in behavior since learning about Ebola.More than half(62%)of the participants had a history of travelling to urban areas,which increases the risk of infection.The multivariable logistic regression analysis showed that community and occupation were variables associated with perceived risk of EVD.Conclusions:Our study showed that community level social mobilization and community engagement were an effective strategy in the special context.

Genetic Polymorphisms of 22 Novel Autosomal Short Tandem Repeat Loci in Sierra Leone Population

Background:Exploring and identifying novel alleles of noncombined DNAIndex System(CODIS)short tandem repeat(STR)loci in different ethnic groups is important for the establishment of forensic reference databases and study of population genetics.Aim:This study is aimed to explore the genetic polymorphism of 22 non-CODIS autosomal STR loci(D6S477,D18S535,D19S253,D15S659,D11S2368,D20S470,D1S1656,D22-GATA198B05,D8S1132,D4S2366,D21S1270,D13S325,D9S925,D3S3045,D14S608,D10S1435,D12S391,D7S3048,D17S1290,D5S2500,D2S1338,and D16S539)in Sierra Leone population and analyze the population genetic relationships in comparison with otherpopulations.Materialsand ethods:The amples of a total of 495 unrelated individuals(274 females and 221 males)from Sierra Leonewere examined by the Microreader^(TM)23SPID System,and their genetic polymorphisms and associated forensic parameters were calculated.The genetic relationships between Sierra Leonepopulation and other populations were evaluated as well.Results:Atotal of 287 alleles were observed with allelic frequencies ranging from 0.001 to 0.399.The cumulative power of discrimination(CPD)of the 22 autosomal STR loci was 0.99999999999999999999999999999538.The cumulative probability of exclusion(CPE)of the 22 autosomal STR loci was 0.9999998514(CPEdous)and 0.9999999999826(CPEtrios).All of the STR loci reached the Hardy–Weinberg equilibrium after Bonferroni correction.The population genetics analysis results demonstrated that Sierra Leone population exhibited distinctive genetic characteristics compared to those of East Asian populations and it had relatively close genetic distances to the Uygur population.Conclusion:The results of this study could enrich the forensic databases with Sierra Leone population.The 22 STR loci are highly polymorphic and could be used for forensic practice and population genetics studies.

Synthesis of Attaining Sustainable Development Goal 6.5: A Case Study of Mano River

The Mano River is a transboundary river that runs through Côte d’Ivoire, Liberia, Guinea, and Sierra Leone. According to a 2018 United Nation report on Sustainable Development Goal (SDG) 6.5, which aims to improve the adoption of cohesive water resource management by 2030;the impact of this goal on the Mano River management is minimal. The research summarizes previous studies using an integrative literature review method, drawing general conclusions and identifying unsolved problems with respect to water resources management. The research finding demonstrated that existing water stress and poor management as exacerbated by socioeconomic practices in the region are the major threats to achieve SDG 6.5. As a result of these activities, long-term management of the river basins has become extremely difficult. The research informs a discussion to achieve cooperative water resource management, which is best achieved by shared collaboration and shared interests as described by SDG 6.5.

Molecular characterization of an outbreak-involved Bacillus anthracis strain confirms the spillover of anthrax from West Africa

Background Anthrax,a zoonotic disease caused by the spore-forming bacterium Bacillus anthracis,remains a major global public health concern,especially in countries with limited resources.Sierra Leone,a West African country historically plagued by anthrax,has almost been out of report on this disease in recent decades.In this study,we described a large-scale anthrax outbreak affecting both animals and humans and attempted to characterize the path-ogenusingmoleculartechniques.Methods The causative agent of the animal outbreak in Port Loko District,Sierra Leone,between March and May 2022 was identified using the nanopore sequencing technique.A nationwide active surveillance was implemented from May 2022 to June 2023 to monitor the occurrence of anthrax-specific symptoms in humans.Suspected cases were subsequently verified using quantitative polymerase chain reaction.Full-genome sequencing was accomplished by combining long-read and short-read sequencing methods.Subsequent phylogenetic analysis was performed based on the full-chromosome single nucleotide polymorphisms.Results The outbreak in Port Loko District,Sierra Leone,led to the death of 233 animals between March 26th and May 16th,2022.We ruled out the initial suspicion of Anaplasma species and successfully identified B.anthracis as the causative agent of the outbreak.As a result of the government's prompt response,out of the 49 suspected human cases identifed during the one-year active surveillance,only 6 human cases tested positive,all within the frst month after the official declaration of the outbreak.The phylogenetic analysis indicated that the BaSL2022 isolate responsible for the outbreak was positioned in the A.Br.153 clade within the TransEuroAsian group of B.anthracis.Conclusions We successfully identifed a large-scale anthrax outbreak in Sierra Leone.The causative isolate of B.anthracis,BaSL2022,phylogenetically bridged other lineages in A.Br.153 clade and neighboring genetic groups,A.Br.144 and A.Br.148,eventually confirming the spillover of anthrax from West Africa.Given the wide dissemination of B.anthracis spores,it is highly advisable to effectively monitor the potential reoccurrence of anthrax outbreaks and to launch campaigns to improve public awareness regarding anthrax in Sierra Leone.

Potential for broad-scale transmission of Ebola virus disease during the West Africa crisis:lessons for the Global Health security agenda

Background:The 2014-2016 Ebola crisis in West Africa had approximately eight times as many reported deaths as the sum of all previous Ebola outbreaks.The outbreak magnitude and occurrence of multiple Ebola cases in at least seven countries beyond Liberia,Sierra Leone,and Guinea,hinted at the possibility of broad-scale transmission of Ebola.Main text:Using a modeling tool developed by the US Centers for Disease Control and Prevention during the Ebola outbreak,we estimated the number of Ebola cases that might have occurred had the disease spread beyond the three countries in West Africa to cities in other countries at high risk for disease transmission(based on late 2014 air travel patterns).We estimated Ebola cases in three scenarios:a delayed response,a Liberia-like response,and a fast response scenario.Based on our estimates of the number of Ebola cases that could have occurred had Ebola spread to other countries beyond the West African foci,we emphasize the need for improved levels of preparedness and response to public health threats,which is the goal of the Global Health Security Agenda.Our estimates suggest that Ebola could have potentially spread widely beyond the West Africa foci,had local and international health workers and organizations not committed to a major response effort.Our results underscore the importance of rapid detection and initiation of an effective,organized response,and the challenges faced by countries with limited public health systems.Actionable lessons for strengthening local public health systems in countries at high risk of disease transmission include increasing health personnel,bolstering primary and critical healthcare facilities,developing public health infrastructure(e.g.laboratory capacity),and improving disease surveillance.With stronger local public health systems infectious disease outbreaks would still occur,but their rapid escalation would be considerably less likely,minimizing the impact of public health threats such as Ebola.Conclusions:The Ebola outbreak could have potentially spread to other countries,where limited public health surveillance and response capabilities may have resulted in additional foci.Health security requires robust local health systems that can rapidly detect and effectively respond to an infectious disease outbreak.