Scholarly article on topic 'Polio infrastructure strengthened disease outbreak preparedness and response in the WHO African Region'

Polio infrastructure strengthened disease outbreak preparedness and response in the WHO African Region Academic research paper on "Economics and business"

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Abstract of research paper on Economics and business, author of scientific article — Koffi Kouadio, Joseph Okeibunor, Peter Nsubuga, Richard Mihigo, Pascal Mkanda

Abstract Introduction The continuous deployments of polio resources, infrastructures and systems for responding to other disease outbreaks in many African countries has led to a number of lessons considered as best practice that need to be documented for strengthening preparedness and response activities in future outbreaks. Methods We reviewed and documented the influence of polio best practices in outbreak preparedness and response in Angola, Nigeria and Ethiopia. Data from relevant programmes of the WHO African Region were also analyzed to demonstrate clearly the relative contributions of PEI resources and infrastructure to effective disease outbreak preparedness and response. Results Polio resources including, human, financial, and logistic, tool and strategies have tremendously contributed to responding to diseases outbreaks across the African region. In Angola, Nigeria and Ethiopia, many disease epidemics including Marburg Hemorrhagic fever, Dengue fever, Ebola Virus Diseases (EVD), Measles, Anthrax and Shigella have been controlled using existing polio Eradication Initiatives resources. Polio staffs are usually deployed in occasions to supports outbreak response activities (coordination, surveillance, contact tracing, case investigation, finance, data management, etc.). Polio logistics such vehicles, laboratories were also used in the response activities to other infectious diseases. Many polio tools including micro planning, dashboard, guidelines, SOPs on preparedness and response have also benefited to other epidemic-prone diseases. The Countries’ preparedness and response plan to WPV importation as well as the Polio Emergency Operation Center models were successfully used to develop, strengthen and respond to many other diseases outbreak with the implication of partners and the strong leadership and ownership of governments. This review has important implications for WHO/AFRO initiative to strengthening and improving disease outbreak preparedness and responses in the African Region in respect to the international health regulations core capacities.

Academic research paper on topic "Polio infrastructure strengthened disease outbreak preparedness and response in the WHO African Region"

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Vaccine

journal homepage: www.elsevier.com/locate/vaccine

accine

Polio infrastructure strengthened disease outbreak preparedness and response in the WHO African Region

Koffi Kouadioa, Joseph Okeibunora *, Peter Nsubugab, Richard Mihigoa, Pascal Mkanda3

a World Health Organization, Regional Office for Africa, Brazzaville, Congo b Global Public Health Solutions, Atlanta, GA, USA

ARTICLE INFO ABSTRACT

Introduction: The continuous deployments of polio resources, infrastructures and systems for responding to other disease outbreaks in many African countries has led to a number of lessons considered as best practice that need to be documented for strengthening preparedness and response activities in future outbreaks.

Methods: We reviewed and documented the influence of polio best practices in outbreak preparedness and response in Angola, Nigeria and Ethiopia. Data from relevant programmes of the WHO African Region were also analyzed to demonstrate clearly the relative contributions of PEI resources and infrastructure to effective disease outbreak preparedness and response.

Results: Polio resources including, human, financial, and logistic, tool and strategies have tremendously contributed to responding to diseases outbreaks across the African region. In Angola, Nigeria and Ethiopia, many disease epidemics including Marburg Hemorrhagic fever, Dengue fever, Ebola Virus Diseases (EVD), Measles, Anthrax and Shigella have been controlled using existing polio Eradication Initiatives resources. Polio staffs are usually deployed in occasions to supports outbreak response activities (coordination, surveillance, contact tracing, case investigation, finance, data management, etc.). Polio logistics such vehicles, laboratories were also used in the response activities to other infectious diseases. Many polio tools including micro planning, dashboard, guidelines, SOPs on preparedness and response have also benefited to other epidemic-prone diseases. The Countries' preparedness and response plan to WPV importation as well as the Polio Emergency Operation Center models were successfully used to develop, strengthen and respond to many other diseases outbreak with the implication of partners and the strong leadership and ownership of governments. This review has important implications for WHO/AFRO initiative to strengthening and improving disease outbreak preparedness and responses in the African Region in respect to the international health regulations core capacities. © 2016 World Health Organization Regional Office for Africa. Published by Elsevier Ltd. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).

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Article history:

Available online 1 July 2016

Keywords:

Polio best practice

Outbreak

Diseases

Response

Preparedness

1. Introduction

Outbreak response activities have been extremely challenging in Africa due largely to the weak health systems. Over the years, the polio eradication initiative (PEI) in the African Region mobilized and trained both health workers and volunteers with specializations on surveillance, social mobilization, supplementary immunization activities (SIAs), data management and coordination of response [1]. With the improvements in implementation of outbreak preparedness and response strategies, transmission of wild poliovirus had been effectively contained in the region. This achievement has been attributed to impressive amount of

* Corresponding author. E-mail address: okeibunorj@who.int (J. Okeibunor).

resources, approaches and practices generated and put in place for meeting the eradication targets [1,2]. Circulation was interrupted in three countries with re-established transmission Angola, the Democratic Republic of the Congo, and Chad by the end of 2012. The 2008-2010 outbreaks in West Africa were rapidly contained.

Polio outbreak preparedness and response resources have in the recent past being deployed to containing the transmission of other disease outbreaks in many African countries the region, including Angola, Nigeria and Ethiopia. For instance, Polio funded staff and resources played a significant role during the outbreak of Marburg hemorrhagic fever and Dengue fever outbreaks in Angola in 2005 [3,4] and 2013 [5] respectively. In Nigeria, the successful response and containment of the Ebola Virus Diseases (EVD) was also attributed to polio resources and infrastructures [6,7]. Similarly, in

http://dx.doi.org/10.1016/j.vaccine.2016.05.070

0264-410X/© 2016 World Health Organization Regional Office for Africa. Published by Elsevier Ltd. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).

Ethiopia, polio funded staff is usually involved in the response to other diseases outbreaks such as the massive outbreak of measles reported 2011 and recurrent outbreak of cholera.

The continuous deployments of polio resources, infrastructures and systems for response to other disease outbreaks in many African countries including Angola, Ethiopia and Nigeria has led to a number of lessons considered as best practice that need to be documented for strengthening preparedness and response activities in future outbreaks [8]. We summarized lessons learned from the Polio eradication Initiative infrastructures on the preparedness and response to epidemic-prone diseases in Angola, Ethiopia, and Nigeria.

2. Methods

2.1. Design

The documentary research design was employed to preparing this paper. We reviewed and described how GPEI strengthened disease outbreak preparedness and response in three countries, namely Angola, Ethiopia and Nigeria (Fig. 1), which were documented as part of the polio best practices documentation in the WHO/AFRO. Evidence from these countries demonstrate the contribution of polio resources and infrastructure to the preparedness and response of the health systems to disease outbreaks in these countries.

2.2. Implementation of polio best practices

In Angola polio human, financial and material resources were deployed to strengthen outbreak preparedness and response. The polio assets including, tools, vehicles and personnel supported the preparedness and response to many other vaccine preventable diseases. They were used for other disease surveillance (i.e., measles, yellow fever, tetanus) in an integrated manner and also for case investigation, contact tracing, social mobilization activities during outbreak. Polio assets were also used for monitoring and supervision activities as well, in particular at peripheral levels. Polio staff and assets were managed daily at all levels within the Ministry of Health (MoH) and key immunization partners agencies, particularly WHO and UNICEF (Fig. 2).

In Ethiopia, PEI infrastructure and resources (i.e., financial, human and logistical resources) were used to support other public health activities such as outbreak control, strengthening of routine immunization program, strengthening of the national surveillance. Weakness of health system in many African countries including outbreak preparedness and response system contributes to the noncompliance to the IHR core capacities facilitating the evolve-ment of infectious diseases outbreaks. PEI assets contributed in strengthening the health system in general and outbreak investigation and response in particular. Other outbreak prone diseases programmes have benefited from the support of WHO Polio officers in preparing integrated annual work plans, in training health

Fig. 1. Countries where impact of polio infrastructure on other diseases preparedness and response was documented (in yellow).

Fig. 2. Overview of Polio Eradication Initiative resources (staff and vehicles) in Angola.

WHO/IVE Polio Funded Staff (88)

1 Non-Polio Funded StaffRoutine Immunization Officer

Polio Funded Staff include-: 1 Epidemiologist 1 M&E Officer 7 Polio Surge Staff 22 Surveillance Officers

1 Logistics Officer

2 Data Managers

lAdministrative Officer 1 Logistics Assistant lTransport Officer lFinance Assistant lProgramme Assistant 1 Human Resource Assistant

1 Health Techninician 20 Secretaries 26 Drivers

Vehicles owned by WHO/IVE -Angola

Year of Purchase Quantity

• 2001 l

• 2007 l

• 2008 l3

• 2009 В

• 2011 2

• 2012 l3

Total vehicles 35

NB : Urgent need to renew this polio fleet with at

least 21 vehicles.

workers, in sharing training materials, guidelines and implementation manuals.

WHO polio officers shared best practice experience by implementing these activities in collaboration with local health workers and health offices from other public health programs. Other public health programmes have learnt in the process of conducting several assessments and efficient responses to WPV outbreak in 2014 in Ethiopia by WHO polio staff (national and international). PEI also supported complicated outbreak response activities in a complex region and environment in the Somali region of Ethiopia where measles outbreaks and other outbreaks were likely to occur. The health system including outbreak response collapses in disaster and insecure prone zone opening a window for the rapid spread of diseases outbreaks. Faced with this situation, novel approaches were implemented to improve the quality of health services including surveillance, immunization campaigns as well as disease outbreaks response in the insecure area of Somali region. Micro planning preparation and implementation, as well as independent monitoring activities were conducted with a strong involvement of national and international partners with a zonal command post established in Dollo.

Nigeria has made remarkable efforts and progress in stopping transmission of polio in the country. In security-compromised states such as Borno and Yobe, a specific strategic operational plan was also developed to respond to wild polio virus (WPV) as well as outbreak of circulating vaccine derived polio virus (cVDPV) (Table 1). The use of polio structure contributed to responding to

Table l

cVDPV outbreak response in 2015.

the 2014 Ebola virus disease outbreak, which was a public health emergency of international concern affecting several countries in West Africa. Early after the index case of Ebola travelling from Liberia was identified in Lagos on July 20, 2014, the Federal Ministry of Health (FMoH) declared an Ebola Emergency. On July 23 the FMoH, with the Lagos state government and activated an Ebola Incident Management center as a precursor to the current (Emergency Operation Center (EOC) to rapidly respond to the EVD Outbreak. The outbreak was contained with no new case report since August 31, 2014. In fact the successful polio EOC in Nigeria was used to quickly establish a National Ebola EOC for responding efficiently to the outbreak of EVD after its importation in July 20, 2014. This Ebola EOC established quickly and using an Incident Management System (IMS), enabled the country to streamline a coordinated and effective response in Lagos and expand that response to Port Harcourt. On arrival on July 20, 2014, the patient was acutely ill and immediately transported to a private hospital. He was isolated and tested for Ebola Virus infection while local public health authorities were already alerted about a suspected case of Ebola. Having the capacity to conduct Ebola laboratory diagnosis in country facilitated the rapid identification of Ebola confirmed positive case and suspects tested negative. An Ebola Treatment Centers (ETC) was quickly set up in Lagos and Port Har-court. Contact tracing investigation were undertaken to assess Ebola symptom development and upon release from the ETC, patients who had been suspected cases stared a new 21-day follow-up. The contribution of WHO Polio staff was significant;

State LGA Waid Date of onset Date ITD result received Type OPV Doses Date state notified (within 24 hrs after results received) Date of outbreak investigation (within 24hrs ofstate notification) Response 1 Large scale (within 4 weeks of state notification) Response 1 Response 3 Vaccine type

Kano Minjibir KUNYA 17/3/2014 18/3/2014 cVDPV 12 On-Time On-Time On-Time On-Time On-Time tOPV+IPV

Bomo Gazamala GBL WEST 5/9/14 5/9/14 cVDPV 5 On-Time Late On-Time Not done Not done tOPV

Katsina Bindawa BINDAWA 12/9/14 29/10/14 cVDPV 35 On-Time On-Time On-Time On-Time On-Time tOPV

Jigawa Dutse MADOBI 1/10/14 14/11/14 cVDPV 22 On-Time On-Time On-Time On-Time Not done tOPV

Jigawa Kyawa SHUWARIN 8/10/14 14/11/14 cVDPV 25 On-Time On-Time On-Time On-Time Not done tOPV

Kano Kura KARSI 14/10/14 14/11/14 cVDPV 9 On-Time On-Time On-Time On-Time Not done tOPV+IPV

Yobe Bade DASONA 16/10/14 14/11/14 cVDPV 6 On-Time On-Time On-Time On-Time On-Time tOPV+IPV

Kano Ajingi TORANKE 2/11/14 11/12/14 cVDPV 14 On-Time On-Time On-Time On-Time Not done tOPV

Yobe Bade ZANGO 16/11/14 15/01/15 cVDPV 10 On-Time On-Time On-Time On-Time Not done tOPV

• In Guzamala LGA of Borno State, the 2nd and 3rd outbreak response could not be conducted due to security challenges.

• The number of LGAs and target population differs across outbreak responses.

the deputy manager of the National polio EOC headed the Ebola EOC in Lagos and seeded the Ebola EOC with secretariat and staff members from national Polio EOC. Several other response activities involving polio assets included also (i) identification of human resources with various competencies and given clear lines of responsibility; (ii) training of various groups of personnel (port authority staff, doctors, nurses, epidemiologists, clinicians, infection prevention and control officers, communicators, logisticians, data managers, internists, etc.) on their various roles; (iii) intensification of case-search by screening teams dispatched to various ports of entry (airports, seaports, land crossings) and big shops, churches using body temperature as an indicator of suspected infection; these suspected cases were referred to the medical unit for secondary screening by clinicians; (iv) identification and daily follow-up of contacts. Contact tracing teams had daily assigned number of homes to visit. Records of the health status of the contacts were reported via smartphone, GPS to the EOC for display on the dashboard and the contact were evacuated promptly if needed; (v) design of database to capture information on all contacts being monitored. Other polio assets such as the dashboard strategy were efficiently used during Ebola outbreak response to monitor activities. The EOC played a remarkable role as the only decision-making body from where all stakeholders obtain regular information on progress being made.

3. Results

Polio resources assets have been used preparedness and response to polio itself but also to other outbreak prone diseases. A polio best practice used in a country such Nigeria can be also used and adapted in other country having almost similar situation (e.g., Insecurity).

In Angola, Polio infrastructures have contributed to strengthening the national Integrated Diseases Surveillance and Response (IDSR) to several outbreak prone diseases. Polio resources have been used in the preparedness and response of all major epidemics that raged Angola over the past 20 years including Marburg, Measles, Dengue Cholera, Anthrax and Shigella. The polio best practice has served as well to the 2014 Ebola epidemic preparedness. Public health managers have unanimously confirmed that polio best practices have benefited and continue to benefit other diseases of potential epidemic in terms of integrated case based surveillance process, tools, vehicles and staff including process and tools to manage data. Epidemic control activities that run in two respective stages of preparedness and response are made in the IDSR model inherited from polio. Polio best practices are benefiting all people at all ages through the surveillance, outbreak preparedness and response, and the management of vaccine preventable diseases (financial, human and material resources). Polio best practice is been used to support or strengthen other priority public health programmes. For instance, The Inter-agency Coordination Committee (ICC) in Angola, used only for Polio Eradication Initiative (PEI) initially was expanded to other outbreak prone diseases. Polio funded staffs within the EPI and administration are regularly serving many other priority health programs including complex emergencies as well as outbreak and disaster response. Polio funded vehicles are used for daily disease surveillance and outbreak response activities (Fig. 2). They are often used for monthly monitoring and supervision activities, in particular at peripheral levels.

The polio resources in Ethiopia contributed to other diseases of potential epidemic to produce high quality reports every month including integrated activity reports, training reports, outbreak investigation and response reports, reports of program review meetings are submitted. Quarterly review meetings carried out

regularly to assess the performance and the implementation status of planned activities from polio team had also benefited to other programs. An integrated support (originally from polio) to other priority health programs is benefiting the population in terms of timely detection, investigation and response to outbreak diseases. Despite the complexity of the Somali region, the response to measles outbreaks have benefited from existing polio resources, tools (e.g., micro plan, risk analysis, dashboard) and staff deployment for case investigation and response.

The role played by the EOC in the success of Nigeria in PEI activities was significant. The EOC contributed to a high-level implementation of the National Polio Emergency Operational Plans strategies and activities with a resultant reduction in number of WPV cases from 122 in 2012 to 53 (57% reduction) in 2013; and 6 (90% reduction) in 2014. The implementation of the prioritized strategies and activities of the National Polio Emergency Operational Plans resulted in tremendous progress toward interruption of poliovirus transmission with no WPV cases in Nigeria for the past 18 months. The national polio EOC model was used to respond to the Ebola outbreak in Nigeria that resulted to the rapid control of the outbreak in 2 affected states and Nigeria was declared Ebola - free WHO within a period of 3 months controlled .The EVD response in a timely manner. At the end of the Ebola control, the total deaths in confirmed cases was 7 including 5 from Lagos and 2 from Rivers. The Cumulative no of contacts listed - 891 (Lagos 365 and Rivers 526); Cumulative cases (confirmed) - 19; Lagos 15 and Rivers 4. EVD Outbreaks impact in other West Africa countries, Guinea, Sierra Leone and Liberia lasted for several months Fig. 3, weakened further the health system and killing thousands of people. The polio best practice had contributed to other programs in a way that the practice of disease surveillance and response was improved in Nigeria.

4. Discussion

In our review of lessons learned from the influence of polio eradication initiative infrastructures in Angola, Nigeria and Ethiopia we found that, the PEI has led to the largest influx of public health resources (human, financial, logistic, time) benefiting to other public health program, especially preparedness and response to other infectious diseases outbreaks (e.g., measles, cholera, EVD, Marburg Hemorrhagic fever and Dengue fever) [9,10]. We also found that Polio Eradication Initiative resources contributed in strengthening integrated diseases surveillance, which is a prerequisite for effective preparedness and response to outbreak plan. It is recommended that any response to outbreaks should always be guided by the valuable information provided by the surveillance system. Polio program staff combined detection of AFP cases to other vaccine preventable diseases (measles, yellow fever, neonatal tetanus). Other study revealed that case detection and confirmation of outbreaks several infectious diseases were conducted using Polio laboratory network, including the specimen transportation system [11]. However high-level MoH authorities also recognized the need to improve laboratory capacity for rapid case confirmation in order to make quick decision for timely response to outbreak. It is claimed that due to much focus on polio eradication, there has been little (financial and human resource) focus on other public health interventions [12,13]. PEI had contributed to the increase of national enthusiasm, and improved the skills of other staff program [10]. In 1998, WHO/AFRO adopted the integrated diseases surveillance and response approach [7,14] with the aim of improving also efficiency epidemic preparedness and response strategy in the region [2,7,8,14,15]. Several epidemic prone diseases such as cholera, Meningitis and yellow fever were

Fig. 3. Trend of Ebola Epidemic in Nigeria compared to Guinea, Sierra Leone and Liberia as of August 2014.

added to countries AFP surveillance, thus benefiting of PEI resources as well.

Some existing studies, reported that polio programs in countries of the AFRO region have more resources (Financial, human, logistic) than other public program that lack of staff to perform surveillance to prevent outbreak for occurring, shortage or lack of fund, lack of vehicles or fuel among others [11]. Surprisingly, it is claimed that due to much focus on polio eradication, there has been little (financial and human resource) focus on other public health interventions [12,13]. WHO Polio Focal persons always include other diseases in their agenda during AFP or Polio training sessions at all level central and operational level. All the countries are required to develop and update annually their preparedness and response plan to WPV importation. Simulation exercises have been conducted in several countries and preparedness and response plans/strategies were inspired from the existing polio preparedness and response plan. WHO Polio staff of IST_ESA has been deployed in several countries of the subregion including Ethiopia to train nationals on Standard Operation Procedures (SOPs) for outbreak response. In regard to the AFRO Polio Eradication and Endgame Strategy, several activities have been conducted in 2015 including, linking Polio legacy to new emerging programme of Emergencies and Epidemics.

PEI resources contribution has gone beyond disease specific approach toward health system strengthening approach in respect to the International health regulation core capacity in order to improve preparedness and response to outbreak in the AFRO region [16]. Polio infrastructure is used in any epidemic preparedness and response [17,18] activities, Marburg, measles, Cholera, Anthrax, Shigelloses, Dengue and EVD affecting the country over the past 20 years as described in Angola. In Ethiopia, technical

support of WHO officers is contributed to the improvement of the health system in general. Capacity building of other nonpolio health programs by polio-funded staff using polio infrastructures is one of the contributing factors to the improvement of the health system. PEI assets strengthened the overall EPI related activities in the Somalie region, including advocacy at all levels. The collaboration with Non-Governmental organization including the United Nation Office for Project Services (UNOPS) facilitated logistics and operations [15,19]. Working with clan leaders, repeated micro planning as well as cross border collaboration contributed to the success recorded in response to disease outbreaks. A more robust, flexible or tailored and holistic approach will need to be considered in any outbreak where the environment (i.e., political, geographic, technical, etc.) makes outbreak control challenging [20,21]. We also found that the national polio EOC model was successfully used to respond to the Ebola outbreak in Nigeria with the strong government leadership and ownership. The situation of EVD was worse in other West African countries including Guinea, Sierra Leone and Liberia probably because the inexistence of an efficient EOC model such as the one used in Nigeria and the non-compliance to the IHR.

The success in responding and controlling the EVD quickly in Nigeria have benefited from the (i) active participation of EPI team leaders in the EOC from partner agencies which fast-tracked coordination, decision-making and implementation of planned activities was important; (ii) the Support from governments of Lagos and Rivers, volunteers, public and private sector; (iii) the existence of a well-developed and experienced polio infrastructure in the country; and from the technical and financial support of development partners (bilateral bodies, UN system led by WHO, UNICEF, CDC, NSTOP, etc.). It is the first time in the history of polio

eradication in Nigeria that its infrastructure and resources contributed largely to the timely control of an epidemic of international concern like Ebola Viral Disease.

In essence, the PEI has made and continues to significant contribution to the global health security agenda (GHSA) by its contributions to disease outbreak preparedness and response in the African Region. GHSA accelerates action and spurs progress toward implementation of the World Health Organization's International Health Regulations and other global health security frameworks, such as the World Organization for Animal Health's Performance of Veterinary Services Pathway [22]. The action packages include the prevention and rapid detection as well as effective response to infectious diseases. The use of the polio emergency operation center (EOC) in Nigeria in coordinating response activities in the EVD outbreak in Nigeria is a clear demonstration of the potential of PEI infrastructure to contribute to the realization of the targets of GHSA if deployed broadly to other infectious disease settings anywhere in the world.

Our study presents some limitations. The impact of polio best practice in the preparedness and response to other epidemic prone diseases is restricted to only 3 (Ethiopia, Angola and Nigeria) out of the 8 countries where best practice investigations were conducted and may have not captured the global picture of PEI best practice contribution to other diseases preparedness and response in the whole African Region. It is known that several PEI best practices and innovation activities are being conducted in several countries but are not yet documented. In Nigeria, during the EVD response, stigmatization and misinformation from contacts and family members may have not provided accurate information.

5. Conclusion

The findings of this study have important implications for WHO/AFRO initiative to strengthen and improve infectious diseases outbreak preparedness and response in the African Region. Therefore, the polio endgame should be scaled-up progressively and smoothly without sudden disruption that could not only jeopardize all polio gains but also threaten Preparedness and response to major epidemic prone diseases and even health systems. In this regard we recommend that additional staff, funds as well as political commitment are required to strengthen preparedness and response to Outbreak in the WHO AFRO region. The initiative to use polio eradication resources should be promoted and supported as polio staff are highly qualified public health professionals with rich work and field experience. We suggest reinforcing the link among epidemiology and laboratory staff to further improves outbreak detection and response. Preparedness and outbreak guidelines and SOPs should be developed, updated and adapted to the local situation.

Conflict of interest

The authors have no conflict to report

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