Welcome back

1. WHO/USAID/GOARN Framework for Preparedness and Response to a Public Health Event of Initially Unknown Etiology

2. Welcome back https://www.youtube.com/watch?v=gJ9ybOumITg

3. Return to work being able to • Use WHO decision criteria to determine whether or not a suspect case is a PHE of concern • Adopt a One Health approach to preparing and responding to PHEs of initially unknown etiology • Identify roles and responsibilities at the country-level of the Emergency Management Committee (EMC) and Rapid Response Teams (RRT) • Differentiate steps and or activities in preparing and responding to a public health event (PHE) of initially unknown etiology with steps for a known etiology. • Apply the three phases of the PHE framework -- preparedness, response, and monitoring and evaluation -- to a simulation of an outbreak of initially unknown etiology in Western Africa.

4. Day Three Agenda

5. Experience circle

6. Experience circle • Share a PHE in which you participated or were impacted by • What was done well and the outcomes • What were the challenges and the impact of these challenges

7. Experience circle • What do you see as common themes that can lead to success? • Or lead to failure?

8. Responding to a PHE requires • A One Health approach • Planning and preparation • Coordination and management • Good communication • Culturally sensitive approaches • Inclusion of local leaders

9. Known versus unknown

10. Public Health Event Results in serious illness Has the capacity to spread Require a coordinated response

11. Etiology means CAUSE

12. Unknown etiology means we do not know the cause

13. Steps in responding to a PHE Disease Surveillance Case Definition Reporting Rapid Response Team Field Investigation Isolation and Infection Prevention Diagnosis Contact Tracing Case Management Communication

14. With an unknown etiology We do not have a Case Definition

15. With an unknown etiology we need to: • Develop a case definition • Determine the mode of transmission and source of the illness • Need to determine if illness is associated with high mortality, or a high rate of hospitalization • Make decisions about the need for isolation, contact tracing, level of personal protection, and other infection control measures • Determine if the PHE should be reported to WHO as a Public Health Emergency of International Concern (PHEIC).

16. Break

17. The way you stop an outbreak

18. Remember, a case definition • Purpose is to locate other cases that may be related • Should include person, place, time, and clinical features • Starts broad and narrows as you collect more data

19. Case Definition #1 A 40 year old farmer presented to the health post with complaints of a high fever for 3 days and mental confusion. His wife provided most of the history. Also reported was an itchy rash on his ears and thumbs, loss of appetite, and blue urine. He appeared to be seriously ill, and his blood pressure was very low despite the fact that he reported no vomiting or diarrhea and did not appear dehydrated. Blood specimens were drawn but no results are available yet. He has most recently been harvesting produce and in the past two weeks has only left his farm to bring goods to market. All family members and other farm workers are healthy. The only unusual contact with animals has been a couple of tick bites and migratory birds that stopped at the pond on his farm for a few days last week.

20. Three cases have presented to a health facility in District A and two more in District B. • District A • Case #1: A 1 year old girl developed sudden onset of severe vomiting and watery diarrhea 5 days ago and was hospitalized. She had a fever that has ended, no cough, no rash and no other symptoms. She improved after 2 days of re-hydration and will be going home soon. Two other family members are sick. • Case #2: A 45 year old man was admitted to the same hospital the next day with similar symptoms. It turns out he is the father of Case #1. He became ill one day after his son. • Case #3: The 10 year old brother of Case #1. He became ill at the same time as his brother, but had only mild fever, diarrhea and vomiting that stopped within hours. He feels well now. • District B • Case #4: An 8 year old girl with sudden onset of severe vomiting and watery diarrhea that began last night. She has a fever, no cough, no rash and no other symptoms. One other family member sick. • Case #5: Older sister of Case#4, similar symptoms that began at the same time Case Definition #2

21. Within the past month, there were 2 outbreaks with high mortality in 2 intensive poultry farms, one in East and the other West Africa. Two weeks ago another country reported a poultry die off in a government farm. The farm supplies live birds to traders and poultry meat that is transported across the country. The initial investigation found no human cases. However, yesterday a poultry worker was hospitalized with signs of acute, severe respiratory distress but recovers. The affected birds died suddenly with showing gross pathological signs. Birds that did not die showed ruffled feathers, stop drinking or eating, were very lethargic and many died in 24 hours of initial symptoms were present. There was blood in the stools but no apparent hemorrhage or ecchymosis on the surface of the body. The humans affected showed high fever, cough and other respiratory symptoms, requiring immediate hospital admission or severe pneumonia would occur, often fatal. Case Definition #3

22. In a major PHE • Every minute lost is critical AND • You need to be mindful of how you use resources…you might need them later Every new case is a potential outbreak

23. EMCs & RRTs

24. EMCs and RRTs • What kinds of teams do you need to respond to a PHE? • What are the roles and responsibilities of each team? • Who should be on the team?

25. EMC is responsible for • National Epidemic and PHE preparedness and response plans • Crisis communication plans • RRT rosters and deployment • Financial resources to support response activities, including RRT personnel, equipment and supplies • Assist ministries with risk mapping, disease surveillance, and establishing priorities • Conduct simulations, regular training or continuing education, and routine after action reviews to understand challenges and discuss lessons learned • Revise plans as needed based on after action reviews

26. An EMC • Finance • Disaster Management • National Laboratories • Communications • Trade and Commerce Additional members might include: Logistics Police and Civil Defense International Donors Humanitarian Agencies Public Sector

27. RRT  Team • Is not a team • It is roster

28. What skills do you need to: • Upon receiving report of an unusual PHE, initiate a multisectoral discussion among Ministries to communicate and share initial information, observations • Verify the report of a possible outbreak • Communicate with and inform responsible province and district officials who can assist RRTs, provide introductions to local leaders, health professionals (human, animal & environmental), non-governmental groups and the private sector • Through interviews with clinicians, cases, families -- characterize illness and provide descriptive epidemiology • Protect people—staff, contacts, general population • Implement immediate containment activities • Conduct active case-finding together with community leaders and volunteers

29. What skills do you need to: • Identify and follow-up contacts to identify possible illness • Safely and properly collect specimens for laboratory confirmation • Investigate source of infection or reservoir (look for human, animal or environmental sources) • Complete, concise report of activities and findings to higher authorities • Request additional assistance and support as needed • Communicate with community leaders and members to restore trust, minimize panic, and engage them in active disease control activities

30. There have been several confirmed cases of highly pathogenic avian influenza (HPAI) in poultry and humans in various regions of the world, mainly in Asia (where most of the cases were confirmed) and a few in Africa and Europe. The mortality rate in humans is around 40%. Although at this time transmission is limited to animal to human transmission, there has been one case of a family member who cared for a sick relative where human to human transmission is suspected to have occurred, but not confirmed. Migratory season has started and many wild bird species have migrated to Africa. Within the past month, there were 2 confirmed cases of HPAI in 2 intensive poultry farms, one in East and the other West Africa. The cases have been controlled as per the methods adopted in the country and endorsed by international bodies and no further cases were suspected. Economic losses were tremendous, mainly for the poor communities affected by the disease, directly due to poultry die off or indirectly due to trade restrictions. Two weeks ago another country reported a poultry die off in a government farm. The farm supplies live birds to traders and poultry meat that is transported across the country. The initial investigation found no human cases. However, yesterday a poultry worker from the impacted farm was hospitalized with signs of acute, severe respiratory distress. As a group, answer the following questions: How would you select a RRT to address this issue? Who should be on the RRT? What role you think the EMC should play? Who would you think should be involved in the coordinated response? Poultry Die Off

31. The capital city of Abuongo is served by a major international airport. The discovery of vast natural resources in the northern district has resulted in a large numbers of people arriving from Southeast Asia and Europe. The mining area is along a border with another country, and about 6 hours by bus from the capital. The city has sections of high-end hotels and restaurants to serve the tourist trade and well off residents, but is largely a composed of sprawling informal settlements, without adequate infrastructure. Three days ago, a miner from the northern district arrived at the main hospital in the city. He had been well until the day before when he suddenly developed a high fever and cough. He had been clearing a section of the land, and discovered a large quantity of dead chickens. No one seemed to know anything about them, so he incinerated them and continued to clear the land. When he got sick, he immediately took a bus to the city because he had heard a rumor that there was a case of Ebola in the area. As a group, answer the following questions: How would you select a RRT to address this issue? Who should be on the RRT? What role you think the EMC should play? Who would you think should be involved in the coordinated response? Outbreak at a Center

32. The government of Abuongo is well aware of the risk of lead (Pb) toxicity, due to this toxic, heavy metal contaminating the environment in areas involved in processing ore for gold. Lead toxicity was highly publicized during gold mining in an area of Nigeria during 2010, and the outbreak resulted in the deaths of hundreds of children. Lead (Pb) is toxic in very low concentrations, and can cause kidney failure, severe anemia, seizures, coma and death; children are the group most severely affected. Experts from WHO, Nigerian technical experts who worked on the crisis there, and other international experts have been meeting with the government for months, and have mitigation plans in place. Word has come from the district that clean up and disposal is lagging behind production at this time and large landfills of contaminated soil and ore are accumulating. Of particular concern is the heavy rainfall the area has been experiencing in recent weeks, which is causing Pb contamination of wells and other water sources for humans and animals. The national disease surveillance system has identified a cluster of cases of possible Pb-related seizures and coma in the area among children that concerns local officials. The EMC is concerned about the health risks to the population and wants to investigate. As a group, answer the following questions: How would you select a RRT to address this issue? Who should be on the RRT? What role you think the EMC should play? Who would you think should be involved in the coordinated response? Lead (Pb) Toxicity

33. Lunch

34. Using the framework

35. Preparedness & Response • Study your assigned section in the framework • Summarize key steps and activities • Create recommendations for broadening the framework to take a One Health approach • Prepare a 30 minutes lesson • Group 2 • Group 1 Phase II: Respond Pages 18 - 29 Phase I: Preparedness Pages 14 - 17

36. Reflections and applications • Which activities in preparing and responding to a PHE do you need to gain proficiency? • How can you developing the skills knowledge you need to gain proficiency? • How might you use the PHE framework when preparing and responding to a PHE of unknown etiology? • What support do you need to be able to use the framework?

37. Monitoring and evaluation

38. Below is a table that visually links the terms inputs, activities, outputs, outcomes and impacts.

39. Monitoring and evaluation is • The systematic collection, analysis and interpretation of data on preparedness and response activities • Used as a basis to plan, implement and improve your public health strategy

40. Monitoring in the framework focuses on • Routine and continuous tracking of EMC and RRT preparedness and response capacities • Efficiency and effective of response action including • Alert management • Field investigation • Field response

41. Monitoring checks for compliance • What services were delivered? • What population was served and what numbers were served? • What staffing and resources were used?

42. Evaluation asks how are we doing How well are the EMCs and RRTs doing in… • modifying high risk behaviors? • reducing population’s exposure to the causal agent? • providing early, optimal clinical care for those infected?

44. Indicators The key to monitoring and evaluation • Measurable - whole numbers, ratios, percentages • Valid - accuracy of measurement • Reliable - consistency of measurement

45. Two types of indicators • Process - measure program and activity performance • Number of times • the EMC met during • the Ebola crisis? Number of times the EMC meet each year?

46. Two types of indicators • Process - measure program and activity performance • Outcome indicators - measure how well the EMC or RTT initiative is accomplishing its objectives How much have health determinants within a defined population improved over monthly intervals after the field investigation and response stages?

47. M&E quiz!

48. What do you think? • What experiences do you have with monitoring and evaluation in your work? • Why do you think monitoring and evaluation might be important during and after a PHE? • What type of indicators would you suggest?

49. Application and reflection

50. Think about • Which activities in preparing and responding to a PHE do you need to gain proficiency? • How can you develop the skills and knowledge you need to gain proficiency? • How might you use the PHE framework when preparing and responding to a PHE of unknown etiology? • What support do you need to be able to use the framework?