WHO/USAID/GOARN Framework for Preparedness and Response to

a Public Health Event (PHE) of Initially Unknown EtiologyPARTICIPANT GUIDE

2015

This guide serves as your learning journal for the course. Use it to capture notes from the lectures, complete classroom activities and record your

reflections.

These materials were developed under the USAID program, Preparedness & Response (P&R)

P&R has a dual mandate to help countries design and implement national preparedness and response plans for public health events of unknown etiology and to establish and strengthen National One Health Platforms. Our goal is to help address the practical issues confronting national governments as they strive to cope with the human, financial, and logistical constraints associated with pandemic threats. The P&R project provides technical assistance and training services to build national and regional capacity in a sustainable manner.

For more information about the P&R project, contact:

Preparedness & Response Project

Development Alternatives Inc. +1 301 771 7600

Steven_O’Connor@dai.com

THE WHO/USAID/GOARN FRAMEWORK FOR PREPAREDNESS AND RESPONSE TO A PHE OF INITIALLY UNKNOWN ETIOLOGYThis course is a microcosm of One Health: In this classroom we are coming together as professionals from across multiple disciplines, to learn together and become a cadre of health professionals who are prepared to respond to a Public Health Event (PHE) of unknown etiology in ways that mitigate the impact of a potential outbreak. Welcome to the course.

During the course, we ask you to:

Share your experiences and listen to the experiences of your classmates Practice inquiry and curiosity Engage in the classroom activities Translate your learning to application

Our Agenda

Day 1

Morning Experience CircleEMC’s and RRTs

Afternoon Preparing and Responding to a PHE of Unknown Etiology using the FrameworkMonitoring and Evaluating a PHE of Unknown Etiology using the Framework

Day 2

Morning Simulation

Afternoon Debriefing the SimulationReflections, Application and Planning

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Course Objectives

As a result of this course, we would like you to go back to your work and continue to:

Use WHO decision criteria to determine whether or not a suspect case is a PHE of International ConcernAdopt a One Health approach to preparing and responding to PHEs of Initially Unknown EtiologyIdentify roles and responsibilities at the country-level of the Emergency Management Committee (EMC) and Rapid Response Teams (RRT) in preparing and responding to a PHE of Initially Unknown Etiology.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.

The goal of the Introduction to One Health Course and this course on the WHO/USAID/GOARN Framework for Preparedness and Response to Public Health Events of Unknown Etiology is for you to:

Gain an appreciation for the importance of using a One Health approach to detect, contain or limit the spread of public health events (PHE).

Know that by being prepared and responding correctly to

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a PHE, you can prevent or stop public health events (PHE) from becoming outbreaks.

EXPERIENCE CIRCLEAt your table, share a PHE in which you prepared for or responded to or were impacted by. The PHE can be at the local or country level and may range from analyzing disease surveillance and response data to field investigations to isolation and infection prevention to diagnosis or case management.

As a table, summarize common elements of everyone’s experience highlighting:

What was done well and the outcomesWhat were the challenges and the impact of those challenges

Record your table summary to share in plenary.

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After hearing the table summaries, what are some themes you heard?

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Common themes we typically hear include are that a successful response requires:

A One Health ApproachPlanning and preparationCoordination and managementCommunicationCulturally sensitive approachesInclusion of local leaders

PREPAREDNESS AND RESPONSE WITH KNOWN VERSUS UNKNOWN ETIOLOGYWhat do we mean by unknown etiology?

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cause

The basic steps in preparing and responding to an outbreak are:

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DiseaseSurveillan

ce

Case Definition

Reporting

Rapid Response

Team (RRT)

Field Investigatio

n

Isolation & Infection

Prevention

Contact Tracing Diagnosis Case

Management

Communication

On the table below, indicate whether the step and actions you take are the same or different if a PHE is a known etiology or an unknown etiology.

Step Same or Different?

Notes

Disease Surveillance

Same Different

Case Definition Same Different

Reporting Same Different

Rapid Response Team

Same Different

Field Investigation Same Different

Isolation and Infection Prevention

Same Different

Contact Tracing Same Different

Diagnosis Same Different

Case Management Same Different

Communication Same Different

Please stay on this page until you complete the entire exercise.

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The key differences when dealing with a case of unknown etiology are you need to:

Develop a case definition

Determine the mode of transmission and source of the illness

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).

Putting it into practiceSince a key difference is that you need to develop a case definition, let’s develop a case definition. In the annex of this guide is a job aid for writing case definitions.

Below are three PHEs of unknown etiology. Your facilitator will assign you a specific case for which you need to write a case definition.

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Remember, an unknown etiology does not classify it as a significant public health threat or even an illness capable of causing an outbreak.

CASE

DEF

INIT

ION

#1A 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. His 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.

CASE

DEF

INIT

ION

#2

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 daughter.

Case #3: The 10 year old brother of Case #1. He became ill at the

same time as his father, 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

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CASE

DEF

INIT

ION

#3Within 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.

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Notes on class discussion on the three case definitions:

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Remember that each step in responding to a PHE requires resources -- time and money. In the event of a major PHE, every minute lost is critical but you need to be mindful of how you are using other resources. You might need those resources for later steps in the process or for another PHE.

EMCs & RRTs Emergency Management Committee (EMC)

Rapid Response Teams (RRTs)

An EMC is a formally recognized body by country governments that has clear executive leadership responsibility for PHEs.

The EMC is responsible for:National Epidemic and PHE preparedness and response plansCrisis communication plansRRT rosters and deploymentFinancial resources to support response activities, including RRT personnel, equipment and suppliesAssist ministries with risk mapping, disease surveillance, and establishing prioritiesConduct simulations, regular training or continuing education and routine after-action reviews to understand challenges and discuss lessons learnedRevise plans as needed based on after-action reviews

A typical structure for an EMC is:

Additional sectors that should have representation on the EMC include:

FinanceDisaster ManagementNational LaboratoriesCommunications (and selection and training of a spokesperson)Trade and CommerceLogisticsPolice and Civil DefenseInternational Donors and Humanitarian Agencies (WHO, CDC, MSF, Red Cross, etc.)

RRT is a list of all qualified, trained personnel with the needed skills and capabilities. When a case is detected, the roster is used to find the right people who are available and willing to respond at the time.

The composition of a RRT will depend on the specific situation. Once a report comes in that needs investigation, the EMC will determine the skills and resources needed. It is important that the roster include ALL areas of expertise and support that the situation may require.

RRTs typically:Investigate rumors and media reportsRecommend whether field investigation is needed Conduct field investigations and report to EMCOrganize risk communication activitiesPlan and support RRT training and capacity buildingParticipate in after-action reviews and evaluations of outbreak responses

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EMC Coordinator

Ministry of Health

Ministry of Agriculture

Ministry of Environment

Public sectorOthers, as available and needed

Notes on EMCs & RRTs

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On an RRT, what skills, knowledge or expertise do you need for each step of a field investigation?

Step Skills, Knowledge, ExpertiseUpon receiving report of an unusual PHE, initiate a multisectoral discussion among Ministries to communicate and share initial information, observationsVerify 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), non-governmental groups and the private sector. Through interviews with clinicians, cases, families -- characterize illness and provide descriptive epidemiologyProtect people—staff, contacts, general population

Implement immediate containment activities

Conduct active case-finding together with community leaders and volunteers

Identify and follow-up contacts

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to identify possible illnessSafely and properly collect specimens for laboratory confirmation

Investigate source of infection or reservoir (look for human, animal or environmental sources)Complete a concise report of activities and findings to higher authoritiesRequest 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.

Putting it into practiceEach table will be assigned one case study. Answer the questions at the end of your assigned case study and be prepared to share your answers in plenary.

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Case

#1

POUL

TRY

DIE

OFF

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?

Notes:

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Case

#2

OUTB

REAK

IN A

LAR

GE

POPU

LATI

ON C

ENTE

RThe 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?

Notes:

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Case

#3

LEAD

(Pb)

TOX

ICIT

YThe 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?

Notes:

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As you listened to call three cases – poultry die off, outbreak in a large population center, lead poisoning – what were the similarities and difference in the RRTs and the role the EMC should play?

Notes:

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PREPARING AND RESPONDINGIn the annex of your guide, is the WHO/USAID/GOARN framework. You will need this for the following exercise.

Directions:Form a group

Phase I: Preparednesspages 14 – 17 associated

job aids

Phase II: Respondpages 18 – 29 and associated

job aids

For your assigned topic:- Study the assigned sections in the framework- Summarize key steps and activities- Create recommendations for broadening their section to take a One

Health approach- Prepare a 15 minutes lesson teaching your phase of the framework to

your classmates

BE CREATIVE…Make the learning fun

Preparation notes:

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Group 1 Group 2

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Learning notes from group presentations:

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MONITORING AND EVALUATIONMonitoring and evaluation is the systematic collection, analysis and interpretation of data on preparedness and response activities. This becomes the basis for planning, implementing and improving your public health strategy.

Monitoring EvaluationAsks the question

What are we doing? How does the situation

change over time?

How well are we doing? Why do we think it is

happening? What are we learning?

Used for Routine and continuous tracking of EMC and RRT preparedness and response

Efficiency and effectiveness of response action planning

Program improvement Generating knowledge Accountability

Frequency Continuous Episodic

Objective Describing Explaining

Method Follows trends, compares actual performance with expected

Compares achievements with counterfactual

Performed by Mostly internal Internal and external

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Uses Alerts when to take action Provides detailed information on what types of actions to take

An indicator are key to monitoring and evaluation. They must be:

Measurable (e.g., whole numbers, ratios, percentages)Valid (e.g., accurate measurements)Reliable (e.g., consistent measurement)

The Framework looks at two types of indicators:

Process indicators which measure program and activity performanceOutcome indicators which measure how well the EMC or RTT initiative it accomplishing its objectives

Additional notes from the lecture:

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Let’s take a quick quiz…

Which is a monitoring question and which is an evaluation question?

Monitoring Evaluation

What are we doing?

Monitoring Evaluation

What have we achieved and how do we explain it?

Monitoring Evaluation

What are the responses behind the observed levels of performance?

Monitoring Evaluation

What does the situation look like over time?

Monitoring Evaluation

Did the expected outcomes occur?

Monitoring Evaluation

How efficient was the program?

Monitoring Evaluation

How do you explain the expected results occur within the target population?

Which is a process indicator and which is an outcome indicator?

Process Outcome

Number of health workers allocated to region X where the highest number cases of disease X were detected

Process Outcome

Percent of health care facilities that have the capacity and conditions to provide basic-level EBOLA testing and clinical management.

Process Outcome

Number of hospital staff trained on infection prevention and control

Process Outcome

Percentage of the population targeted not believing myths X and Y about Ebola

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transmission.

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REFLECTION & APPLICATION PLANNINGRecord your reflections:

In which steps in preparing and responding to a PHE do you need to gain proficiency? How can you develop the skills and knowledge you need?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?

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REFLECT & PLAN

THE SIMULATIONWelcome back! This morning we will bring together the concepts, skills and knowledge you have gained about preparing and responding for a PHE of unknown etiology. Over the next three hours, you will be taking on different roles in a simulation in which you will respond to a series of events during a potential PHE. The simulation will take place in eight stages. At the beginning of each stage, your group will receive an updated message with questions to prompt your next steps.

During the simulation you be aware of your individual and team effectiveness, how effectively you are using a One Health approach, and how effectively you are using the framework. Your facilitators will also be observing the class in order to provide feedback at the end of the simulation.

A PUBLIC HEALTH EVENT OF UNKNOWN ETIOLOGYSimulation Evaluation

During the simulation, be aware of what you and your team are doing that is effective and not effective in responding and individual and team effectiveness in responding and mitigating the impact of the PHE. Make notes about what is working and not working in the categories below.

Team Effectiveness Yourself Your team

Ensured everyone listened, contributed and opinions were valued

Managed time so that we were able to complete each section

Utilized team member skills and strengths

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One Health Approach Yourself Your Team

Considered the interrelationships among humans, domestic animals, wildlife and the environment

Solicited inter-disciplinary knowledge

Incorporated the local context - language, culture, beliefs, economics

Effectively using the Framework Yourself Your Team

Preparedness: Understood how preparedness could have altered the scenario

Response: Identified the basic steps of the 3 response phases

Alert management

Field investigations

Field response

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Case definition: Able to develop a case definition for person with an illness due to an initially unknown etiology

Communication plan (other government and locals): Understood the role of communication between agencies, between countries, and with the general public

Additional Areas of Focus

The simulation is intended to be a learning experience. There are no right or wrong answers. Draw from your own experiences and knowledge and

remember to have fun.

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ZOOM OUT: SIMULATION INTERVENTION POINTS

Where could you have intervened to protect animals, people and the environment?

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REFLECTIONS, APPLICATION AND PLANNING Instructions: Please place carbon paper behind this page (place the carbon paper between pages 32 and 33) to make a copy of this page.

Spent the next 30 minutes thinking about: What were some key learnings over the last three days?How can you apply the learning? How could taking a One Health approach make you more effective in your role preparing for and mitigating the impact of PHEs?What would you like to learn more about related to One Health and preparing and responding to PHEs of unknown etiology?What information are you going to share with your colleagues after this class?

Name: ____________________________

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REFLECTIONS, APPLICATION AND PLANNING – COPY PAGEInstructions: Please place carbon paper behind this page (place the carbon paper between pages 32 and 33) to make a copy of this page.

Spent the next 30 minutes thinking about: What were some key learnings over the last three days?How can you apply the learning? How could taking a One Health approach make you more effective in your role preparing for and mitigating the impact of PHEs?What would you like to learn more about related to One Health and preparing and responding to PHEs of unknown etiology?What information are you going to share with your colleagues after this class?

Name: ____________________________

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Guide to Developing Case Definitions of Illness during a Public Health Event (PHE)1

Purpose of a case definitionDevelopment of a clear case definition is critically important to support an effective investigation of a Public Health Event (PHE), including a disease outbreak. Use of a common case definition can aid health officials during field investigations to properly identify persons with similar symptoms in a specific area (e.g., village), who likely have the same disease. Understanding disease symptoms during illness can further assist to determine the type of disease causing an outbreak, better understand the possible mode of transmission, as well as identify the likely cause.

Developing outbreak case definitions2

A case definition includes criteria for (1) person (2) place (3) time, and (4) clinical features; possible information on “risk factors” may also be included. These should be specific to the outbreak under investigation. In addition, laboratory results can be useful to categorize persons with a degree of specificity; for example, an ill person considered a “possible case” could be a “confirmed case” if the blood culture or other appropriate test were “positive.”

1. Person: describes key characteristics among persons with similar symptoms likely due to the disease of interest. These characteristics include: age, sex, race/ethnicity, occupation and exclusion criteria (e.g., “persons with no history of X disease”).

2. Place: typically describes a specific geographic location or facility associated with the PHE or outbreak.

3. Time: is used to determine the period of time associated with illness onset for the outbreak being investigated. Limiting the time period enables exclusion of similar illnesses which are unrelated to the outbreak of interest (e.g., experienced or reported symptoms in the two weeks prior to interview, or during the month of November 2013). Parents or adult family member usually serve as a proxy to report the symptoms in infants, young children, or deceased person

4. Clinical Features: are specific symptoms among the affected persons that can help identify other persons with a similar illness in the geographic area of the outbreak.

1 Adapted from CDC Case Definitions available at http://www.cdc.gov/urdo/downloads/casedefinitions.pdf

2 Principles and Practice of Public Health Surveillance. S.M.Teutsch, R.E. Churchill. Oxford University Press 1994; Pg.21.

JOB AID

Table: Examples of Person, Time, and Place characteristics that could be used for an outbreak case definition.

Element* Descriptive features Examples Person Age group children under 5 years of age

Sex Male, Female, or “Unknown”Occupation health care workers at hospital XExclusion criteria persons with no previous history of chronic cough

or asthma; person previously vaccinated against a specific disease of interest (e.g., yellow fever)

Race/EthnicityPlace Geographic location A resident of health zone “X” or province “Y”, during

October -- November 2013 periodFacility Hospital A; or Secondary School B

Time Illness onset Onset of illness (symptoms) between October 1, 2013 and November 15, 2013

Clinical features CoughFever

Acute onset of cough (<2 weeks)Acute onset of fever (in previous 2 weeks)

Rash (exanthema) Redness or pustules observed on skinLaboratory criteria

CultureSerologyChest X-Ray (CXR)

Pneumococcus isolated from blood culture; PCR test positive for influenza virus Infiltrate or consolidation observed on chest x-ray

Initially, the focus on clinical features should be simple and objective (e.g., sudden onset of fever, or acute onset of cough).

1. Example of a written Case Definition (from above table):

a. Case Definition (Suspected Pneumonia): “Any child less than 5 years of age, previously well, living in Health Zone “X” who between Oct 1, 2013 and Nov 15, 2013 was reported to have an acute onset of cough (< 2 weeks of coughing) and acute onset of fever.

b. Case Definition (Confirmed Pneumonia): Any child classified as a suspected pneumonia case with one of the following laboratory tests:

i. Blood culture positive for Streptooccus pneumoniaeii. PCR test positive for influenza

iii. Evidence of lung infiltrate or consolidation on chest x-ray

2. Example of a Case Definition for an outbreak (Possible Meningitis or Toxic Exposure):

a. Possible Case (Illness of unknown cause): “Any child less than 5 years of age, previously healthy, living in Health Zone “Y”, who between October 1, 2013 and November 15, 2013 experienced unusual drowsiness, somnolence, coma, seizures or death.”

Note: Case definitions may change over time. For example, if field investigators find evidence additional children may have been ill earlier in the year with similar symptoms and illness, the case definition could be modified to capture information about these children as they may be part of the same outbreak.

REFERENCE MATERIAL