JON BARDEN: The UK’s offer in response to a disease outbreak in a low- or middle-income country is designed to be seamless, from first detection and rapid investigation through to treatment of individual patients. The rapid detection is carried out by the UK’s Public Health Rapid Support Team. And this transitions through to the treatment by the UK’s emergency medical team. Well, as far as the UK is concerned, it will not deploy teams unless there’s been a request from the country for international assistance.
If that request comes from the WHO’s GOARN, the Global Outbreak and Alert Response Network, or from the WHO’s Emergency Medical Team Secretariat, that goes through to the respective team and their individual minister will decide whether or not the UK should respond. The pathway for deployment will depend on who made the request. If it came bilaterally, then the host government will provide the necessary authorization for access to the country and choose the site of operations for the team. However, the UK Public Health Rapid Support Team will carry out the deployment of staff, provide all the management and logistic support to make the mission a success. It will provide the security framework to keep staff safe and happy during their deployment.
And in most cases, the UK government will cover the cost. If the call comes from GOARN, on the other hand, then much depends on the size of the request. If it’s a small request for one or two people, then it’s expected that the World Health Organisation will provide the logistics and management support to the team, and will often cover the costs. If the response is large and requiring several teams from different countries, the role of GOARN would be to assist the local authorities in coordination of all the teams. However, the teams themself would be expected to manage and deploy their own staff and pay for them.
Key to the success of any deployment are preparation, planning, and a good knowledge of the situation in country. These will be different depending on the nature of your team. If your team is large and carries with it its own infrastructure, then your preparation will be around supply chain and logistics. And your in-country planning will be around the site selection to ensure best success for your team. If your team is small and needs to move around, talk to local communities, for example, then your preparation will be about the security planning, the transport, accommodation, all the things that will enable that team to move around safely, especially the robustness of your security plan.
One thing to remember above all, especially when many of today’s outbreaks are in fragile states or complex situations, is the duty of care you have to your staff. Remember that the primary employer is always responsible for duty of care for its staff, regardless of how long they’ve been away from their duty station, who they’re seconded to, or where they are. So it doesn’t matter who is organising the mission and how good their reputation is. If you are the primary employer, you must make sure that all the measures put into place by that organisation are good enough to keep your staff safe and secure throughout the mission.
TONY STEWART: So the national government has primary responsibility for facilitating the coordination of national and international inputs. For safety and security, and for the well-being of its own citizens, for the safety and security of humanitarian workers and other expatriates, for the protection of refugees within its border, and for maintaining law and order, the country has control over admissions into the country. As custodians of the International Health Regulations, the World Health Organisation has special responsibilities with respect to infectious hazards. The International Health Regulations outline the procedures that WHO must follow to uphold global public health security.
WHO’s emergency response framework provides guidance on how WHO manages the assessment, grading, and response to public health events and other public health emergencies in support of member states and affected communities. Experts deployed through GOARN have the additional protection by the UN system for safety, security, health care, and medical evacuation, should it be necessary.
ESTHER NGADAYA: External outbreak response teams work together with the regional and district teams to respond to the outbreak. The government of Tanzania, through the regional and district outbreak response, are in charge and overall directing external teams, as it is difficult for an external team to understand the local situation. In Tanzania, Multidisciplinary Outbreak Investigation and Response Committee is one of the subcommittee under Disaster Management Commission. The National Disaster Management Commission is under the Prime Minister’s office. And Multidisciplinary Outbreak Investigation and Response Committee is under the Minister of Health.
Brings together over seven permanent members and few co-opted members, depending on the nature of the outbreak, both at the regional and district level, who coordinate and provide the staff and resources in response to acute public health events. The Ministry Level in Tanzania oversee the activity. And if needs arise, they also join the team in the region and district where the outbreak occurred to join forces to respond to the outbreak. Tanzania is projected to have over 50 million people living in 31 regions. Or what, on average, there are three to nine district in one region. And there are several wards in a district.
There are multidisciplinary outbreak investigation and response teams at all levels, from the national, regional, district, and ward level, although at the ward level, they are normally responsible to report rumours to a higher level and also work with the regional and district level response teams during outbreak response. Multidisciplinary outbreak investigation and response teams at the regional and district level include a medical officer, who is a chair, health officer, who is a secretary, nursing officer, laboratory officer, pharmacist, accountant, procurement and supplies, social mobilisation and communication officer, and epidemiologist.
Depending on the nature of the outbreak, a veterinary officer in case of a zoonotic outbreak, such as anthrax outbreak, and engineering officer, in case of a waterborne disease such as cholera join the team. At the district level, the multidisciplinary regional outbreak investigation response team structure is replicated. In terms of resources, both the regional and district set some funds in their comprehensive health annual plans, although the budget is always falls short of what is needed. Normally, the response teams at the regional level receive rumours or other information above an outbreak from the district level on the same day the rumours occurred through integrated disease surveillance and response (IDSR).
The regional and council level then sends a multidisciplinary investigation team, whose members are also members of the response team, to confirm or refute the rumours. If the investigation team determine it is likely an outbreak, the regional multidisciplinary outbreak investigation team convene a meeting, including any co-opted member, to set an action plan and leverage resources to support the district outbreak response team with the investigation, laboratory confirmation, and later response to that outbreak. Usually, the regional multidisciplinary team joined the district multidisciplinary outbreak response teams at the outbreak location and all work together with the ward team to combat the outbreak and conduct community awareness creation sessions to create community awareness about the outbreak.
For example, in a previous anthrax outbreak in Kilimanjaro, one of the region in the northern part of Tanzania, regional and district outbreak response team received a rumour of the presence of a case. And each level convened a meeting the same day. On day two, the investigation team went to confirm the rumour. On day three, the response team were deployed. It costed around $12,000 to $15,000 USD for the health outbreak investigation activities, including follow-up activities. It may last for two weeks, up to a year sometimes, depending on the outbreak. Preventing further spread of disease is always cost-effective. Taking into consideration of resources that might be spent to manage further spread of a epidemic and life lost from epidemic prone diseases.
TONY STEWART: Cox’s Bazar is an example of a typical GOARN response. Following violence in Rakhine state, Myanmar, hundreds of thousands of Rohingya crossed the border into Cox’s Bazar, Bangladesh, joining those that fled in earlier waves of displacement. Living conditions in these temporary settlements created the environment for outbreaks, both in camps and the local host community. In this context, the diphtheria outbreak was reported by MSF. The outbreak extended from the megacamp to other small camps at Cox’s Bazar. Emergency medical teams supplemented the response by MSF and the International Organisation for Migration. And GOARN deployed some 42 experts in the disciplines of epidemiology, surveillance, data management, laboratory, case management, infection prevention and control, and project management.
GOARN continues to evolve to meet the needs of international health emergencies and outbreaks. The review of the West Africa outbreak response recommended that WHO should encourage long-term investments in partners and the strategic development of GOARN to increase integrated national, regional, and global capacities in the areas of training, research, tools development, risk assessment, and rapid response.
JON BARDEN: I’ve been lucky enough to deploy teams on numerous occasions to various different responses. Mostly, they go well. Sometimes, they don’t. So I’ll try and give some examples of why a deployment might go well and why one might not through two examples. Let’s look at one that went well. In December 2017, diphtheria had broken out in the Rohingya refugee camp in Cox’s Bazar, Bangladesh. And the World Health Organisation put out a call for emergency medical teams to respond. The UK Emergency Medical Team put up a submission to the minister that we should respond, and approval was given. So I began to mobilise the team just before Christmas.
Now, with a disease outbreak, there’s a little more time than you get with a sudden onset disaster. So I was able to send a recce team. So a recce team is a small team of individuals who will go out prior to a mission to check that the conditions are right to send your larger team. So why send a recce team in this instance and not just send your team? Well, there were two main issues. One, it was Christmas. And if I was going to take people away from their families at Christmas, I had to make absolutely sure that they were put straight to work. Otherwise, they would have been twiddling their thumbs and got very annoyed, as would their families.
The other issue was that New Year is a huge holiday in Bangladesh. And we had heard that all the hotels were fully booked. Now, I needed a place for my team to stay safely, eat safely, travel safely to where they were going to work. So in this instance, a recce team was a must. We’d been told by the Bangladeshi government that we couldn’t take our deployable infrastructure, our field hospital. So I had to make sure also that the places where my staff would work were fit for purpose. We were also told that we would work with another organisation.
I had to make sure that the terms of reference between our team and them were also fit for purpose, that we could deploy the team into their organisation, that management lines were clear, that it was clear who would provide transport, and all these kinds of things you need to look at. Above all, in working in a refugee camp, which is so large, the largest in the world, I had to make sure that my staff were safe, that the conditions for their travel, that the condition for their work was safe. We were told that we’d have to do night working so that once we started a course of treatment we could finish it.
This was going to be very difficult, given that there was a curfew in the camp. So again, the security procedures and the transport to get these staff home once they’d finished was absolutely paramount. All this were reasons why we had to be absolutely sure that conditions were safe and secure. My recce team confirmed to me that all the conditions were in place and were positive. So over the next six weeks, we deployed two teams of about 35 each, 30 clinicians and 5 support staff. They worked together with national doctors and nurses to tackle the disease outbreak. We managed to get that disease outbreak under control with just two deployments over six weeks. This was a success.
It wasn’t just a success for Bangladesh or for the Rohingya, though. Diphtheria is a disease which hasn’t been seen in the UK for many years– I think 10 cases in the last 20 years. And it’s very difficult to diagnose early on. Due to this deployment, we now have some 60 doctors and nurses across the UK who can identify diphtheria quickly and make sure it doesn’t spread.
Then there was the one that didn’t go so well. A few years ago, I was asked to deploy a team into a spike in the Gaza conflict. This was going to be a small team of surgeons and rehabilitation experts. In this instance, a recce team was not an option. So all of my in-country information had to come from people on the ground. This meant that the information was not consistent. It depended on the experience of the person or the organisation working in Gaza. As we were preparing to send the team, I began to hear that they probably wouldn’t get the necessary travel documents they needed to move from Israel into the hospitals in Gaza.
I, therefore, recommended that we put the mission on pause until such time as we could get their travel documents. This advice was ignored, and we sent the team anyway. That meant that a team of very experienced surgeons sat for two weeks in a hotel in Israel doing nothing and then came home. Now, this is bad for them. But it’s also bad for the reputation of your team. What you should never do is set your team up to fail. It will affect their morale, and they will often not work for you again.