Who responds to outbreaks?

SPEAKER: The objective of this presentation is to present a broad overview about outbreak response, specifically disease outbreaks that require an international response. We will discuss who responds to outbreaks, then learn how actors and disciplines work together in order to respond to outbreaks. And then we’ll end with some aspects of what a successful outbreak coordination looks like among actor types and roles. So who responds to outbreaks? There are two layers of actors that respond to outbreaks. There is the organisational layer and the technical layer. Let’s start with the organisational layer. There is the affected population that are not only the beneficiaries of the response, but they also organise to stop the outbreak also.

There are also existing local non-governmental organisations and community-based organisations, and there are some that may emerge in order to combat the disease outbreaks. Then we have governmental institutions that have a mandate and a responsibility to protect public health. We have international organisations that often get involved if the outbreak cannot be effectively controlled at the national level, and international actors, which include non-governmental, multilateral and bilateral entities, as well as charities and private industry. Within these organisations, there are key technical functions that must be delivered through experts and health professionals. This is the second layer. These roles include coordination. We will discuss this more later in this lecture. And then we have epidemiology-related functions to detect and monitor the disease.

We have case management and infection control to treat infected persons and prevent further spread of the disease, and WASH, or Water, Sanitation And Hygiene. These professionals work alongside of environmental professionals and are essential for protecting and sanitising water supply and removing environmental hazards. To further engage with communities, communication specialists are needed. There may also be a need for professionals trained in psychosocial support to deal with the trauma of death, injury, and stigma of survivors. Logistics is the backbone of any effective response to outbreaks. It encompasses moving people, vaccines, and medicines, as well as protective equipment. It also includes setting up mobile treatment units and much, much more.

We looked at multidisciplinary teams and roles in week one, and we will revisit them later this week. In an international coordinated outbreak response, there are often many actors on the ground at once. This slide provides an example of some common organisations that respond to disease outbreaks. Specific actors depend on the outbreak extent, the state of the affected community, and the capacity of the national technical bodies. You will see that there are traditional domestic and international health actors, including ministries of health, such as the US Centres for Disease Control and Prevention, and often the World Health Organisation is represented at country, regional, and international levels.

The WHO often provides leadership for technical expertise in disease outbreaks, and it also leads the health cluster for humanitarian response activities. In resource-constrained settings and/or conflict settings, humanitarian actors such as Médecins Sans Frontieres, the International Rescue Committee, and the local and international branches of the Red Cross often work in tandem and sometimes in parallel with traditional development and public health actors.

GOARN, the Global Outbreak Alert and Response Network, is a network of experts and partner institutions that support countries to control disease outbreaks or public health emergencies. This mechanism has been responding to outbreaks since the year 2000. Following the West African Ebola outbreak, groups similar to GOARN have emerged to provide technical reinforcement to outbreak response efforts. The UK Public Health Rapid Support Team is one of these groups that often works by contributing and supporting GOARN missions. In recent years, national public health institutions from low- and middle-income countries have also been responding to support neighbouring countries. The Nigeria Centres for Disease Control has become a strong resource for field epidemiologist and data expertise in Africa.

This includes their direct support to Liberia and Sierra Leone in the 2014-2015 Ebola outbreaks, as well as their sharing of their growing expertise on how to control diseases like monkeypox and Lassa fever with neighbouring countries. As we saw in week one, and we’ll revisit again later this week, outbreak preparedness and response involves multidisciplinary teams. When trying to combat an outbreak, there are many time points that require specialised and effective interventions that can only be carried out by such teams. For example, in the control phase, interventions that keep community members aware of disease symptoms are essential. Interventions may require social and behavioural activities, engagement with the media, and identification of cultural phenomena that may be affecting the response strategy.

In this example, epidemiologists are needed to monitor close contacts of suspected and confirmed cases, and communication experts are integral to convey new case definitions and translating community concerns. Anthropologists can provide social, cultural insights that can inform interpretation, investigation, response and analysis of the event. Another specialised intervention is medical countermeasures. Medical countermeasures are lifesaving medicines and medical supplies that can be used to diagnose, prevent, protect from, or treat conditions associated with health threats, emerging infectious diseases and natural disasters. Examples include vaccines for prevention, diagnostics to identify cases and therapeutics to treat cases. This picture is from a mass diphtheria immunisation campaign among the Rohingya population in a refugee camp in Cox’s Bazar, Bangladesh.

In 2017 and 2018, this population infamously suffered from a large-scale diphtheria outbreak. Diphtheria is a preventable disease that has had a highly effective vaccine for decades. Mass vaccination campaigns like the one employed in Cox’s Bazar, is a common medical countermeasure that is implemented during a public health emergency. As this is a more specialised intervention, it requires well-trained clinicians. Logisticians with experience in transporting and storing vaccines are also involved, and epidemiologists usually manage the planning of these campaigns, including estimating the amount of vaccine doses required.

Microbiologists are needed to test and confirm diagnosis, and finally, infection prevention and control specialists implement strategies that mitigate possibilities for disease transmission during mass immunisation campaigns, including by ensuring that personal protective equipment is available and utilised. Since nearly all outbreaks have an environmental or animal source, it is vital to work with counterpart ministries and institutions and to take a One Health approach to investigating and responding to disease outbreaks. As we’ve explored in previous steps, One Health is an integrative approach that engages human, animal, and environmental disciplines to design and implement public health programmes and policies. This picture shows a WASH intervention that was put in place during the 2013 to 2016 West African Ebola outbreak.

Ebola virus disease is spread through contact with infected individuals. This includes contaminated surfaces, such as hands. Thus, frequent handwashing was recommended to communities to prevent transmission. Handwashing stations like this blue bucket included rinse water treated with a 0.05% chlorine solution. Use of these stations was found to be effective in reducing the persistence of organisms on hands. During the outbreak response, epidemiologists and sanitation experts worked closely together to ensure that the community was well aware of the benefits of this intervention. This photo is of a giant fruit bat. It is a suspected reservoir for Nipah virus. Nipah virus causes Nipah virus infection, which is associated with encephalitis.

Outbreaks of Nipah virus infection have resulted in high fatality rates and long-term sequelae in survivors. Mainly countries in the Asia region have reported Nipah virus outbreaks, including Malaysia, Singapore, India, Bangladesh and the Philippines. Animal and human field investigations have identified that certain strains of Nipah virus have been transmitted initially from bats to pigs. Incidental human infections resulted after exposure to infected pigs, infected bats or other infected humans. WHO instructs that in order to effectively detect, respond to and prevent outbreaks of zoonoses and food safety problems, epidemiological data and laboratory information should be shared across sectors.

Government officials, researchers and workers across sectors at the local, national, regional and global levels should implement joint response teams to conduct field investigations in order to study the human, animal and environmental sources of infection, risk factors and modes of transmission. So what is a successful outbreak coordination among actors? In an international coordinated response, there is often a dual coordination mechanism, as you can see in this figure. There is a national local mechanism, as you can see on the left, and a mechanism for international stakeholders, as you can see on the right. In each mechanism, there is usually a lead entity. For the local or national response, often the National Public Health Institute or the Ministry of Health will lead.

For the international response, often a United Nations agency such as the WHO or UNICEF will coordinate the other actors in the response. For example, in a 2017-2018 outbreak of listeriosis in South Africa, it required international support. The South African government shared detailed outbreak information with WHO, which allowed WHO to activate GOARN and bring in additional foreign experts for disease surveillance and infection prevention and control. In the field, a multiagency and interdisciplinary team often comprises of both national and international technical actors to carry out the strategy envisioned by the leadership. These actors work in collaboration with the affected community to control and monitor the outbreak.

In South Africa, the National Institute for Communicable Diseases worked with partners such as WHO and partners from GOARN and the International Food Safety Authorities Network, or INFOSAN, to identify 1,060 cases with 216 deaths between January 1 2017, and July 17 2018. Partners also helped South African authorities identify the cause of the outbreak and determine the source as a ready-to-eat meat product produced at a meat plant owned by a company that shipped to 15 African countries. WHO and INFOSAN then worked with countries in the African region to improve ability to prepare for, detect and respond to potential listeriosis outbreaks.

It is best for the host government to take the ultimate lead, often by creating a task force that reports directly to an executive office, like the minister of health or the president. In South Africa, the lead entity that was in charge of monitoring and coordinating the listeriosis outbreak response was the National Multisectoral Outbreak Response Team, or MNORT, led by the National Department of Health and includes the Department of Agriculture, Forestry and Fishery, the Department of Trade and Industry and the National Institute for Communicable Diseases. Other relevant stakeholders, including WHO and GOARN, deployed personnel that followed the strategic guidance of the national response team to implement outbreak response activities.

There are many different ways to measure the successful coordination of a multiagency, interdisciplinary response to a disease outbreak. In a 2016 BMJ Global Health paper, Olu et al. provided recommendations and important lessons learned from coordinating the Ebola virus disease outbreak in Sierra Leone. As they describe the journey of transitioning from an emergency operation centre to a national Ebola response centre, they explained how strong governmental support and leadership from the highest levels was critical to giving the actors authority to coordinate and carry out response activities at all levels of government. In Sierra Leone, a presidential Ebola task force was created and chaired by the head of state.

It provided overall policy, strategic and political direction for the response to the EVD outbreak. Like in many outbreaks, communities are essential to controlling and ending an emergency, and so community engagement and participation in the coordination of outbreak control is vital. The authors suggest employing modalities for ensuring better community engagement, such as conducting ongoing anthropological studies to better understand the community context and cultural norms. In Sierra Leone, the actors employed an incident management-based system. This is a common framework used in many sectors to respond to emergencies. It often includes incident command and emergency operations structures, as well as standardised guidance on response strategies.

Specifically, the authors recommend early implementation of an IMS coordination system, which is based on humanitarian cluster coordination principles and combined with a command and control style of coordination. While many times outbreak response and coordination can be very centralised, in Sierra Leone and the other Ebola impacted countries, they found that creating coordination and functional hubs closer to the outbreak epicentre allowed for actors to make decisions faster due to less bureaucracy and reduced time between information being produced and received. Communication and reporting channels between the operational and technical components should be distinct and consistent at both district and national levels. The authors recommend regular information sharing with streamlined outbreak information dissemination, as well as sharing of meeting minutes.

The authors cite the need for clear demarcation of roles and responsibilities between different levels. They further recommend that a separation of duties should be clearly articulated, with the national level focusing on technical guidance, policy and strategy development, as well as resource mobilisation and technical oversight, while the district should be empowered to conduct the day-to-day coordination and operation of the outbreak response. During the early phases, the authors observed that logistical challenges, such as the mobilisation and deployment of required resources, was one of the most critical challenges to the EVD response. Also, the inability to forecast and procure commodities resulted in insufficient supplies. The authors recommend streamlined supply chain systems and coordination hubs closer to the outbreak epicentre.

They also remark that a national inventory system to ensure coordinated resource mobilisation and deployment should be an imperative. And last but not least, the authors recommend that there be an ongoing, on-the-job training for coordination leaders. These trainings should equip leaders on the general principles of health coordination, including management of coordination meetings; strategies for identification and filling of critical gaps in the response; communication; conflict management; and inventory and logistics management skills. In summary, when responding to disease outbreaks, experts within appropriate organisations must work collaboratively and strategically to effectively combat disease and stop the outbreak. Remember that both national and international actors have a part to play in responding to outbreaks.