What lessons have been learned from outbreaks?

SPEAKER: Outbreaks of infectious diseases have been around since the beginning of mankind. Outbreak events over many centuries dating back to ancient times demonstrate rudimentary efforts in case management, infection prevention and control, and surveillance. This module, however, will focus on the last 20 years, which has arguably seen three key moments that have significantly influenced the international outbreak response capacities. In 2000, the Global Outbreak Alert and Response Network was formed under the premise that no single organisation can provide the comprehensive needs of an international outbreak response. So 60 partners agreed to this mechanism, and today go on remaining strong with well over 200 partners within the network.

In 2003, the SARS outbreak, together with concern over pandemic influenza, led to an accelerated revision of the International Health Regulations, which are covered in another step in this teaching series. The third moment was the West African outbreak of Ebola in 2014 and 2015, which led to several high level reviews of how international outbreak responses needed to be improved, and saw significant reform within WHO, which I’ll discuss later on in this module.

I mentioned the complexity and various facets of a major international outbreak response. This graphic illustrates the need to understand the various components, and therefore the importance of coordination. Some boxes are more or less important in different outbreaks and at different times in a particular outbreak. Epidemiology helps us understand the progress of the outbreak and the effect of the interventions in place. They work alongside contact tracers and help in case finding. Labs confirm the diagnosis and support IPC in measures such as cohorting of cases. Ideally, they can also support case management with crucial basic biochemistry and the like.

Case management needs to optimise outcomes, and with good infection prevention and control practises, ensure a safe working environment, protecting health care workers and other patients in the health care setting for other reasons. And this system needs to ensure maintenance of usual essential health services. Logistics and security will oversee many needs, including health care workers’ safety, equipment, salaries of locally recruited staff, communications, and transport. The importance of social mobilisation until recently has surely been under recognised. Engaging the community and understanding beliefs, behaviours, and cultures is critical to a successful response. Each component of this outbreak response matrix requires dedicated efforts from experienced and skilled professionals, teamwork, and coordination to bring all this together.

This graphic shows technical disciplines deployed by WHO through GOARN since 2000. The emphasis has traditionally been on epidemiology and laboratories, as well as logistics, Infection Prevention Control or IPC, and case management. The importance of social mobilisation, anthropology, and communications has been recognised as key to a successful outbreak response. GOARN and its partners have acted to build this capacity recently to meet these demands.

Following on from the increased recognition for social engagement, and the fact that such professionals are increasingly part of a deployment team, here is a list of examples identified during a recent Ebola response. By talking to communities as the central unit of analysis, social sciences allows understanding of context, and how certain components of context and local practises may increase or decrease the risk of transmission.

Furthermore, by engaging with families and communities at the centre of a response, social science analysis and an understanding of local beliefs, practises, and customs have direct impact on designing the components of a response to optimise the likelihood of acceptance and therefore success. Situational understandings are always important, but never more so when an outbreak occurs in a setting with pre-existing armed conflict and violence. The first test of what was an evolving globally coordinated outbreak response network came in the form of the Severe Acute Respiratory Syndrome, known as SARS. It emerged in China, was exported to Hong Kong by a doctor who transmitted to many travellers, which facilitated spread ultimately to 37 countries and involved over 8,000 cases and 700 deaths.

There was a well coordinated effort to identify the virus, but nonetheless, a laboratory diagnosis was not available until the late stages of the international outbreak.

The diagnosis was made on clinical criteria and supported by epidemiologic links. This slide shows the late stages of bilateral infiltrates on a chest X-ray, as well as progressive tachycardia and a relentless rise in temperature, despite antibiotic treatment. SARS was in fact a trigger to rapidly review the International Health Regulations, which were first created in 1969. The 2005 edition outlined the obligation for all member states to develop, strengthen, and maintain core public health capacity for surveillance and response. There are specific commitments which apply at the local community level, including the primary public health response, and there are also clear responsibilities stated at the national level.

It allows for oversight of emerging events, and ultimately the identification of Public Health Emergencies of International Concern, otherwise known as a PHEIC. I know you have received some learning already on PHEICs, which have been called on four occasions. These are swine flu in April 2009, polio eradication in May 2014, Ebola virus disease’s outbreak in West Africa in August 2014, and the Zika outbreak in the Americas in February 2016. To ensure compliance with the International Health Regulations, a monitoring and evaluation process was established, known as the Joint External Evaluations. In this, member states have provided a scorecard, including areas of deficiency for further work.

Following the West African Ebola outbreak, there was significant criticism of the WHO, leading to much review, including three groups of considerable status. There was a recognition that the Global Outbreak and Alert Response Network was not established for the required scale of this operation. Furthermore, it would be necessary to build on GOARN, as well as other platforms, to create new mechanisms as required for future events. This led to the establishment of the WHO Health Emergencies Programme, and within that framework came the development of emergency medical teams. At national levels, countries were building on or developing new rapid response capacity.

There were also recommendations for further administrative support of these programmes, as well as a drive towards standards and improved performance, which could be best delivered by developing training, as well as research aspects within outbreak response. Emergency medical teams first emerged during the West African Ebola outbreak to complement the national expertise, as well as resources provided by groups, including the WHO, GOARN, and its partners. EMTs can take the form of any of four categories. They are trained, they arrive, and they perform as a team to undertake a specific task. Earlier I mentioned the WHO Health Emergencies Programme, which brings with it some important principles, including all hazards in that efforts are not limited to infectious diseases only.

In my mind, what is most important is the concept of no regrets. That means that if a risk assessment suggests significant concern, and the particular actions are put in place, then we would never regret committing energy and resources into a response that in hindsight might not have been needed. The WHO Emergencies Programme was established to add support to GOARN, as well as emergency medical teams. Furthermore, it undertakes an important role in alert, early warning, risk assessment, training, research, and communications. When the WHO becomes aware of an event, it is graded, whereby grade 1 is of the least concern and should be manageable at the country level.

Grade 3, on the other hand, is potentially a more substantial event, requiring at least regional support. The grading of an event can inform the support required, and it does this in terms of technical, financial, or human resources. It is essential that such grading be done as a matter of urgency, using a variety of assessors, particularly in the early stages.

Once the urgency and the scale of the problem are understood as part of the risk assessment and to properly assess the needs, the complexity in the context of the situation are considered. Some typical considerations are listed here.

This table outlines the types of response the WHO might provide in terms of technical, financial, and human resources, depending on whether the event is graded at levels 1, 2, or 3. It is no longer deemed acceptable to simply provide a response when it is needed. There is now a demand for improved quality. It means a robust system, where countries are made as capable as possible through the IHR JEE process. And when an event occurs, the risk assessment is sound. Furthermore, there needs to be a certain standard in deployees, which can be encouraged by quality training programmes. And this represents another area of solid recent investment. In the response, it also means good communications, good social mobilisation, and community engagement.

Not surprisingly, when an outbreak occurs, appropriate research is not high on the agenda, as everyone is naturally very busy. Going forward, this is also no longer acceptable, because we need to learn from outbreaks, and indeed evaluate outbreak responses and identify areas for improvement. This graphic looks very similar to one I showed earlier, and it highlights how research can be developed into all components of the outbreak response. There is potential to identify questions in the areas of epidemiology, laboratory, clinical, and infection prevention and control, as well as social sciences. This can involve a number of methodologies as illustrated. Research needs to be considered during non outbreak periods.

Some can be done at this time, but at a minimum it can be planned in anticipation of a future outbreak, together with protocols, relationship building, and resource attainment. Ethical considerations are likely complex and time consuming, and certainly warrant preemptive consideration. I’ll not expand further on ethics here, as it is addressed elsewhere in this course. Moving forward we need to increase our efforts between outbreaks, which must have a focus on the development of national capacity broadly. It includes maintaining those who have developed skills in previous outbreaks. Training can be provided, and research can be planned. Outbreaks can be seen as a time when national strength can be built, and NGOs in the field can be best utilised.

There is a growing trend for those requesting assistance to seek longer deployments, and often these are in insecure settings. It is fair to say that there have been many areas identified for improvement, and the international outbreak response community is acting. I’ve highlighted a number of topics through this talk, and while each has significant efforts going in now, there is still going to be areas for improvement for some time to come.