Basic Level Public Health Emergency Management Training

for Participants

February 2023

Addis Ababa

Acronyms
AAR After _Action Review

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AR Attack rate
ARI Acute Respiratory Infection
BPR Business Program Reengineering
CFR Case fatality ratio/rate
CRF Case fatality rate
CTC Cholera Treatment Center
DHS Demographic Health Survey
EBS Event base surveillance
EDKs Emergency Drug Kits
EOC Emergency Operating Centers
EOCs Emergency Operation Centers
EPEP Emergency Preparedness and response plan
EPHI Ethiopian Public Health Institute
ESCM Emergency Supply Chain Management
EVD Ebola Virus Diseases
EWAR Early warning and response
EWARS Early warning and response system
FSX Full-scale exercises
FX Functional exercises
HEW Health extension worker
HSR Health System Resilience
IAR Inter-Action Review
IBS Indicator Based Surveillance
IBS Indicator base surveillance
IDP Internal Displaced Peron
IDS Integrated disease surveillance
IDSR Integrated Disease Surveillance and Response
IHR International Health Regulation
IHR International health regulation
IMS Incidence Management System
IPC Infection Prevention and Control

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IPC Infection Prevention and Control
IR Incidence rate
LLINs Long-Lasting Insecticide Treated Nets
M&E Monitoring and Evaluation
MCMs Medical countermeasures
MOU Memorandum of Understanding
NDSS National Disease Surveillance System
NGOs Non-Governmental Organizations
NNT Neonatal tetanus
PDNA Post-disaster need assessment
PEA Post Emergency/Event Assessment
PHE Public Health Emergency
PHE Public health Emergency
PHE Public Health Emergency
PHEM Public Health Emergency Management
PHEOC Public Health Operations Center
PHERRT Public Health Emergency Rapid Response Team
PPE Personal Protective Equipment
RCCE Risk Communication and Community Engagement
RRT Rapid response team
RRT Rapid Response Team
SNNPR South Nation Nationality & People Region
SPM Strategic Planning Management
STD Sexually Transmitted Disease
TOR Term of Reference
TTX Tabletop exercises
VHF Viral hemorrhagic fever
VRAM Vulnerability risk Assessment and mapping
WASH Water, Sanitation and Hygiene
WHO World Health Organization
WHO World health Organization
WRF Weekly reporting Format

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WRF-HEW Weekly reporting Format for Health Extension Workers
YF Yellow Fever

Table of Contents
Acronyms....................................................................................................................................................II
Module 1: Introduction................................................................................................................................1
1.1 Background of Public health emergency management......................................................................2
1.2 History of Public Health Emergency Management (PHEM) in Ethiopia..........................................3
1.3 Public Health Emergency Management System................................................................................4

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 1.4 Pillars of Public Health Emergency Management.............................................................................5
1.5 Purpose of the Manual.......................................................................................................................5
1.6 Scope and Applicability of the Manual..............................................................................................6
1.7 Target group for the course................................................................................................................6
1.8 How to use the modules.....................................................................................................................6
1.9 Learning methods and Resources......................................................................................................6
1.10 Duration of the training....................................................................................................................7
1.11 Updating the modules and availing them.........................................................................................8
Module 2: Early Warning and Surveillance................................................................................................8
2.1 Introduction........................................................................................................................................8
2.2 Purpose of Early warning.................................................................................................................10
2.3 Component of Early Warning System.............................................................................................11
2.4 Public Health Surveillance System..................................................................................................20
2.5 Surveillance Data Analysis and Interpretation.................................................................................22
2.6 Communication of Surveillance Information..................................................................................26
Module-3: Public Health Emergency Preparedness..................................................................................27
3.1 Introduction......................................................................................................................................27
3.2 Definition of terms...........................................................................................................................28
3.3 Purpose of Preparedness..................................................................................................................28
3.4 Elements of preparedness.................................................................................................................29
3.5 Practical Exercises...........................................................................................................................36
Module 4: Public Health Emergency Response.......................................................................................40
Learning Objectives...............................................................................................................................40
Contents of the module..........................................................................................................................40
4.1 Introduction......................................................................................................................................41
4.2 Definition of Terms..........................................................................................................................41
4.3 Purpose of Outbreak Investigation...................................................................................................41
4.4 When to conduct an investigation....................................................................................................42
4.5 Steps of Outbreak Investigation.......................................................................................................42
4.6 Response Coordination for Public Health Emergencies..................................................................46
4.7 Response to other Humanitarian Public Health Emergencies.........................................................48
4.8 Practical Exercises...........................................................................................................................50

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Module 5: Recovery and Resilience........................................................................................................56
5.1 Definition of Terms..........................................................................................................................56
5.2 Purpose of Recovery from Public Health Emergencies...................................................................57
5.3 Principles of Recovery.....................................................................................................................58
5.4 Stage of Recovery............................................................................................................................58
5.5 Recovery Process.............................................................................................................................59
5.6 Recovery Plan..................................................................................................................................60
5.7 Health system resilience...................................................................................................................61
5.8 Pre-Emergency Health System Resilience.......................................................................................62
5.9 Health System Resilience during Emergency..................................................................................62
5.10 Post Emergency Health System Resilience.....................................................................................2
5.11 Practical Exercises.........................................................................................................................28

List of Tables

Table 1: The difference between IDSR and PHEM..................................................................................................4

Table 2: Reportable diseases under national surveillance system of Ethiopia........................................................16
Table 3: List of reporting forms and frequency of reporting in different levels......................................................20
Table 4 Sample 'excel' worksheet to estimate required supplies for management of cholera.................................38

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Table 5: Stages of Recovery...................................................................................................................................58

List of Figures

Figure 1: Pillars of Public Health Emergency Management System........................................................................5

Figure 2: Components of Early Warning System...................................................................................................12
Figure 3: Process of IBS and EBS..........................................................................................................................13
Figure 4: Notification of immediately reportable diseases to the next level...........................................................18
Figure 5: Formal and informal flow of surveillance data and information and feedback throughout the health
system.................................................................................................................................................................... 19
Figure 6: Critical elements of PHE preparedness...................................................................................................29
Figure 7: Volunteer management cycle..................................................................................................................34
Figure 8: Organogram for Incident Management System (IMS), Ethiopian Public Health Institute.......................48

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Module 1: Introduction
Module objectives
The general objective of this module enables the trainee will have the opportunity to acquire basic
overview about the public health emergency management, familiar with PHEM pillar, PHEM structure
in the PHEM system.

Learning objective
 Describe the background for developing each of the modules
 Acquire knowledge and skill related to the objectives of the course and types of training modules
 Familiarize yourselves with the purpose of the modules, scope, and be able to use of the modules
and training methods and resources
 At the end of this training module, you will be able to:
 Define public health emergency management
 List pillar of public health emergency management

Content of the module

 PHEM Background
 Introduction to PHEM Basic Training
 Training Objectives
 The Modules
 Training Method
 Training Materials
 Pillars of public health emergency management system

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1.1 Background of Public health emergency management
Natural and manmade public health emergencies and disasters have become major challenges around the
globe. Climate change, increasing human population, industrialization, rapidly growing international
trade and tourism, emergence and re-emergence of infectious diseases, natural disasters, rise in acts of
terrorism, and other factors further pose a risk to the public’s health.

Since the past decade, the African region has faced challenges with new diseases, conditions and events
that resulted in revision of public health priorities. Although communicable diseases have predominated
as the leading cause of illness, death and disability in the African setting, non-communicable diseases
such as hypertension and diabetes are emerging as threats to the well-being of its communities. In recent
years, the concept of one health through the integration of human and animal health surveillance has
become a high priority for many countries demonstrating the relevance of extending a multi sectoral and
multidisciplinary approach. Moreover, the adoption of the International Health Regulations (2005) by
countries in the African region including Ethiopia has underscored the need to strengthen national core
capacities for surveillance and response across all health systems.

Among the major outbreaks happened globally which impacts the country health system structure, the
2018 Ebola Virus Disease (EVD) outbreak in West Africa which resulted in over 11,000 deaths, the
ongoing emergencies of the Middle east Respiratory Syndrome Corona virus (MERS-COV) since 2012,
the 2009 H1N1 influenza pandemic which affected several parts of the world resulting in over 14,000
deaths, the 2004 avian influenza and the currently ongoing COVID-19 emergency were the major one.

In addition, Ethiopia has been also receiving hundreds of thousands of refugees from neighboring
countries particularly from Eritrea, South Sudan, and Somalia. It is estimated that the country hosts close
to 1 million refugees. Thus, the public health risks associated with international travel and cross-border
communicable disease spread prompts strong public health emergency preparedness and response plans
at Points of entries (POE) across shared border with neighboring countries. Ethiopia engages in body-
temperature screening of all international travelers’ at all international airports and designated land
crossing-sites since 2014 EVD outbreaks in West Africa. In addition, the country in recent years saw an
unprecedented increase in the number of internally displaced persons (IDPs), following a spike in
intercommoned conflicts and extreme weather conditions (drought and floods) leading to an estimated
IDPs of 2.5 million in the first half of 2018, surpassing both Syria and Yemen.

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Historical evidence shows that, the initiative to strengthen the disease surveillance system that promotes
the integration of surveillance activities in Ethiopia was started in 1996. Later in 1998 the WHO/AFRO,
following the resolution of the 48th assembly, started promoting Integrated Disease Surveillance and
Response (IDSR) for all member state to adopt as the main strategy to strengthen national disease
surveillance system.
The emergence and reemergence of new and old pathogens, new risk factors, the ease of spread of
diseases often raising political and economic concerns, has made detection and investigations of diseases
more complex in nature than they were in the past. Ethiopia has reported outbreaks of viral hemorrhagic
fever such as yellow fever, dengue fever chikungunya and sandfly fever Sicilian viruses. Except yellow
fever, which was reported after 50 years of occurrence, the other diseases were reported for the first time
in the country. Outbreaks of dengue fever have been reported from Dire Dawa, Somali and Afar regions,
while Syncytial virus was reported from Afar region and yellow fever outbreak from South Omo zone of
Southern Nations Nationalities and Peoples Regions (SNNPR) of Ethiopia.
Major public health emergencies contributing to increased morbidity and mortality are of viral, bacterial,
or parasitic origin such as measles, dengue, cholera, typhoid fever, dysentery, meningococcal
meningitis, malaria is frequent. Non-communicable diseases such as diabetes, hypertension, various
types of cancer, mental health disorders and substance abuse are on the rise. Events of public health
importance including maternal and perinatal deaths, road traffic accidents, displacement of populations
remain priorities.
1.2 History of Public Health Emergency Management (PHEM) in Ethiopia
Historical evidence shows that the initiative to strengthen the disease surveillance system that promotes
the integration of surveillance activities in Ethiopia was started in 1996. Later in 1998 the WHO/AFRO,
following the resolution of the 48th assembly, started promoting Integrated Disease Surveillance and
Response (IDSR) for all member states to adopt as the main strategy to strengthen the National Disease
Surveillance System (NDSS).

After the Business Program Reengineering (BPR) of the health sector in 2009, PHEM was identified as
one of the strategic objectives in the health sector and emerged as a core process to address the ever-
growing public health challenges related to emergencies and disasters. Public Health Emergency
Management (PHEM) defined as: the process of anticipating, preventing, preparing for, detecting,
responding to, controlling, and recovering from consequences of public health threats in order that

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health and economic impacts are minimised while Public Health Emergencies defined as events or
disasters that threaten the health of communities or groups of people.

In line with this, the national PHEM at EPHI has been tasked to conduct surveillance for the early
identification and detection of public health risks and prevent public health emergencies through
adequate preparedness; alert, warn and dispatch timely information during public health emergency;
respond effectively and timely and ensure rapid recovery of the affected population from the impact of
the public health emergency.
Table 1: The difference between IDSR and PHEM

1.3 Public Health Emergency Management System

Public Health Emergency Management is the process or a system of anticipating, preventing, preparing
for, detecting, responding to, controlling, and recovering from consequences of public health threats in
order that health and economic impacts are minimized. PHEM is designed to ensure rapid detection of
any public health threats, preparedness related to logistic and fund administration, and prompt response
to and recovery from various public health emergencies. It is a fully integrated, adaptable, all-hazards
and all health approach of national early warning, preparedness, response, and recovery. Every public
health emergency management has a starting and ending point.

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1.4 Pillars of Public Health Emergency Management
The four areas highlighted in the figure correspond to the four pillars of PHEM:
(i) Early warning and surveillance
(ii) PHE Preparedness
(iii) PHE response
(iv) Recovery

As indicated in figure 1-1 below, the process starts with early warning and ends with recovery.
However, it should be noted that in real situations the steps move forward and backward.

Early
Risks to
Warning
Public Health
Need of the
Public to be Identified Risks
protected
Public Health
Emergency
PREPAREDNESS
System, supplies and trained
Identified HR
Threats Public Health
Emergency
Reports RESPONSE
/Data

RECOVERY
Correctiv
e Actions
The Public will be protected
from health consequences of
emergencies

Figure 1: Pillars of Public Health Emergency Management System

1.5 Purpose of the Manual

The main aim of this manual is to provide a clear guidance on the proper implementation of public
health emergency management activities throughout the country. Thus; this document is produced as a
general guide to assist all health professionals who take part in public health emergency management to
implement it in a standardized way throughout the country.

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1.6 Scope and Applicability of the Manual
The training will equip and extend opportunities for the PHEM staff to obtain knowledge and skills of
PHEM through sharing knowledge. As a trainee you will be able to use the data you collect from the
system, detect and respond to priority diseases, risks, conditions and events and thereby contribute to
reduction of the burden of illness, death and disability in the Ethiopian Communities. And to familiarize
the trainee with the activities done in PHEM and introduce them to the institution. This manual is
implemented at national’s level. And regions can also be incorporated during their new staff orientation.

1.7 Target group for the course

The training is intended to build the skills and knowledge of the Public Health Emergency Management
teams at woreda and zonal level with special emphasis on woreda PHEM staff, surveillance
officers/focal points and health facilities. Therefore, the modules will help to improve your knowledge
and practice at your working environment in PHEM. Public health officers, environmental health
technologists, laboratory technologists, nurses and others who are assigned as focal points at the woreda
health system including personnel at health facilities are target groups for the training.

1.8 How to use the modules

To meet the training objectives, the course consists of 5 modules. These include Module 1 Introduction,
Module 2 Early warning & Surveillance, Module 3 Preparedness, Module 4 Response, and recovery.
The modules are interrelated to one another and are provided in sequence for a complete understanding
of PHEM with the provision of concepts of Basic Field Epidemiology. Hence, each preceding module is
a prerequisite for the subsequent module. Each module consists of learning objectives, course content,
training methods, exercises or case studies, reference materials and subject specific guidelines or
modules for further reading. You are expected to attend all the sessions, do all the exercises, read the
participant modules and reference materials as instructed in the modules.

1.9 Learning methods and Resources

The learning approach follows that of an adult learning indicating that it is learner centered. You are
expected to share your experiences and challenges in the PHEM system for obtaining maximum benefit
from the course.

1.9.1 TEACHING METHODS

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  Lecture with discussion by facilitators
 Exercises (individual and group)
 Case studies
 Reading assignments (Individual and group reading)
 Mentorship during on-job-training
1.9.2 TEACHING RESOURCES

• Participant manual
• Trainer guide
• PHEM guideline
• Other disease specific guidelines
• Other reading materials
• Case studies
• PHEM data
• PowerPoint slides
• Pictures
• Computer
• Flipchart
• Markers
• White or black board
1.10 Duration of the training
The training has two parts. Part I, the intensive phase is a 07-day training that requires classroom-based
teaching -learning and dedicated time for undergoing through the 5 modules of the training. Part II is an
on-job training which is part and parcel of the PHEM activities in the respective woredas. This phase of
the training is assisted by mentors who are experts in the field epidemiology including the respective
PHEM staff. Two different outputs are expected from the on-job training (E.g., surveillance data
analysis and outbreak investigation or woreda health profile or any other combination suggested by
mentors). The outputs will be presented and delivered to zonal or regional PHEM with approval of the
respective mentors. A description of the mentorship is provided as part of the participant modules.

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1.11 Updating the modules and availing them
The modules will be live and updated regularly. When there are some changes of policies concepts and
practices it is the responsibility of course facilitators and program owners to include updated versions in
the PowerPoint presentations as well as including corresponding references and guidelines for the
updates. The module would be printed and provided to each participant in hard and soft copies.

Module 2: Early Warning and Surveillance

General objective of the module
The general objective of this training is to gain appropriate knowledge and skills to identify and analyse
data for priority diseases, conditions and events to help for response and control.
By the end of this module, you will be able to:
 Describe early warning and surveillance systems
 Identify priority diseases and conditions for surveillance and define reportable disease based on
standard and community case definitions
 Identify sources of information for event base surveillance
 Describe reporting of priority diseases, conditions, and events under surveillance,
 Perform surveillance data analysis, interpretation, and communicate results
Content of the Module
 Introduction
 Purpose Early warning
 Components of Early warning system
 Public health of surveillance
 Surveillance data analysis and interpretation
 Communication

2.1 Introduction
Early Warning is a process with a set of defined activities that helps to provide advance information of
an incoming threat in order to facilitate the adoption of measures to reduce its potential health impact.
The traditional framework of early warning systems is composed of three phases: monitoring of
precursors/signals, forecasting of a probable event, and the notification of a warning or an alert should

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an event of catastrophic proportions take place. Early warning and risk communication starts by
identifying cases and / or events at health facilities, Port of Entries (POEs) and community level and
ends by sharing data and information for all relevant stakeholders in real-time. It also uses IHR
notifications on events happening in other countries with possibility of expansion.

Surveillance is the process of gathering, analyzing, and dissemination of information for the purpose of
proper planning, implementation, and evaluation of health services/interventions. It is also defined as
“Information for Action”. A functional disease surveillance system is essential for defining problems
and taking action. Proper understanding and use of this essential epidemiological tool (public health
surveillance) helps health workers at the woreda and health units to set priorities, plan interventions,
mobilize and allocate resources, detect epidemics early, initiate prompt response to epidemics, and
evaluate and monitor health interventions. It also helps to assess long term disease trends.

2.1.1 Definitions of Terms

Attack rate: The number of new cases during specified period divided by the number of persons at risk

Case definition: A set of criteria used to decide if a person has a particular disease or if the case can be
considered for reporting and investigation.

Case-Fatality Rates (CFR): Then number of diseases from specified disease divided by total number of
cases from that specific disease.

Completeness of a report: The number of health facilities reported by that week divided by total number
of health facilities expected to report.

Incidence: The number of new cases or events for a given time interval divided by the total population
at risk.

Morbidity rate: The number of diseases occurring in a population in a specific period (usually a year)
divided by the number of persons at risk of being sick during that period

Mortality rate: The number of deaths occurring in a population in a specific period (usually a year)
divided by the number of persons at risk of dying during that period.
Prevalence: The number of cases of disease or event at a specific time divided by the proportion at risk
at that time.

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Threshold: The level or marker that should be reached to indicate that something should happen or
change.

2.2 Purpose of Early warning

The purpose of early warning is to enable the provision of timely and effective information to the public
and to responders, through identified institutions that allow preparing for effective response or taking
action to avoid or reduce risk.

Major Activities

 Data collection, cleaning, analysis and interpretation of public health and related data
 Public health risk assessment and Forecasting/predicting of PHE risks
 Evaluate potential for epidemic transmission
 Identify Public Health emergency epidemic-prone areas and populations at risk
 Prediction of possible health outcomes
 Communication message development with suggested possible interventions
 Dissemination & communication of PH risks
 Evaluation of early warning system and message utilization
 Amendment of communication approaches
 Sentinel surveillance focused on early warning purpose
Major Indicators of Early Warning System

 An increase in the number of cases beyond expected /occurrence of outbreaks,

 Unexplained morbidity and mortality in human and animal
 An increase occurrence of malnutrition cases (SAM, MAM, GAM)
 Evidence of increase in zoonotic disease in animal and human
 Evidence of increase in vector abundance of specific diseases
 Environmental changes such as air pollution, water quality changes, contamination
 Occurrence of natural disasters such as drought, fire, flood, earthquake, severe weather
(meteorological information/prediction)
 Agricultural events such as reduced harvest, occurrence of pests or diseases
 Important industrial accidents; chemical spills and possible biological attack

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  Risky personal behaviors / lifestyles exposing to non-communicable diseases
 Occurrence of PHEs of international concern in other countries
 Occurrence of PHEs at cross border areas

Prediction / Forecasting

It is determining what is going to happen in the future by analyzing what happened in the past and what
is going on now. Health forecasting involves a degree of uncertainty, as it is virtually impossible to have
a perfect (i.e., 100 % error free) prediction. The main activity for predicting/forecasting possible public
health risks, emergencies and events includes:

 Data collection from health and other sectoral data

 Data cleaning
 Identify predisposing factors/variables for the occurrence of PHEs
 Identification of the type of data
 Selection of the type of model to build
 Estimate the parameters
 Develop tools for model estimation
 Validate the tool
 Forecast/predict PHEs occurrence by using the newly reported data
 Develop risk mapping by using the tool
 Estimate possible effect of forecasted/ predicted PHEs

2.3 Component of Early Warning System

1. Community and Event-based surveillance: - refers to structured or unstructured data gathered
from sources such as media reports, community concern, and rumors etc.
2. Indicator-based surveillance: - refers to structured data collected through routine integrated
disease surveillance, sentinel and laboratory surveillance.

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Figure 2: Components of Early Warning System

Process of Indicator Based Surveillance and Event Based Surveillance

Signals are data and/or information which can be detected through any potential source (health or non-
health, informal or official) including the media. Raw data and information (i.e., untreated, and
unverified) are first detected and triaged to retain only the one pertinent to early detection purposes i.e.,
the signals. Once identified signals must be verified. When it has been verified, a signal becomes an
“event”.

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 Figure 3: Process of IBS and EBS

2.3.1 Community and Event-Based Surveillance (CEBS)

Community and Event Based Surveillance systems (CEBS) could function during pre-emergency,
emergency, and post-emergency periods. During the pre-emergency period, it provides transfer of early
warning messages and alerts about the incoming/forecasted threat by considering signal data on hand.
CEBS during an emergency period can actively detect and notify cases and deaths and engage in
response activities. CEBS at the post-emergency period can monitor the progress towards emergency
control.
CEBS provides a reliable and immediate communication structure to alert bordering areas by giving
voice to the existing local knowledge to identify and notify public health emergencies and other risks as
early as possible. Active community participation/engagement in a reliable response network is key
features of an effective CEBS system.
Event-Based Surveillance (EBS): is an ongoing active process in detecting, collecting (mainly
unstructured information), interpreting, notifying, responding to and monitoring public health
emergencies and events at each structural level of the health system. This system complements the
Indicator Based Surveillance (IBS) system, relatively well functional at health facility level, by
capturing signals and unusual occurrence of PH risks. The event-based surveillance system is very
sensitive, and information received through it should be synchronized with IBS and rapidly assessed for

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the risk the event poses to public health and responded to appropriately.
In summary, an even-based surveillance (EBS) is:
 Designed for early warning and rapid response
 A systematic monitoring of events, event assessment and verification, and data dissemination
 The collection and collation of information that is processed in real time
 A reporting system without designated timeline or predefined structure
Community-Based Surveillance (CBS): it is an ongoing active community participation in the
process of detecting, collecting, interpreting, notifying/reporting, responding to and monitoring public
health emergencies, events, and public health related risks in the community. The scope of CBS starts
from systematic and on-going detection of PH risks/ early warning signals, collection, notification,
verification, response, and recovery as necessary. CBS widens the surveillance network to reach
communities and enable it to capture public health related events that are not captured by the routine
IBS system. Generally, Community-Based Surveillance (CBS) is expected to timely capture PH early
warning signals happening in the community such as unusual and unknown occurrence of diseases
or/and conditions, cluster of cases and/or death of humans and animals that may indicate public health
hazards and rumors of unexplained death of humans and animals.
CBS has several advantages over case-based surveillance because case-based surveillance has at least
the following limitations:

 Produces credible information but reporting is often delayed

 Is designed for known diseases and diseases are often not reported until the etiology is
known; Is not well-established in all countries
 Is limited to the health sector, whereas media and other types of open-source reports often
originate from highly motivated entities, such as journalists who promptly provide
information to open sources
Sources of CEBS Data: include existing channels of established formal and routine reporting systems,
and informal open channels, media scanning such as ProMed, blogs, social media, radio, and television,
health workers and community notification, private sectors, and non-governmental organizations. CBS
systems collect various types of information from different sources such as community members, public
and private institutions, traditional healers, local associations, and organizations depending on the local
context across the country.

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2.3.2 Indicator-Based Surveillance (IBS)

Indicator-based surveillance refers to structured data collected through routine integrated disease
surveillance, sentinel and laboratory surveillance. It is the systematic (regular) identification, collection,
monitoring, analysis, and interpretation of structured data, such as indicators produced by several well
identified, mostly health-based, from formal sources as listed below;
 Sentinel Surveillance System (SSS): A given number of health facilities or reporting sites
designated as sentinel sites for early warning and reporting of priority events such as pandemic
or epidemic events and other events of public health importance. Sentinel sites are usually
designated because they are representative of an area or are in an area of likely risk for a disease
or condition of concern. Ethiopia is implementing sentinel surveillance for selected disease
conditions, including:
o Severe Acute Respiratory Syndrome (SARI) and Influenza Like Illness (ILI) sentinel
surveillance
o Climate sensitive diseases surveillance
o AFI (Acute Febrile Illness) and others
o Arboviral diseases sentinel surveillance
Based on the importance and impact of the disease condition as well as the necessity of sentinel
surveillance, other events/disease conditions might be included in the sentinel surveillance
system as required.
● Laboratory-based surveillance is the key part of the overall surveillance as the detection and
control of outbreaks requires rapid identification of the pathogens and their source of infection.
Starting from the national level to the health post level, suspected outbreaks should be confirmed
by laboratory investigation.
Chemical, Biological and Radio nuclear (CBRN) Surveillance
Chemical, Biological and Radio nuclear hazards/agents include toxic chemicals that can cause
poisoning, biological agents causing infection or disease; and radioactive materials with the potential to
affect human health. CBRN incidents can be caused by the accidental or deliberate release,
dissemination, or impacts of CBRN agents.
Priority Diseases and Conditions for Surveillance
It is clearer that surveillance could not be carried out for all diseases and conditions. Therefore, priority
should be given to those diseases that are of interest at national and international levels. In Ethiopia 36
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 diseases and conditions (22 immediately and 14 weekly) are selected to be included into the routine
surveillance system. These are selected based on one or more of the following criteria:
● Diseases/conditions which have high epidemic potential (anthrax, avian human influenza,
cholera, measles, meningococcal meningitis, pandemic influenza, smallpox, severe acute
respiratory syndrome (SARS), viral hemorrhagic fever (VHF), and yellow fever), chikungunya,
COVID-19, Severe pneumonia in children under 5 years age, TB, Monkeypox, Rift Valley Fever
● Diseases/conditions required internationally under IHR2005 (smallpox, poliomyelitis due to
wild-type poliovirus, human influenza caused by a new subtype, SARS).
● Diseases targeted for eradication or elimination (poliomyelitis due to wild-type poliovirus,
dracunculiasis, neonatal tetanus (NNT) and Obstetric Fistula.
● Diseases/conditions that have available effective control and prevention measures for addressing
the public health problem they pose.
● Diseases/conditions which have a significant public health importance (rabies, dysentery,
malaria, relapsing fever, and severe acute malnutrition, moderate acute malnutrition, maternal
death, perinatal deaths, adverse events following immunization, Diarrhea with dehydration in
children less than 5 years of age, Acute jaundice syndrome within 14 days of illness, scabies,
new HIV cases, new diabetes cases, new hypertension cases, tuberculosis, severe pneumonia in
children under 5 years age, Obstetric Fistula, Brucellosis
Furthermore, it is required to report the Clusters of emergency illnesses or health conditions that are of
concern to the public which need early intervention/response.
Note: Region specific disease or events that have public health importance which warrant surveillance
can be added to their surveillance system.
Table 2: Reportable diseases under national surveillance system of Ethiopia

Immediately Weekly

1. Anthrax 23. Malaria

2. Measles 24. Diarrhea with dehydration in U5 children

3. Human influenza caused by new subtype 25. Acute Jaundice Syndrome within 14 days of illness

4. Adverse Events Following Immunization 26. Severe Pneumonia in children under 5 years age
(AEFI)

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5. Neonatal / Non-Neonatal Tetanus 27. Dysentery

6. Rabies 28. Relapsing Fever

7. Smallpox 29. Meningitis

8. severe acute respiratory syndrome (SARS) 30. Severe Acute Malnutrition (SAM)

9. Yellow Fever 31. Scabies

10. Poliomyelitis (Acute Flaccid Paralysis) 32. New HIV cases

11. Chikungunya 33. Hypertension new cases

12. Cholera 34. Diabetes new cases

13. Dracunculiasis (Guinea Worm) 35.Tuberculosis

14. Dengue Fever 36. Moderate Acute Malnutrition (MAM) in U5C /PLW

15. COVID-19/SARS COV-2

16. Monkeypox virus

17. Brucellosis

18. Rift Valley Fever

19. Viral Hemorrhagic Fever (VHF)

20. Maternal death

21. Perinatal death

22. Obstetric Fistula

Case Detection/Identification and Notification

Case detection can be done at health service delivery units by health professionals or from community
level by Health Extension Workers or any community members.
Case Definitions: It is a set of criteria used to decide if a person has a particular disease, or if the case
can be considered for reporting and investigation.
● Standard Case Definition: It is a case definition that is agreed upon to be used by everyone

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 within the country. It can be classified as confirmed, probable, and possible or suspected. These
definitions must be used at all levels including the community, health professionals working at
health posts, health centers, hospitals, health offices at different levels, private health facilities,
other government health facilities and NGO clinics.
● Community Case Definition: It is a case definition of disease and conditions adapted to suit
health extension workers (HEWs) working at a health post level. The community case definitions
were modified for simplicity and ease of understanding by HEWs.
Surveillance Data Reporting Periodicity
The identified 36 diseases and conditions are classified into two reporting periods (immediately, weekly)
depending on their epidemic potential, acute severity, diseases targeted for elimination and eradication.
Immediate Reporting: For the immediately reportable diseases, a single suspected case is considered as
a suspected outbreak. Therefore, suspected outbreak of these diseases should be notified from level to
level within 30 minutes of identification as follows:
● From community or HP or HC to woredas health office within 30 minutes
● From woreda health office to zone/region within another 30 minutes
● From zone to regional office within another 30 minutes
● From region health bureau to federal level within another 30 minutes
● MOH to WHO within 24 hours of detection.

Figure 4: Notification of immediately reportable diseases to the next level

Report Case-Based Information to the Next level

If an immediately reportable disease, condition, or other public health event is suspected:
● Make the initial report by the fastest means possible (telephone, text message, facsimile, e-mail,

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 radiophone). The health facility should contact the district health authority immediately and
provide information about the patient.
● Complete and submit manually or electronically
● Make sure patient identifying information’s are registered correctly
Weekly Reporting: Reporting of the total number of cases and deaths seen within a week (Monday to
Sunday) and should be reported to the next level as follows:
● HFs report data from Monday to Sunday to woreda every Monday till mid-day.
● Woredas report to the zone/region every Tuesday till mid-day.
● Zone (if applicable) report to region every Wednesday till mid-day;
● Region reports to EPHI /PHEM every Thursday.
● EPHI /PHEM report to stakeholders every Friday.
Reporting can be done verbally or by telephone, printed report/paper based, radiophone or using
electronic methods such as email, fax, mobile short message service (SMS) based on the real situation
on the ground.

Figure 5: Formal and informal flow of surveillance data and information and feedback throughout the
health system

Reporting Tools and Period of Reporting

Reporting of prioritized diseases and conditions should be done by using their own appropriate reporting
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formats. The reporting procedures might vary from reporting in the normal situations. This includes
utilization of different disease/event specific reporting formats, change in reporting frequencies and
maintaining daily zero report, which is not routinely practiced. Different reporting tools/formats are
developed to facilitate and guide the reporting of prioritized diseases and conditions to be utilized at
different levels of the health system. The table below shows the list of different reporting formats with
their application level and periodicity of reporting.
Table 3: List of reporting forms and frequency of reporting in different levels

Level Formats to be used Periodicity

Weekly reporting format for HEW Weekly
AFP case investigation format Immediately
Case-based reporting format Immediately
Health Post
Line list Daily
Rumor log book for suspected epidemics weekly
Modified IDS Case-based Reporting Format–NNT Immediately
Case-Based Reporting format Immediately
Case Investigation format Immediately
Modified IDS Case-based Reporting Format–NNT Immediately
Guinea worm case-based reporting format Immediately
Health Center /
Influenza case-based reporting format Immediately
Hospital
Rumor log book for suspected epidemics Immediately
Arboviral diseases case-based reporting format Immediately
Weekly reporting form Weekly
Line list Daily
Daily epidemic reporting format for Woreda Daily
Woreda Health
Weekly reporting format Weekly
Office
Rumor log book for suspected epidemics Immediately
Daily epidemic reporting format for region Weekly
Zone/Region
Line list for guinea worm Immediately
Health
Line list daily
Bureau
Rumor log book for suspected epidemics Immediately

2.4 Public Health Surveillance System

Public Health Surveillance is an ongoing, systematic collection, organization, analysis, interpretation,

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and dissemination of information, in order that action may be taken. It is the use of data to monitor
health problems to facilitate their prevention and control. Surveillance is also defined as “Information
for Action”.

Purpose of Surveillance:

 To early detect epidemics (outbreaks) so that they can be controlled in a timely manner
 To monitor trends in endemic / priority non-communicable disease to inform policy decisions for
changing trends
 To evaluate an intervention so that effective and efficient policies are identified and supported
 To monitor progress towards a control, elimination, and eradication programs so that
achievements against targets are measured
 To monitor program performance with a view to enhancing it
 To predict/forecast public health emergencies occurrence and plan health services to prevent,
mitigate, respond/control and rec over effectively
 To estimate future PHEs impact and develop health services according to predicted needs
 To predict and prevent entry/exit and spread of infectious disease from neighboring countries
and international travelers and conveyances
Types of surveillance
 Passive surveillance:
 A system in which the recipient waits for the health providers report
• E.g., Routine reporting of notify able diseases;
 Active surveillance:
 Cases are actively sought out by the persons running the surveillance system. This
involves:
• Regular telephone contact
• Visit to health facilities with register reviews
Core functions of surveillance
 Identify cases and events
 Report suspected cases, conditions or events to the next level
 Investigation

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  Analyze and interpret findings
 Communicate with and provide feedback to health workers and the community
 Evaluate and improve the system
Support functions of surveillance
 Support functions improve or enhance the core functions
o Resources - financial & human
o Training
o Communication
o Transport & logistics
o Support supervision

2.5 Surveillance Data Analysis and Interpretation

Surveillance data analysis and interpretation is a crucial part that guides responses to public health
emergencies. Data analysis and interpretation should be done daily and weekly at each level where data
is collected (starting from health facility level to national level). The analysis provides key information
for taking prompt public health actions.
Data analysis provides the following important outcomes:
● Frequency count by reporting units help in identifying outbreaks or potential outbreaks.
● Analysis of routine data provides information for predicting changes of disease rates over time
and enables appropriate action.
● Disease rates change over time.
● Identifies problems in the health system; so that gaps can be effectively implemented.
● Identifies the most appropriate and timely control measures in outbreaks and acute epidemics.
The major steps in data analysis are creating database or filed paper data, data cleaning and data
analyzing (by time, place and person) and interpretation (information generation).
● Create an electronic database or file paper data: The reports that are being received daily and
weekly must be entered on daily basis into an electronic database or kept on file using a paper
format at each level of the health system and make a backup saved data.
● Data Cleaning: before starting analysis check if the data is complete. If reports are missing or
part of the data is incomplete, try to get the data before starting analysis.
● Data Analysis: data analysis practice that must be generated includes Trends over time (line

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 graph, bar graph or histogram), Geographic distribution of the disease or the outbreak (dot map),
Frequency of cases, deaths (table), Case Fatality Rate (CFR), and Attack rate (AR).
Analyze data by time
Time includes variables such as day, week, month, and year. The purpose of “time” analysis is to detect
changes in the number of cases and deaths over time. It also helps to compare the current disease trend
with previous trends. It enables you to see if thresholds are reached or not. Data about time is usually
shown on a graph.
Analyze data by place
Analyzing data according to place gives information about where a disease is occurring such as woreda,
kebele, town, etc. Establishing and regularly updating a spot map of cases for selected diseases can give
ideas as to where, how, and why the disease is spreading.
Use manual methods or geographic information system (GIS) software to create a map to use as part of
routine analysis of surveillance of disease.
Analyze data by person
Analysis by person includes the variables such as age, sex, ethnicity, and other occupational risk factors
such health workers, food handlers, miners, etc. A simple count of cases does not provide all the
information needed to understand the impact of a disease on the community, health facility, or woreda,
but simple percentages and rates are useful for comparing information reported. Make a distribution of
the cases by each of the person variables in the reporting formats.
Disease frequency measures
 Prevalence= # of new + old cases in a specified time
Average/mid-year pop. during
x 10n

 Incidence= # of new cases in a specified time

x 10n
Average pop. during that time
 Mortality= Number of Deaths
x 10n
Total population

Case Fatality Rate (CFR): The case fatality rate helps to

● Indicate whether an outbreak is identified timely,
● Indicate whether the case-management is performed properly,
● Identify the level of response to treatment (virulent, new, or drug-resistant pathogen),
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 ● Indicate poor quality of care or no medical care,
● Compare the quality of case management between different catchment areas, cities, and woredas.
Public health programs can reduce case fatality rate by ensuring that cases are timely detected, and good
quality case management takes place. Some disease control recommendations for specific diseases
include reducing the case fatality rate as a target for measuring whether the epidemic response has been
effective.
To calculate CFR, use the following formula:
CFR=Number of deaths ¿ a specific disease ¿ the same specific disease ¿ ×100
Total number of cases ¿

Attack Rate (AR): Calculate AR on a weekly basis during an epidemic. Calculating AR helps to:
● Calculate the resources needed to respond to the epidemics,
● Evaluate if the threshold is reached,
● To know the speed of dissemination of the disease
AR is a variant of an incidence rate, applied to a narrowly defined population observed for a limited
period, such as during an epidemic.
Number of new cases during a specfic period
Attach Rate= ×100
Number of susceptible persons

Compare the current situation with previous week/months/quarter, seasons, and years:
● Observe trends on line graphs to see if cases and deaths are stable, decreasing or increasing.
● If CFR calculated, is the rate the same, higher, or lower than it was in the previous months.
● Determine if thresholds for action have been reached or crossed.

Action and Alert Thresholds

Thresholds are markers that indicate when something should happen or change. They help surveillance
and program managers answer the question, “When will you take action, and what will that action be?”
Thresholds are based on information from two different sources as follow:
● A local situation analysis for the specific disease or condition describing who is at risk for the
disease, what are the risks, when is action needed to prevent a wider epidemic, and where do the
diseases usually occur (example – a specific Kebele level malaria epidemic threshold should be
determined based on the 5 years’ average data);
● International recommendations from technical and disease control program experts.
Alert threshold: suggests to health staff that further investigation is needed and preparedness activities

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should be initiated. Health staffs respond to an alert threshold by:
● Reporting suspected problem to next level,
● Reviewing data from the past,
● Requesting laboratory confirmation,
● Be more alert to new data and trends,
● Investigating the case or condition,
● Prepositioning of drugs and supplies,
● Mobilization of the needed resources,
● Alerting specific program manager and woreda epidemic response team
Action threshold: triggers a definite response. It marks that findings from either routine surveillance or
special investigation signal a need for action beyond confirming or clarifying the problem. Possible
actions include, communicating lab confirmation to concerned health centers, implementing an
emergency response such as immunization, awareness campaign, or infection control practices in
healthcare settings

Action Thresholds during Humanitarian Disasters

Most epidemic thresholds have been developed for stable populations because these thresholds require
longitudinal data over a period of years. There are few data on the use of these epidemic thresholds in
emergency situations with recently displaced populations. Nevertheless, the establishment of a
surveillance system early in an emergency will ensure that baseline data on diseases with epidemic
potential are available. This will allow an assessment of whether an increase in numbers of cases or
deaths requires action or not. At the onset of health activities, the health coordination team should set a
threshold for each disease of epidemic potential above which an emergency response must be initiated.

Summarize analysis results

Consider the analysis results with the following factors in mind:

● Trends for inpatient cases describe the most severe cases of a particular disease; this is because
generally only severe cases are hospitalized. Deaths are most likely to be detected for cases that
are hospitalized.
● Increases and decreases may be due to factors other than a true increase or decrease in the
number of cases and deaths being observed. For example, large population movements or
changes in health services can affect disease patterns.

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 ● If no decrease is occurring while undertaking appropriate health intervention, number of cases is
same or increasing, consider whether any of the following factors are affecting reporting:
o Has there been a change in the number of HFs reporting information?
o Any change in the case definition that is being used to report the disease or condition?
o Is the increase or decrease a seasonal variation?
o Any community outreach/health education that would result in more people seeking care?
o Any recent immigration or emigration to the area or increase in refugee populations?
o any change in quality of services at the facility? For example, lines/waiting times are
shorter, health staffs are more helpful, drugs are available, and clinic fees are changed.

Data Quality: Completeness and Timeliness

For routine weekly surveillance data calculate the completeness of the reports. All woredas and levels
above should calculate the completeness of the reports received on a weekly basis. A report is said to be
complete if all the reporting units within its catchment area have submitted the reports on time. E.g., if 9
out of 10 health facilities have submitted, then the report is said to be incomplete (or 90% complete).
the number of health facilities which reported∈that week
Completeness= report ¿ ×100
total number of health facilities expected ¿

Note that “the number of health facilities that are expected to report” for a particular level (e.g., for a
woreda) is the sum of all government hospitals, health centers, health posts, other health facilities such
as NGO health facilities, and other government health facilities.
A report (from a reporting unit) is said to be on time, if it reaches the designated level within the
prescribed period. If it reaches later, then the report is late.
The timeliness of a reporting unit can be calculated by assessing how many of its expected reports have
come on time.
the number of health facilities which reported ontime∈that week
Timeliness= report ¿ ×100
total number of health facilities expected ¿

2.6 Communication of Surveillance Information

The main objective of outbreak communication is to build, maintain, or restore trust, and encourage
participation in the early warning activities. Mechanisms of accountability, involvement, and
transparency are important to establish and maintain trust. Elements of communication include risk
communication, alert/ warning, and provision of feedback.

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Module-3: Public Health Emergency Preparedness
Module Description: This chapter provides the basic knowledge and attitude on PHE preparedness
activities categorized in each element of coordination & collaboration, assessment, planning for the
identified risks/hazards and monitoring and rehearsal/simulation of preparedness.

Module Objective: By the end of this chapter participants will be able to define PHE preparedness and
identify main activities in each element of preparedness.

Enabling Objective: By the end of this chapter participants will be able to

 Introduce about preparedness

 Define key terms of preparedness
 Describe the purpose of Preparedness
 Identify elements of Preparedness
 Perform exercises of preparedness
Module outline
3.1 Introduction

3.2 Definition of terms

3.2 Purpose

3.3 Elements of preparedness

3.4 Practical exercise of preparedness

3.1 Introduction
Preparedness is defined as “the range of deliberate, critical tasks and activities necessary to build, sustain, and
improve the operational capability to prevent, protect against, respond to, and recover from incidents” and those
tasks/activities are undertaken before the occurrence of the emergency considering the existing hazard
and expected risk getting the information mainly from EWAR, surveillance findings and making ready
all needed manpower, logistics and finance for averting and minimizing the consequence of the expected
emergencies.

27
It also works on system establishment and maintenance considering the current public health emergency situation
at each level of the health structure.

It involves a range of players and partners engaging in initiatives that promote health, prevent and control diseases
and conditions and protect people from the consequences of health emergencies due to manmade and natural
causes and those players and partners include all levels of government, private sector, not-for- profit sector,
institutes, and professionals’ associations.

The preparedness activities need also consider on maintaining the routine health service activities. The
way forward to implement sound preparedness measures is to accomplish first and foremost a paradigm
shift from managing emergencies to managing risks

3.2 Definition of terms

Hazard: Man-made or naturally occurring event or situation with the potential to cause physical or
psychological harm (including loss of life) to members of a community, damage or loss to property,
and/or disruption to the environment or to structures (economic, social, political) upon which a
community’s way of life depends e.g., presence of outbreaks, flood, storm, chemical release.
Threat: intent and capacity to cause loss of life or create adverse consequences to human welfare
(including damage to property and supply of essential services and commodities), environment or
security.
Vulnerability: The susceptibility of a community, service, or infrastructure to damage or harm by a
realized hazard or threat.
Risk: The probability of harmful consequences or expected loss (of lives, people injured, economic
activity disrupted or environmental damaged) resulting from interactions between natural or human
induced hazards conditions. Risk is defined as a product of the likelihood of the occurrence of a given
hazard (epidemic disease, drought, flood, etc.) and the vulnerability to the impact. For example:
Measles epidemic (hazard) in a community - The potential impact and risk will depend on
vulnerability and Capacity based on the immunization level, nutrition status etc.
Capacity: is the combination of all the strengths, attributes and resources available within a community,
society, organization or a system that can be used to achieve agreed goals or reduce disaster risks

3.3 Purpose of Preparedness

The aim of preparedness is to strengthen capacity in preventing, predicting, preparing, detecting,
recognizing and responding to public health emergencies through conducting regular risk identification

28
and analysis, establishing partnership and collaboration, enhancing community participation and
implementing community-based interventions and strategic communication during the pre-emergency
phase and ensuring their monitoring and evaluation.
The main objectives of health emergency preparedness include:

● Preventing avoidable crisis and catastrophes

● Reducing morbidity and mortality effects

● Ensuring availability of required resources

● Minimizing disruption to health services

● Maintaining business continuity as far as possible

● Reducing disruption to society as much as possible

● Reducing deleterious effect of the emergency on quality of life

3.4 Elements of preparedness

In the public health context, the preparedness sub process is comprised of the following broad activities:

Coordination and
Collaboration

Monitoring
and Capacity Building
Rehearsal
PHEM
Preparedness

Planning VRAM

Figure 6: Critical elements of PHE preparedness

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3.4.1 Coordination and Collaboration
In order to have effective preparedness and response activities, we need to have a system that will
address possible collaborators and engage alarming situations for participation, management, legal
binding and putting clear roles and responsibilities.

Coordination will be better managed if a committee or task force of all the stakeholders and partners is
established in advance. There is no need to create a committee for emergency preparedness. Instead, it is
advisable to work within established structures and systems such as task force, technical working group,
rapid response team, health committee etc.
Horizontal coordination addresses links among different sectors and institutions at national, regional,
zone, woreda and kebele levels. Horizontal coordination also includes cross-border coordination with
neighboring countries and inter-regional, between zones or woredas or kebeles within the country.
Vertical coordination addresses the hierarchy from the national level to the Kebele level.
Activities and steps required for effective coordination and collaboration include:

● Identification of all sectors, collaborators and partners, their areas of intervention and capacity

for public health emergency management;

● Development of a list and keep a register of all institutions and organizations relevant to PHEM

and update the list of institution, their focal persons, and experts biannually;

● Communication with all partners and establish a coordination/collaboration forum;

● Development of Term of Reference (TOR), Memorandum of Understanding (MOU) to guide the

framework;

● Monitoring and evaluation, participation and implementation of public health emergency

30
 activities as per the TOR or MOU;

● Formation of a Rapid Response Team (RRT) to initiate activities at the time of response;

● Revision of membership, TOR or MOU and amend/update as per the findings of the review.

3.4.2 Assessment of Public Health Emergency Preparedness

Baseline and periodic assessment
The baseline and periodic assessment are an evaluation of health status of the community through
systematic, comprehensive data collection and analysis to provide information and critical reference
point on the current levels and perspective health status of the community.
Baseline Assessment: provides information on the situation to initiate a surveillance system for
that specific disease and events. It provides a critical reference point for assessing changes and
impact, as it establishes a basis for comparing the situation before and after an intervention, and
for making inferences as to the effectiveness of the campaign. The assessment needs to be
conducted when there is occurrence of new public health problem, new diseases, diseases added
to surveillance, etc.
Periodic Assessment: it is a screening tool used by PHEM Unit in collaboration with
stakeholders and partners at each level to evaluate the health and nutrition situation, based on
public health interest to evaluate the public health concerns and to know capacity and
preparedness on readiness of the surveillance system. It can be conducted alone or combined
with other public health readiness needs.
Vulnerability and Risk assessment and Mapping(VRAM)
It is the process of determining and ranking of the risk level of a frequently existing hazards. It needs to
consider many parameters that will aggravate or minimize the risk level of the hazard. Basically, during
risk assessment we need to consider the existing hazard, vulnerable condition, and existing capacity on
preventing and responding the consequence of the predicted hazard. It is undertaken by organizing multi
-disciplinary and multi sectoral team having the aim of getting pertinent information on the assessment
parameters (Hazard, Vulnerable condition, and existing capacity). The VRAM assessment finding is
basically used for planning purpose.

Risk=Hazard (H)*Vulnerability (V)/Capacity(C)

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3.4.3 Planning for the Identified Risks and Hazards
Planning is the theme of the whole emergency preparedness exercise. Plans should be updated regularly
especially following major incidents and mock exercises to include lessons learned. The plans should
form the basis of estimation of required resources for predictable emergencies including training. It
should be exercised periodically to ensure that partners are familiar with the plan and able to execute
their assigned role.

In addition to revising of existing plans, plans for hazards which are becoming increasingly important
and may not have received due attention in the past such as chemical, biological, radiological, nuclear
(CBRN) threats, non-communicable diseases need to be prepared. The purpose of planning at this stage
is to have agreed upon, implementable and/or operable plans in place, for which commitment and
resources are relatively assured. This includes readiness plan with different sectors.
The activities and steps in the process of planning include:

• Identify and convene preparedness planning team(s)/experts from different sectors including
partners,
• Coordinate and integrate all response and recovery agencies/organizations in the planning
process,
• Identify needs required to respond to potential emergencies,
• Discuss with partners to endorse and agree on their roles and responsibilities,
• Develop plans, to prevent, protect against, respond to, and recover from natural and man-made
disasters,
• Prepare monitoring mechanisms and tools to ensure preparedness plan is operationalized,
• Ensure the integration of the plan in the sector regular plan.

3.4.4 Capacity Building

The World Health Organization (WHO) defines capacity building as the development of knowledge,
skills, commitment, structures, systems, and leadership to enable effective health promotion.

Capacity building activities shall be carried out in order to effectively mitigate, prepare for identified
risks, and respond to any occurrence of PHE events. The capacity building activity could focus on

32
establishing and/or strengthening system and human resource needs related to PHEM: surveillance
system, communication, laboratory and logistics.

System Development:

The Health System Development (HSD) is a structure designed to underpin the significance of
leadership roles, and the paramount value to prepare health professionals for effective communication
and decision-making at all levels

It improves the overall structure of health care delivery in the following ways.

 Strengthen the inflow of gathered information from all sources in a timely fashion,
 Develop/strengthen communication procedures, and systems that support required
communications with all levels
 Provide ICT support to early warning sub process
 Coordinate procurement and placement of communication systems based on a gap analysis of
requirements versus existing capabilities

Workforce development

Recruiting and maintaining a highly qualified health workforce with appropriate technical training,
scientific skills and subject-matter expertise to prevent, prepare for, detect and respond to public health
emergency events is the key element of health emergency and disaster preparedness.

Workforce capacity building activities improve performance of the staff according to specific, defined
competencies related to planning, implementation, and monitoring of health emergency preparedness,
response and recovery activities.

The implementation of workforce capacity building strategies should be informed by demands and need
assessment at sub national and lower levels of the health system and the existing community structures
and also take into consideration the health sector priorities and strategic objectives of strengthening
primary health care to achieve universal health coverage and health security. Surge capacity and
volunteer management are under workforce development.

The following activities should be considered as part of a comprehensive workforce capacity building
strategy for health emergency preparedness and response at all levels.

33
  Training needs assessment
 Preparing updated list of trained staff at all levels
 Identifying and addressing gaps in the existing training
 Working with public health training institutions
 Planning and implementation of training based on need, identified gaps and health sector
strategic objectives.

Surge Capacity:

Surge capacity is the ability to provide adequate healthcare during health emergencies that may exceed
the limits of normal health system capacity (staff, supplies, space and system) of affected country,
region or community. The need for surge capacity is influenced by features of the health emergency
event, available resources and support for the ministry of health or agency responsible to coordinate the
response, the need for specific expertise and needs of the affected population.

When public health demand increases or is likely to increase, workforce surge processes should be
initiated as early as possible and decisions about surge requirements should be made by public health
authorities at national or local level according to existing guidelines.

Surge staff is mobilized when the magnitude of the health emergency event exceeds available capacity
of existing health workforce

Identifying, training and deployment of surge staff with various backgrounds may be engaged to provide
diverse technical skills required during a surge response and types of surge staff that contribute to health
surge response include; health professionals (e.g., physicians, nurses, etc.), non-health professionals
(e.g., logistic and supply chain specialists.) and administrative support personnel.

Volunteers Management:

A volunteer is an individual, institution, agency and others who render aid and service without pay or
remuneration. Emergency volunteers may be recruited and deployed to the health facilities by an
organization (affiliated), or may present themselves spontaneously (unaffiliated).

34
Figure 7: Volunteer management cycle

Logistics

Emergency Supply Chain Preparedness:

The key emergency supply chain management and preparedness activities involve; identifying disease
threats and needed commodities that should be stocked in the emergency supply chain, as well as
deciding whether to stockpile some of these commodities in advance, and planning storage, transport,
and logistics in the event of an emergency.

Demand forecasting: Before procurement of Emergency products, demand and forecasting is a critical
step in the Emergency Supply Chain Management (ESCM) of PHEM. By determining how much of
certain MCMs will be needed in an anticipated or actual crisis, EPHI/PHEM lays the groundwork by
preparing a preparedness plan for an effective response and it reduces supply shortages in the event of
an outbreak.
Sources of data for quantification are: population at risk, attack rates, past incidence numbers,
epidemiological behavior of pathogens, previous consumption, “belg and meher” survey figures,
program data and analysis of triggers and quantification activity is being done by different groups.
Emergency Supply Chain Coordination

35
Effective ESC coordination is helpful for proper utilization of resources in emergency situations and it is
important that governments together with all aid agencies engaged on disaster relief are clear on who
does what, when and where.
Resource Mobilization and Mapping: The active engagement of humanitarian and development
partners, private sectors and communities at large are critical in resource mobilization through existing
coordination forums at all levels. The existing preparedness, coordination and planning forums in the
humanitarian and development forums play a vital role in engaging all actors for resource mobilization
and PHEM should coordinate resource mapping and mobilization for emergency situations.
Local Capacity with respect to Emergency Supplies: In mobilizing resources, it is important to
consider the local capacities as one of the strategies to produce emergency supplies as encouraging local
manufacturing capability across the developing world will not only support the immediate response to
specific pandemic but it also creates more resilient health systems and supply chains going forward.
Emergency Procurement Management

EPHI/PHEM or through its procuring agent must rapidly procure additional goods and services to enable
an effective response. The public health and medical resources needed during an emergency are
frequently different in character and quantity than those used daily to address routine circumstance so
that the institute or its procuring agent should have a comprehensive list of potential sources for all
essential commodities.

First-line suppliers should be pre-identified, vetted, and contracted ahead of time to limit lead times.
Suppliers should also be diversified to limit risks such as long production lead times or local factory
shutdowns due to the spread of infection

3.4.5 Monitoring and Rehearsal/Simulation

Monitoring: This activity focuses on monitoring the implementation of identified activities indicated in
the sub-processes and reporting the status to respective stakeholders based on the frequency set in the
PHEM core process design. Validation and revision of operational and epidemic preparedness and
response plan (EPRP) through exercises, training, and real-world events, and the use of after-action
reports also contribute to evidence-based assessment of functional capacities and opportunities. Findings
from these experiences guide the refinement of the successive plans that will be used at different phases.
Document findings and lessons learnt and share with all stakeholders. Therefore, the indicator should be
refined and qualified according to the contexts in which preparedness activities are to be carried out.

36
Simulation: Simulations are conducted in order to test preparedness in the absence of an event suitable
for an after-action review, to check or validate response capacity, and monitor for improvement in
identified areas. Such exercises are structured whereby the items at all levels test efficiency and
reliability of preparedness activities in an ideal setting.

3.5 Practical Exercises

Exercise 1: Coordination and Collaboration

In this exercise, you will share your experiences by answering the questions given below. First
document your individual experiences. Second share your experiences with smaller group. Third each
small group selects the best experience and present to the larger group.

1. What is your experience in public health emergency?

2. What structures do exist with regard to collaboration and coordination?

3. Who should be included as members of the emergency management committee? What will be their
roles?

4. Who should the Woreda health Office send to the field to investigate? What was the role of RRT?

5. What do you want to improve?

Exercise 2: Vulnerability assessment and risk mapping and planning

In this exercise, you will share your experiences by answering the questions given below.

1. Document your individual experiences by listing risks in your woreda

2. Analyze the risks and prioritize using impact and likelihood table 3. Conduct risk
evaluation using the risk matrix and develop EPRP plan.
4. Each small group selects the best exampled woreda and present to larger group

Exercise 3: Capacity Building

Your woreda has 8 kebeles, with a population as follow: -Kebele Aa= 45000, Bb= 35000, Cc= 45000,
Dd=50000, Ee= 30000, Ff=10000, Gg=80000, &Hh = 55000

37
 The tables below provide a national assumption and can give you a general approach on how to
estimate of a mount of supplies needed according to the number of people in area at risk. Construct a
simple excel spread sheet to calculate the logistic, human resource, operational budget and supplies
that are required for your planning exercise.

AWD – General Assumption

At risk woredas = woredas affected at least once

Attack Rate = 0.2% (National attack rate) Depends on the region (you can calculate the exact figure if you
have previous data)

Severe cases= 20% (you can calculate the exact figure if you have previous data)

Adult = 85%

Children U5 = 15%

Pregnancy = 2%

RL = 120 bag per 20 severe cases

ORS sachet (for 1 liter each) = 650 sachets for 100 cases

Doxycycline = 3 capsules per one severely ill case

Amoxicillin, 250 mg/5ml susp, 100ml/bottle= one bottle for one severely ill CHILD case

Erythromycin, 250 mg= 12 capsuls for 1 severely ill Pregnant case

Tetracycline (TTc), 250 mg= 24 capsules for 1 severely ill case

IV cannuala = one cannula for sever case

Scalp vein sets = one cannual for one sever case and 50% require it.

Adult Nasogastric Tube ( NGT) = one for one sever case, & 15% require it.

Pediatric Nasogastric Tube ( NGT) = One tube for one severe case, & 15% requir it

Large water dispensers with tap ( marked at 5 & 10 liter level) for making ORS soluation in Bulk= 2 for
every 100 patients

Bottles ( 1 liter) for ORS e.g empty IV bottles) = 20 for sever 100 patients

Bottles ( 0.5 liter) for ORS = 20 for sever 100 patients

Tumblers, 200 ml = 40 for every 100 patients

Wastage factor = 15%

CTC = 1 CTC with 10 beds. Bed occupancy rate 3 days

38
 Table 4 Sample 'excel' worksheet to estimate required supplies for management of cholera
AWD supply
plan

Zinc RL/NS Doxacyclin Amoxicillin Tetracyclin Tetracyclin

Total seve ORS 20mg bag of e 100 m, tab 250mg e 20mg, tab e 20mg, tab IV
PNG ANG Scalp
S. Expect r [satchets tablets 1000m (Adults) disp.tab/PAC (PW) (PW) Cannul CTC
T T Vein
N Kebel ed case ] (children l -100 a
o e Pop cases s ) (children)

A B C D E F G H I J K L M N O

B=0.2 C = D = 6.5 E = B x F= C x G = 3 x C x H= C x 15% I = C x 2% J = C x 2% K = L= M= N= O=

% XA 20% x B 15% x 10 6 x1.15 85% x1.15 x 12 x x 12 x x 24 x 15% x 85% x 1.15% 0.5 x C/10
X B x1.15 x 1.15 1.15 1.15 1.15 Cx Cx x C 0
1.15 1.15 C x1.1
1 5

39
Module 4: Public Health Emergency Response

Learning Objectives

At the end of this training module you will be able to:

• Define cluster, outbreak, and epidemic

• List the reasons that health agencies investigate reported outbreaks

• List and describe the steps in the investigation of an outbreak

• Draw and interpret an epidemic curve

• Calculate the appropriate measure of the association from two by two table

• Identify Interventions of specific outbreak

• Communicate findings of outbreak investigation in scientific way

Contents of the module

The major contents of this module are the following:

40
 • Definition of Terms

• Purpose of outbreak investigation

• When to conduct an outbreak investigation

• Steps of outbreak investigation

• Other Humanitarian Public Health Emergencies

• Response Coordination for Public Health Emergencies(EOC/IMS)

• Monitoring and Evaluation

• Practical Exercises

4.1 Introduction
Public health emergency response comprises from case investigation to result communication and
Response to other Public Health Emergencies (natural and manmade disasters). Rapid response limits
the number of cases and geographical spread, shortens the duration of the outbreak and reduces
fatalities. These benefits not only help save resources that would be necessary to tackle public health
emergencies, but also reduce the associated morbidity and mortality. It is therefore important to
strengthen epidemic response, particularly at woreda and community levels.

Public health emergency response has to be initiated upon receipt of an alert or rumor, or detection of a
deviation of the disease trends from the expected trend while performing weekly surveillance data
analysis.

4.2 Definition of Terms

Epidemic: the occurrence of more cases of disease than expected in a given area or among a specific
group of people over a particular period of time. Usually, the cases are presumed to have a common
cause or to be related to one another in some way

Outbreak: epidemic limited to localized increase in the incidence of disease Cluster: aggregation of
cases in a given area over a particular period without regard to whether the number of cases is more than
expected

41
Disaster: A disaster is a serious disruption of the functioning of a society, causing widespread human,
material, or environmental losses which exceed the ability of affected society to copy by using its own
resources.

4.3 Purpose of Outbreak Investigation

• Verify the outbreak or the public health event and risk.

• It also helps to establish the existence of an outbreak by collecting specimen and relevant
information.

• Identify and treat additional cases that have not been reported or recognized.

• Collect information and laboratory specimens for confirming the diagnosis.

• Identify the source of infection, transmission pattern or cause of the outbreak.

• Describe how the disease is transmitted and the populations at risk.

• Select appropriate response activities to control the outbreak or the public health event

• The investigation provides relevant information for taking immediate action and improving
long-term disease prevention activities.

• Communication

4.4 When to conduct an investigation

Conduct an outbreak investigation when:

• A report of a suspected epidemic of an immediately notifiable disease is received

• An unusual increase is seen in the number of deaths during routine analysis of data
• Alert or action thresholds have been reached for specific priority diseases
• Communities report rumors of deaths or about a large number of cases that are not being seen
in the health facility
• A cluster of deaths occurs for which the cause is not explained or is unusual (for example, an
adult death due to bloody diarrhea)

It is important that after receiving the alert report the Woreda PHEM Committee or Taskforce need to be
activated. Note that woreda should aim to initiate investigation of the suspected outbreaks within three
hours.

42
4.5 Steps of Outbreak Investigation
In investigating an outbreak it is an important to follow the following steps. However, in reality it might
not follow the steps mentioned

I. Prepare for fieldwork

 It should ideally involve the following experts but might be expanded depending on the
disease suspected and the control measures required. The RRT should include: An
epidemiologist; Clinician; Laboratory technician; Environmental health specialist; Public
health officer; a representative of the local health authority; and more professionals based
on the type of the PHE. Prior to deployment, all members of the RRT should be briefed on
the situation, the roles and responsibilities they are expected to play, means, time, and
frequency of communication etc. One team member should be assigned as the team leader.
 Staff who might be able to take part in the investigation should already be identified and
trained in the form of RRT.
 Avail relevant resources that are required during the field activity such as: case-based
formats, line list, outbreak reporting formats, guideline, Supplies for collecting lab
specimens, personal protective equipment (PPE), laptop, wireless network, and mobile
phone.
II. Establish the existence of an outbreak
 Review trends in cases and deaths due to the disease over the last 1-5 years (if available);
 Determine a baseline number to describe the current extent of the disease in the catchment
area;
 Know the epidemic threshold for that particular disease;
 Compare the reported case versus the baseline and the threshold per month or week under
that particular catchment area;
 Consider factors influencing disease occurrences such as seasonal variations in some of
the diseases such as malaria and meningitis.
 Based on the finding, decide whether the outbreak exists or not.

III. Verify the diagnosis

 Identify as accurately as possible the specific nature of the disease.

43
  Examine patients and review records to confirm signs and symptoms meet standard case
definitions.
 Review laboratory results for the people who are affected. If you are at all uncertain about
the laboratory findings, you should have a laboratory technician review the techniques
being used. Collect samples to isolate the organism or identify the evidence for infection.

IV. Define and identify cases

 Establish a case definition, or a standard set of criteria for deciding whether, in this
investigation, a person should be classified as having the disease or health condition under
investigation.
 Search for additional suspected cases and deaths in registers of facilities with reported
cases,
 Search for suspected cases, deaths, and contacts in the community by identifying areas of
likely risk where the patients have lived, worked, or traveled.
 Talk to other informants in the community such as health extension workers, pharmacists,
school teachers, veterinarians, farmers, and community leaders etc.
 Collect information that will help to describe the magnitude and geographic extent of the
outbreak.
 Record information on a case-based form for all patients from which lab specimens will
be taken.
 Record any additional cases on a line list when more than five to ten cases have been
identified, the required number of laboratory specimens have been collected,

V. Analyze data collected in terms of time, place and person

 Analyze Data by Time: Prepare a histogram using data from the case-based reporting
forms and line lists. Plot each case on the histogram/epi-curve according to the date of
onset. As the histogram develops, it will illustrate an epidemic curve.
 Determining incubation period and period of exposure: In common source outbreaks
involving diseases with known incubation periods, epidemic curves can help determine
the probable period of exposure.

44
  Analyze Data by Place: Construct a spot map by using the place of residence on the case
reporting forms or line lists. Identify and describe any clusters or patterns of transmission
or exposure, depending on the organism that has contributed to this epidemic, specify the
proximity of the cases to likely sources of infection, calculating place/location specific
attack rates in addition to examining the number of cases in each locality allows
comparison on the rate of transmission in different population sizes.

VI. Develop hypotheses

The hypothesis should address the source of the agent, the exposures that caused the
disease, etc. While developing hypotheses consider what you know about the suspected
disease outbreak and look at the issues such as:

What is the agent’s usual reservoir? How it is usually transmitted? What vectors are
commonly implicated? What are the known risk factors?

VII. Evaluate hypotheses

There are two types of analytic studies: cohort studies and case- control studies. Cohort
studies compare groups of people who have been exposed to suspected risk factors with
groups who have not been exposed. Case-control studies compare people with a disease
(case-patients) with a group of people without the disease (controls). The nature of the
outbreak determines which of these studies you will use.

VIII. Refine hypotheses and carry out additional studies

When analytic epidemiological studies in steps above do not confirm your hypotheses, you
need to reconsider your hypotheses and look for new vehicles or modes of transmission.
The circumstances may allow you to learn more about the disease, its modes of
transmission, the characteristics of the agent, and host factors.

IX. Implement control and prevention measures

Depending on the outbreak or event, the success of the response depends on activation of
the IMS and implementation of intervention strategies such as:

 Overall coordination;

45
  Case management as well as infection prevention and control (IPC);
 Logistics and supply chain management;
 Laboratory or diagnostic surveillance and epidemiology;
 Social mobilization and risk communication;
 Reactive vaccination;
 Water, sanitation and hygiene (WASH);
 Vector control.

X. Communicate findings

Situation updates are produced and distributed on a regular basis, daily to weekly, depending on the
public health emergency events. An email distribution list, decided by the IM, will be formed containing
all response members. The update should be disseminated to response members, relevant private and
government sectors, and partners. This communication usually takes two forms: an oral briefing for
local health authorities and a written report. Select appropriate communication methods that are present
in your area such as: radio, television, newspapers, meetings with health personnel, community,
religious and political leaders, Posters, brochures, leaflets, stickers, banners, and presentations at
markets, health centers, schools, women’s & other community groups, service organizations and
religious centers. Select and use a community liaison officer or health staff to serve as spokesperson to
the media. As soon as the epidemic has been recognized, release information to the media only through
the spokesperson to make sure that the community receives clear and consistent information.

4.6 Response Coordination for Public Health Emergencies

Response activities could be initiated with or without the activation of the Emergency Operation Center
(EOC) and or Incident Management System (/IMS) or any name like Woreda task force, just depending
on the scale and scope of emergency situation.

Concepts of EOC: Public Health Operations Center (PHEOC) is a physical or virtual space that public
health emergency management personnel assemble, coordinate operational information and resources,
strategically manage public health events and emergencies. The primary objectives of the PHEOC at
national, regional and district levels are improving continuity, collection, organization, analysis,
presentation and utilization of data and information, communication and coordination with internal and
external response partners, preparation of public communications to support community awareness,
outreach and social mobilization, identification, prioritization, acquisition, deployment and tracking of
46
resources such as human, material and financial to support all PHEOC functions, mobilization of
resources, monitoring financial commitments and providing administrative services. A PHEOC will
bring together multi-disciplinary and multi-sectoral experts to coordinate responses to PHEs in a
structured manner using IMS, which is a standard and proven response management system.

Activation Levels of EOC: Activation of the EOC enhances EPHI/MOH ability to provide immediate
response in the event of a public health emergency. An activated EOC supports rapid response through
various activities, including not limited: mobilization of staff and resources, organizations of response
actions and centralized location of technical expertise and subject matter experts for decision making
and the drafting of plans. The EOC may be activated for an event anywhere within the district, region, or
the nation. Whenever any of the public health emergency response activation criteria are met, the
PHEOC Manager informs all key stakeholders and partners within 1 hour through a phone call followed
by email or other available communication tools. EOC activation levels are designated based upon a
level of effort, and not strictly by the total number of personnel involved in the response. There are three
activation modes.

Watch Mode: The watch mode corresponds to the normal day to day activities. The watch staff
constantly monitors and triage information on public events by facilitating the collection, organization,
analysis, dissemination and archiving of information. The PHEOC is constantly in watch mode
throughout the different modes of operation. The responsibilities of watch staff include,

 Rumor collection, communication and/or verification

 Media (social media, TV news, newspaper, radio and etc.) and web scanning
 Screening routine public health surveillance data for unusual occurrence
 Preparing and sharing of weekly summary report; of SPOTRep and SITREP
 Compilation and documentation of events and the intervention activities
 Ensure that the PHEOC has supplies and are functional
 Familiarity with responding agency’s culture or system
 Authority to administer finance and mobilize resources.

Alert Mode: This is the early standby phase of activation when an emergency has occurred or is
imminent. The PHEOC conducts intensive monitoring of an incident or event in preparation for a

47
potential PHEOC activation. Besides the watch mode activities, the alert mode activities include, but
not limited to:

 Intensified monitoring or enhanced surveillance

 Intensified communication with the relevant stakeholders
 Ensure a preliminary assessment conducted for PHEOC activation
 Initiation of preparation for deployment of resources
 Identification of experts to staff the IMS positions and mobilize from the other units
 Official letters signed by the DG or delegate shall be sent to all stakeholders and external
partners to notify them about the possible PHEOC activation
 Pre-activation notification will be sent for the identified IM, section chiefs and general staffs
from the available roster through phone calls / SMS and email to fill the IMS functions (Pre-
activation notification template).

Response Mode: The response mode is the phase after the PHEOC activation notification sent. In the
initial phase of PHEOC activation, the PHEOC manager or the PHEM lead will temporarily assume the
IM position.

NDRM FMOH

PHEM TF EPHI PHEOC Manager

Incident Manager

Public Information Officer Liaison/Partnership

Security/Safety Officer Operations Section

Planning Section

Logistics Section

Admin/Finance Section

Regional Health Bureau-PHEM

Figure 8: Organogram for Incident Management System (IMS), Ethiopian Public Health Institute 48
Deactivation of EOC: EOC deactivation is a process that begins while the EOC is activated and
requires the attention of EOC staff during the response phase of a public health emergency. The
objective of an EOC is reaching deactivation because it indicates that the public health threat has been
stabilized. When the response is declared over or incident is stabilized, the PHEOC will be deactivated
and return to normal or routine operation. (Refer for the National Public Health EOC guideline)

Read the detail of these steps from PHEM guideline second edition section 4 (Page 63-77).

4.7 Response to other Humanitarian Public Health Emergencies

Public health emergencies arising from mass causalities, flooding, landslides, in the immediate
aftermath of drought, population displacement due to conflicts, biological, chemical, radiological etc…
are considered in this document as other public health emergencies and needs to undertake the following
tasks in humanitarian settings:

 Maintaining essential health services,

 prevention and control of disease outbreaks, investigation of outbreaks,
 risk communication and community engagement,
 essential drugs and supplies availability and
 monitoring and evaluation mechanisms are crucial components of public health disasters’ responses
Monitoring and Evaluation

As a PHEM Officer, you have to closely monitor and evaluate the response activities during emergency
to ensure the effectiveness of the intervention and to support resource mobilization efforts. Read the
detail from PHEM Guideline

What elements are to be monitored for response activities?

The following are some of the elements to be monitored:

 Disease trends in order to assess the effectiveness of the response measures, the extension
of the outbreak and risk factors
 Resources assessment of the rational utilization, adequacy and sufficiency and
determination of additional needs

49
  Effectiveness of the response: case fatality rate, incidence rate
 Implementation status of the identified intervention activities (program coverage, safe
water coverage, immunization, hygiene and sanitation activities, public communication
and education, ITNs distribution, etc.

Key Monitoring indicators for public health emergency response

• Proportion of rumors of PHE verified within 3 hours of initial notification

• Percentage of woredas with functional RRTs

• Percentage of out breaks that have been investigated within 48 hours

• Percentage of outbreaks that have CFR within the accepted norm

• Proportion of suspected outbreaks of epidemic prone diseases in which lab confirmation

are completed according to the guideline

• Proportion of PHE with prevention and control measures initiated within 48 hours of
identification of risks and characterization of threats

• Percentage of out breaks contained with an acceptable containment time (as per specific
guidelines recommendation)

4.8 Practical Exercises

In this exercise, you will read about an outbreak and the steps that were taken to investigate it and then
answer the questions that follow each section. Your facilitator may suggest that participants do this
exercise in pairs or small groups of 3 to 4 people.

Case study 1

Scenario 1: A suspected outbreak of a food borne disease which occurred after attending a wedding
ceremony on morning of Tir 27, 2003 in a small town X was reported to your Woreda health office on
the same day in the afternoon. The patients present with vomiting, diarrhea and abdominal pain.

1. As Woreda PHEM Officer what first actions do you take?

2. What is the composition of the team that you need to send to the field to investigate the
situation? Why?

50
Scenario 2: The Woreda RRT who went to the site (town X) has found the list of25cases who have
the symptoms mentioned above form Health Center record and 5 more cases by searching among of
most of the attendants of the wedding ceremony.

Part of the line list of the suspected cases is as follows.

Time of Abdominal
SN Name Town Sex Age Vomiting Diarrhea Others
onset pain

1 GK X F 20 7:30 1 1 1 0

2 PG X M 44 8:00 1 1 1 0

3 JK X M 7 8:30 1 0 1 1

4 WL X F 47 8:45 1 0 1 0

5 WW X F 10 8:45 1 0 1 1

6 OM X M 13 8:45 1 1 1 0

7 SO X F 20 7:30 1 1 1 0

8 OD X F 39 7:30 1 1 1 0

9 ER X F 17 7:30 1 0 1 0

10 DS X M 44 7:00 1 1 1 0

11 LK X M 46 8:30 0 1 1 0

12 RE X M 38 9:00 1 0 1 0

13 LO X M 40 8:00 0 1 1 0

14 KO X F 60 8:00 1 0 1 0

15 PO X M 22 7:00 0 1 1 0

16 DE X F 28 8:45 0 1 1 0

17 GS X F 20 7:30 1 1 1 0

18 FK X F 44 7:00 0 1 1 0

19 NU X M 7 8:00 1 0 1 1

20 PQ X F 47 7:30 1 0 1 0

21 KS X M 40 8:30 1 0 1 0

22 KA X F 40 8:00 0 1 1 0

23 NK X F 20 7:30 0 1 1 0

51
24 HD X M 24 8:00 1 1 1 0

25 XE X M 22 7:00 1 1 1 0

26 MA X M 20 6:00 1 0 1 0

27 ER X F 50 8:30 1 1 1 0

28 BN X M 26 7:30 1 0 1 0

29 MZ X F 16 7:00 1 0 1 0

30 MX X M 10 8:30 1 0 1 1

3. What could be the case definition that was used by the Woreda RRT? What information
helped them to generate case definition?

4. Draw an epidemic curve of the outbreak and tell the type of “source of outbreak” it was.

5. What further information the RRT need to collect to know the possible source of
infection?

6. To identify the cause of the outbreak what kind of the samples and at least how many
samples the RRT should collect? To which laboratory they could send?

Scenario 3: The Woreda RRT was informed that 80 people attended the wedding. The teams managed
to interview 72 of them, 30 met the case definition. All cases ate from 7 items served at wedding. The
investigation team identified the number of wedding attendees those ate and did not eat from each
food items according to the table below.

Exposed to People Who Ate People Who Did not Eat RR

Ill Not Ill Total AR (%) Ill Not Ill Total AR (%)

(a) (b) (c = (d = a/c) (e) (f) (g = e+f) (h = e/g) (d/h)

a+b)
Doro wat 7 35 42 7 23 30
Kitfo 10 26 36 8 28 36
Kurt (Beef) 8 36 44 6 22 28
Tibs 5 45 50 4 18 22

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Rice 8 33 41 7 24 31
Fruits cocktail 6 22 28 9 35 44
Mixed salad 20 11 31 3 38 41

7. To test the association between exposure and the illness, what kind of analytical study is
more appropriate? What is the appropriate measure of the association?

8. Calculate the attack rate for all food items.

9. Which food item shows the highest attack rate?

10. Is the attack rate low among persons not exposed to that item?

11. Calculate and interpret the relative risk for each food items?

12. Which items were associated with the illness? Interpret it

13. If the lunch was served at 6:30 and the source of the outbreak is mixed salad, what could
be the possible explanation for the case happened at 6:00?

Case Study 2

Scenario 1: On 17 Meskerem 2004, the health officer working in Y Health Center reported one death
associated with acute watery diarrhea and vomiting. By 20 Meskerem, the health officer reported 6
cases and 3 deaths to you, as Woreda PHEM Officer, by telephone. Since 2 weeks ago, you also have
previous report that there was a confirmed cholera outbreak in neighboring Woreda X.

1. List all possible reasons that might justify initiation of an investigation?

2. How do you verify the existence of the outbreak?

3. List all materials you must have before deployed to field?

4. If the laboratory personnel have no this information so far, what kind of information do
you give so that he or she has to prepare to take all laboratory materials required?

5. To whom do you talk after you arrived at affected site?

6. How do you verify the diagnosis?

Scenario 2: The Woreda RRT reached the site on 23 Meskerem and developed a summary of
information about cases and deaths that occurred during the outbreak. The RRT identified a total of 33

53
cases and 8 deaths since the onset of the first case. To have more information they talked to some
patients in the community. Up on the discussion, one of the patients told them that on 16 Meskerem
2004 one of their Kebele resident was died of diarrhea and vomiting after returning back from funeral
ceremony of his relative in Woreda X. Following the funeral ceremony of his dead body on 18
Meskerem 2004,the cases were more expanded in the community by affecting new villages.The RRT
sent five stool specimens to regional public health laboratory, four of them were tested positive for
Vibrio-Cholera.
7. Q1. What prevention and control measures should RRT take at this stage? When?

8. How frequently should they communicate with Woreda Health Office?

Scenario 3: The RRT together with Kebele Administration, start providing health education to the
community at large, provide case management training for health workers and established cholera
treatment center (CTC) on 24 Meskerem. On Tikimt 3, 2004 heavy rain occurred and the area was
flooded. Following this situation the number of cases had been increasing and the RRT widely
distribute water purification chemicals and kebele administration together with HEW conduct social
mobilization on latrine construction, hand washing and utilization of water chemicals starting on
Tikimt 6, 2004. At the end of the outbreak the RRT identified and summarized a total of 113 cases
with 14 deaths from four villages in which a total of 6176 population lives. Review the tables below
and then answer the questions that follow.

Village Population Case

Total Male Female Tota M F

l
Village A 1300 663 637 29 13 16
Village B 789 454 436 26 15 11
Village C 1987 526 505 39 16 23
Village D 2100 1071 1029 39 20 19
Total 6176 2714 2607 133 64 69
9. By looking at the table which village do you think is most affected?

10. Calculate crude and sex specific attack rates and interpret the findings? Which Village is
most affected?

54
11. Look at the following graph and interpret. Why most of the deaths happened at the
beginning of the outbreak? Why the trends is decreasing after 24-Meskerem? Why it rises again on
5-Tikimt? Why do cases kept decreasing significantly after Tik-8?

What is the possible explanation for the occurrence of this outbreak?

12. To whom do you report the findings of the outbreak investigation and how?

13. Mention the major components of outbreak reporting format.

55
Module 5: Recovery and Resilience
Module Objectives: This chapter provides the basic knowledge on public health emergencies recovery
for which participants get familiar with public health recovery concepts, resilience and rehabilitation
purpose, principles and priority interventions.

Learning Objectives
 Define recovery, rehabilitation and resilience
 Explain the purpose of recovery and rehabilitation
 Understand post emergency assessment process
 Identify the possible intervention after the occurrence of public health emergencies
 Explain health system resilience pre-emergency, during emergency and post emergency phases
Contents of the Module
 Definition of Terms
 Purpose of Recovery from Public Health Emergencies
 Principles of Recovery
 Stage of Recovery
 Recovery Plan and Process
 Health System Resilience in pre-Emergency, during and post emergency phases
5.1 Definition of Terms
Disaster: A disaster is a serious disruption of the functioning of a society, causing widespread human,
material, or environmental losses which exceed the ability of affected society to copy by using its own
resources.

Recovery: Recovery is defined as the process of rebuilding, restoring, and rehabilitating the community
following an emergency, but it is more than simply the replacement of what has been destroyed and the
rehabilitation of those affected.

AAR: is a means of identifying and documenting best practices and challenges demonstrated by the
response to the event and can be built into the end of mission debrief of the response to EPHI and
FMOH.

56
IAR: is to reflect on ongoing response activities to identify gaps, best practices, and lessons learned and
recommend corrective actions to improve and strengthen the continued response.

Resilience: “The ability of individuals, households, communities, cities, institutions, systems and
societies to prevent, resist, absorb, adapt, respond and recover positively, efficiently and effectively
when faced with a wide range of risks, while maintaining an acceptable level of functioning and without
compromising long-term prospects for sustainable development, peace and security, human rights and
well-being for all” (UN Chief Executive Board, 2017).
Rehabilitation: The actions taken in the aftermath of a disaster to enable basic services to resume
functioning to assist victims’ self-help efforts to repair physical damage and community facilities, revive
economic activities and provide support for the psychological and social wellbeing of the survivors.
Psychosocial Support: An approach to victims of disaster, catastrophe or violence to foster resilience of
communities and individuals. It aims at easing resumption of normal life; facilitating affected people's
participation in their convalescence and preventing pathological consequences of potentially traumatic
situations.

5.2 Purpose of Recovery from Public Health Emergencies

The goal of recovery is to ensure the economic sustainability of a community and the long term physical
and mental well-being of the affected community, to rebuild and repair the physical infrastructure, and
to implement mitigation activities to reduce the impact of future disasters. The regional and local health
departments have a key role to play in all these response and recovery activities. Restoring lifesaving
services and assisting communities to cope with former and new health threats is a necessity to mitigate
the impacts.
Recovery in the health sector represents opportunities to catalyze action on health policy and strengthens
the capacity of countries and communities to manage risks of future events. As recovery is community-
led, policy implementation at the local level will be the responsibility of the community. Recovery
should be a deliberate, planned process that allows the community to define its own goals for recovery
and assist in that effort. This will depend on the status of development of a country and what a country
can afford to sustain.

● First, it is better that the reconstruction addresses key issues currently faced by the health sector

and provide better health service like accessibility to the poor and other vulnerable populations.

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 ● Second, the future health system should be designed to be prepared for and responsive to all

major hazards in the future.

● Third, the existing health system in the affected areas may need to be streamlined to meet the

changed needs because of different population profiles and epidemiology.

5.3 Principles of Recovery
Recovery is most effective where recovery management arrangements provide a comprehensive and
integrated framework for managing all potential emergencies and where assistance measures are
provided in a timely, fair, and equitable manner and are sufficiently flexible to respond to a diversity of
community needs.

The following lists are the key recovery principles;

● Equity: Expansion of service to underserved areas, the poor and vulnerable population.

● Effectiveness: Increasing the access to and the quality of key services

● Appropriateness: Adoption of new service delivery models to respond to new health needs if the

previous system was outdated.

● Efficiency: Greater overall efficiency with savings used to finance some of these measures

5.4 Stage of Recovery

Recovery consists of short-, medium-, and long-term stages and the promotion of disaster risk reduction
to minimize future damage to the community and environment. It includes measures such as the return
of evacuees, provision of psychosocial support, resumption of impacted businesses and services,
provision of financial assistance, and the generation of economic impact assessments and recovery
strategies, infrastructure repairs and environmental rehabilitation

Table 5: Stages of Recovery

Stage of Recovery Features

Short-term (e.g.,
• Begins simultaneously with the onset of response activities.
days to weeks after
• Ensures basic human needs are met and key support services are

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 the emergency) provided.
• Informed by a Post Disaster Needs Assessment
• Restoring basic functions of society depends on how quickly recovery
activities and plans are initiated.

Medium-term (e.g., • Involves completing emergency response activities and transitioning

weeks to months) to activities geared specifically to recovery. Involvement of NGOs,

insurers, financial institutions, and volunteer groups.
• Is informed by iterative post-disaster needs assessments.
• Focuses on movement of goods and services, infrastructure repairs,
resuming business and economic functions, reconnection to the
environment, social health and wellness.

Long-term (e.g., • Involves sustained efforts to adapt to the changed conditions, which

months to years) may include replacement, rebuilding, or improvement.

• Focuses on risk reduction through changes in building codes and
land-use designations (transitioning to mitigation), permanent housing
and facilities, business resumption, and long-term mental health and
social support services to individuals.
• The objective is to use the recovery, rehabilitation, and reconstruction
phases to increase community resilience through the integration of
practical disaster risk reduction measures

5.5 Recovery Process

After the occurrence of an emergency or a disaster, the impact of damage that occurred on the health of
the population and the system that serves them needs to be objectively assessed to clearly identify the
gaps and to design the appropriate strategy for the specific context. Hence, a major activity during the
recovery process is an effective Post Emergency/Event Assessment (PEA) to guide the
implementation of recovery activities. The elements within each building block considered during the
assessment include the following examples:

● Service delivery: availability and accessibility of essential services

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 ● Leadership and governance: Health sector policies; harmonization and alignment; oversight
and regulation; governance capacity; and coordination mechanisms.
● Health workforce: workforce policies and plans; human resource norms, numbers and types of
health workers, distribution and competencies
● Information: Facility and population-based information and surveillance systems; data analysis
for decision making
● Medical products, vaccines, and technologies: Access to essential medical products, vaccines
and technologies with assured quality, safety, and efficacy.
These are major assessment areas;

● Pre-crisis baseline: health status and pre-existing health risks, pre-existing policies,
performance, and challenges in the health system (preparedness strategies and plans, disaster
risk management program)
● Impact of the disaster: Impact on the burden of disease/event, health infrastructure and on
health system functions.
● Response: Includes humanitarian interventions to address changes in the BOD, establish
lifesaving services, and restore the functioning of the health system
Conducting PDNA (Post-disaster need assessment) enables us to inform and determine priorities,
funding mechanisms, and recovery coordination for all relevant sectors at national, regional, and local
levels.
5.6 Recovery Plan
The Post disaster need assessment will inform the development of a recovery plan. A recovery plan is
developed in consultation and active involvement of local authorities and the target community and must
integrate into the overall recovery and rehabilitation plan, outlines recovery needs, and describes the
actions envisaged in the plan to take in delivering recovery services to the affected communities,
infrastructures, and the health system, including funding required and timeframes for
implementation. The regional and local authorities can assist with identifying programs available for
communities to implement the post emergency recovery plan.

Prioritization of Recovery Actions: The (PDNA) and recovery plan will assist the responsible
authorities and partners to allocate recovery resources, including human and financial, by identifying
priority recovery needs and recovery objectives. These should be activities that lessen humanitarian

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impacts as soon as possible. The next phase of prioritization is identifying medium to long-term
recovery needs and the generation of sustainable and resilient livelihoods. Prioritization is based on
scope and scale of recovery needs and availability of resources by sector.

5.7 Health system resilience

Health System Resilience (HSR): Health system resilience is defined “as the capacity of health actors,
institutions, and populations to prepare for and effectively respond to crises; maintain core functions
when a crisis hits; and, informed by lessons learned during the crisis, reorganize if conditions require it”.
Health systems are resilient if they protect human life and produce good health outcomes for all during a
crisis and in its aftermath.
Building Health System/ Service Resilience aims to :
● Enable health workers, health facilities and health organizations to better withstand and recover from
a disruptive acute PHE more quickly and effectively
● Reduce the impact of chronic stresses on the health system due to PHEs
● Improve the public’s trust in the health system and therefore better utilization of health services
which improve population health outcomes
● Avert the high socio-economic cost of responding to PHEs and other shocks with poor preparedness
and lack of resilience capacities.
Health system resilience capacities

An alternative framework for resilience focuses on three aspects: absorptive, adaptive, and
transformative capacities. These relate to the protection of service delivery during crises, the ability of
the system to manage health crises using fewer resources and its ability to introduce realistic reforms in
response to the changing environment.
● Adapt and coping capacity: the capacity of the health system actors to deliver the same level of
healthcare services with fewer and/or different resources, which requires making organizational
adaptations.

● Absorptive capacity: the capacity of a health system to continue to deliver the same level (quantity,
quality, and equity) of basic healthcare services and protection to populations despite the shock
using the same level of resources and capacities.

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● Transformative capacity: the ability of health system actors to transform the functions and
structure of the health system to respond to a changing environment.

5.8 Pre-Emergency Health System Resilience

Health system resilience in the pre-emergency phase focuses on building capacities of the system to
forecast the potential risks.

Mitigation process includes:

● Identify and estimate the magnitude of vulnerability

● Identify and engage all stakeholders relevant to the public health emergency mitigation process
● Developing and designing mitigation strategies specific to the identified risk/risks by considering
all hazard approach principle
● Include disaster mitigation measures in health sector policy and in planning of new facilities
● Ensure that disaster mitigation measures are taken into account in a facility’s maintenance plans,
structural modifications, and functional aspects
● Inform, sensitize, and train those personnel who are involved in planning, administration, and
operation of disaster mitigation.

5.9 Health System Resilience during Emergency

Building health system resilience is an ongoing process, however the resilience capacity of the health
system is tested during health crises. During public health emergencies, in parallel with responding to
the ongoing health event, essential health services and essential public health functions have been given
due attention.
Maintaining Essential Service during Emergency Response

Public health emergency responses require additional resources which can compromise the routine
health service delivery. But there are health services by any means that should be available, these are
essential health services. The major components of the essential health services of Ethiopia are
organized into the following components:
● Reproductive, maternal, neonatal, child and adolescent health services
● Major communicable diseases
● Non communicable disease(NCD)
● Surgical care

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 ● Emergency and critical care
● Neglected tropical diseases(NTDs)
● Hygiene and environmental health services
● Health education and behavior change communication services
5.10 Post Emergency Health System Resilience
Emergencies often have a direct impact on public health systems of an affected region or country,
particularly in resource-constrained areas. The effects of an emergency on the performance and capacity
of these systems depend upon a variety of interrelated factors, which include the pre-disaster status of
the systems, the type of emergency, the effectiveness of the response, and the initiation of recovery
activities.
Learning from Emergency Experiences to Build Health System Resilience

To learn from the experience of the past public health emergency, the after and/or inter action reviews
should be conducted. The after and/or inter action review can be conducted at national, regional, zonal
or woreda levels and even at health facility level depending on the extent and type of the event. After
action review (AAR) conducted after response efforts are completed and emergency is declared over,
ideally within three months after emergency is declared over.
An AAR/IAR seeks to identify:
● Actions that need to be implemented immediately, to ensure better preparation for the next event;
● A medium and long-term actions needed to strengthen and institutionalize the necessary
capabilities of the public health system
● The AAR/IAR process involves three phases i.e. pre-AAR, during AAR and post AAR
Post-emergency Health System Transformation

The impact of PHEs is quantified with human lives and suffering, psychosocial impact, and economic
slowdown. These constitute strong reasons to translate experiences into actionable lessons, not simply to
prevent similar future crises, but rather to improve the whole spectrum of population health and the
health system. The focus areas in transforming the health system are;
● The health system infrastructure
● Health information management system
● Health service delivery modalities
● Health workforce management/ capacity building

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● Community level mitigation strategies
● Restructuring/reforming coordination platforms
● Revision or development of health emergency policies, guidelines, strategies

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5.11 Practical Exercises

Case Study 1
Scenario 1: On August 26/2021 a heavy rain fell in Town A. The rain fell for 24 hours and the
environment was over flooded. Hundreds of thousands of people were stuck in office buildings, homes
and bus stations around the town. The flood damaged living houses, schools, health centers, bridges
and disrupted businesses, traffic and transportation, telephone and internet service. More than 100
people in and around the town lost their lives while thousands were left homeless and stranded with no
food and supplies. Drinking water schemes were also damaged. Drug medical supply store was
destroyed and taken by flood. Finally, after huge social and economic disruption the flood came back
to normal. The town administration office reports the situation to the Woreda health office.

1. If you were a Woreda PHEM officer, what first action you could take at this moment?
2. How you identify priority for recovery activities
3. If you need to conduct a Post disaster assessment, list the possible steps you need to follow?
4. Health center was disrupted and the health service was interrupted by flood. What could you do to
continue the service?
5. What kind of health threats you might suspect and why?
Scenario 2: As a result of the health section post disaster assessment, a lot of losses were identified. A
total of 500 houses were destroyed and 2800 people were left without houses. 300 were severely
wounded and 150 lost their child. Approximately, more than 100,000,000 birr economy was
destroyed.

6. What kind of possible recovery activities do you undertake?

7. How do you undertake recovery activities?
8. What kind of reconstruction activities you suggest as part of the development