0

1

CONTACT ADDRESS: e-mail:werew@ecsa.or.tz

Mob:+255707548393

EBOLA VIRUS DISEASE (EVD) Willy Were

Ebola Virus Disease (EVD), the clinical condition caused by Ebola virus, first appeared in 1976 in 2 simultaneous outbreaks: one in Nzara, near Maridi in south western Sudan1 (June-November 1976), and the other in the locality of Yambuku2 (1st September to 5th

Novermber 1976), Democratic Republic of Congo. The latter, was the very first Ebola epidemic to be investigated and controlled with the help of WHO. The former was described retrospectively. The DRC epidemic occurred in a village near the Ebola River, from which the disease takes its name. The index victim, Mabalo Lokela, was a village school instructor. He, along with some workmates, had toured an area near the Central African Republic border along the Ebola River between 12–22 August. Along the way he bought some bush meat. On 26th August he felt unwell and on reporting at the local Yambuku Missionary Hospital (YMH), he was treated with an injection of chloroquine for presumptive malaria. On 1st September he was admitted with more serious feverish illness to YMH and on 8 September he died of what would become known as the Ebola Haemmorrhagic Fever due to Ebolavirus (EBOV) that was very closely related to Marburg virus. The hospital itself was closed temporarily on 30th September after 11 of its 17 staff had died of the same illness.

2

Map of DRC and Sudan showing the location of Yambuku and Maridi:

Source: WHO files

Causative Organism Ebola virus disease is caused by four of five species of viruses that belong to the genus Ebolavirus, of the family filoviridae and order mononegavirales3. The disease occurs in man and non-human primates and some mammals. The four disease causing species are Ebolavirus (formally called Zaire Ebola virus-ZEBOV), Bundibugyo Ebola virus (BEBOV), Sudan Ebola virus (SEBOV) and Tal Forest/Cote d’Ivore virus CIEBOV). Reston Ebola virus is not known to have caused disease in humans. In experimental animals, pigs have been found to get infected.

Ebolavirus (formally Zaire Ebola virus) is the most virulent and has been responsible for the largest and worst epidemics. The current epidemics in West Africa and in northern Democratic Republic of Congo are due to this very species.

Electronic microscopy appearance of ebolavirus. Not to scale

Transmission The natural reservoir of Ebola virus are fruit bats of the family Pteropodidae and the genera Hypsignathus, Epomops, and Myonycteris. The geographic distribution of Ebola and Marburg viruses probably corresponds to that of fruit bats of the family Pteropodidae in sub-Saharan Africa, the only region of the world where Ebola epidemics have occurred. The life cycle of Ebolavirus has two phases: an ezootic cycle within the natural reservoir, the fruits bats; and epizootic one within land mammals that get in contact with

3

fruits bitten by the bats. Chimpazees, duikers and gorillas have been particularly cited as common victims. Contact between such animals and man through, for instance, hunters getting in contact with animal blood during butchering and eating of raw meat4. The cycle in humans then begins.This is why in many cases epidemic in land mammals precedes that in humans.

Ebola viruses in humans are transmitted by direct contact with bodily fluids of an infected person or by contact with objects contaminated by the virus, particularly linen, needles and syringes and other medical equipment used during the care of infected persons. Body fluids that may transmit Ebolavirus include saliva, mucus, vomit, feces, sweat, tears, breast milk, urine, and semen. Entry points include the nose, mouth, eyes, or open wounds, cuts and abrasions. Semen may be infectious up to 7 weeks among survivors4. Asymptomatic individuals who are infected with Ebolavirus are less likely to transmit the virus. However, because symptoms (see below) mimic many other diseases, there is, in many instances, a delay in determining whether a sick person’s symptoms are due to Ebola or any other cause. Therefore transmission can occur before the diagnosis is

established or symptoms become more obvious.

Adapted from: WHO/HSE/PED/CED/2014.05

Presentation The early clinical features of EVD mimic many tropical fevers. They include: fever (> 380C), tiredness (malaise), headache, severe muscle pains, joint pains, hiccups, stomach pains, conjuctivitis (red eyes), nausea and loss of appetite, sore throat and difficulty in swallowing, abdominal pain and diarrhea (bloody or not).

4

Later in the course of the disease, patients may develop: confusion and irritability, fits, chest pain, diarrhea (watery or bloody), vomiting (Bloody or not), skin rash, Internal or external bleeding, miscarriage, respiratory distress, shock and other features of circulatory failure. The cause of death is usually multiple organ failure5,6. It is important to note that though EVD is a “haemorrhagic fever”, bleeding and fever do not occur in all cases of EVD. In the Bundibugyo outbreak, fever plus haemorrhage was reported by only 3/26 (12%) admitted patients and no individual whose axillary temperature was recorded at presentation to the Ebola ward had fever. This implies that in epidemic situations, every recognized symptom should be cause for suspicion and investigation to rule out EVD5. In many instances, a biphasic pattern can occur, with a brief remission

followed by a recurrence of fever and more severe late stage disease7.

Management Diagnosis

During an outbreak, or if there is potential for the outbreak to spread, high suspicion index among community health workers and formal clinical health workers is very

5

essential. The travel and work history along with exposure to wildlife meat or caucuses or participation in funerals that could have involved touching the body, are important clues to consider when the diagnosis of EVD is suspected. Thorough clinical examination should be conducted The diagnosis is confirmed by isolating the virus, detecting its RNA or proteins, or detecting antibodies against the virus in a person's blood, in the laboratory5.

Differential Diagnosis

The clinical features of EVD are similar to those of Marburg virus disease. They could also be confused with other haemorrhagic fevers which are common in Tropical Africa (dengue, yellow fever, rift valley fever). Other conditions that may mimic Ebola include: falciparum malaria, typhoid fever, shigellosis, typhus, cholera, gram-negative septicaemia, relapsing fever or EHEC enteritis.. Others may include: leptospirosis, scrub typhus, plague, Q fever, candidiasis, histoplasmosis, trpanosomiasis, visceral leishmaniasis, hemorrhagic smallpox, measles and fulminant viral hepatitis.. Non-infectious diseases that can be confused with EVD are acute promyelocytic leukemia, hemolytic uremic syndrome, snake bite, clotting factor deficiencies/platelet disorders, thrombocytopenic purpura, heridetary

hemorrhagic telangiectasia, Kawasaki disease and even warfarin poisoning.

Prevention

There is no known vaccination nor treatment against Ebola. There are however some experimental drugs on trial. Therefore the best defence, at this point in time, against Ebola is prevention.

General population

The practice of careful hygiene is recommended at all times. For example, washing hands with water and soap or use of alcohol-based sanitizer are good habits. People should avoid handling blood and body fluids with unprotected (eg without gloved) hands. Communities should be educated not to handle items that may have come in contact with an infected person’s blood or body fluids (such as clothes, bedding, needles, and medical equipment). Funeral or burial rituals that require handling the body of someone who has died from Ebola should be desisted. Burial teams of specially trained individuals should lead the

6

management of burials of Ebola victims.Contact with bats and nonhuman primates or blood, fluids, and raw meat prepared from these animals should be avoided. Isolation and quarantine measures have been used successfully to control transmission of Ebola. Individuals who are infected should be kept away from other members of community after being explained.

A burial team conducting a burial

Contact tracing, the process of finding everyone who came in contact with an Ebola patient and observing them for 21 days for symptoms of Ebola so that those who are found infected, are isolated as early as possible, is a very important strategy in arresting the spread of EVD8.

Healthcare Settings

Universal Standards of infection prevention and control9 should be practiced at all times. These include: Washing hands with soap before and after

handling every patient; safe handling and disposal of sharp instruments and equipment, including needles and syringes; wearing protective clothing, including masks, gloves, gowns, and eye protection and routine practice of proper infection control and sterilizationmedical equipment measures.Single use equipment where available should be preferred.

Where VHF is suspected

Isolate patients with Ebola from other patients; avoid direct contact with the bodies of people who have died from Ebola; notify the Ministry of Health if you have received a suspected Ebola case.

Treatment Treatment is basically supportive and palliative5-7 in nature and includes minimizing invasive procedures, balancing fluids and electrolytes to counter dehydration, administration of anticoagulants early in infection to prevent or control disseminated intravascular coagulation, administration of procoagulants late in infection to control bleeding, maintain oxygen levels levels, pain management and the use of medications to treat bacterial or fungal secondary infections. In addition to biological interventions, psychosocial support, and information and education campaigns to cause behavior change in

7

affected communities are essential components of treatment10. Early treatment improves prognosis.

Epidemiology Ebola outbreaks have occurred only in sub-Saharan Africa, in the areas that coincide with the natural habitat of the fruit bats. Since 1976, the current West African outbreak is the 26th. Because of the similarity in presentation with many conditions, Ebola virus spreads markedly in human populations before sometimes even suspicion is made. This is mainly because it mimics many conditions therefore health workers take long to even suspect it. Ebola can infect any person of any age. The index patient of the current West African outbreak was a two-year child who infected the mother, sister and grandmother. It took long for even the highest level clinicians in the countries affected to suspect Ebola. In the Zara outbreak, most of the patients were young adult females who acquired the infection through injections in RH services. Because health workers get in contact with Ebola patients without suspicion, the death toll of health workers in all epidemics is high. It is generally about 8-10%. Funerals where handling of bodies is done have been responsible for Ebola spread in many epidemics including the current West African one.

The Ebola belt, coincides with natural habitat of fruit bats

The Reston species of Ebola that has been described in the Philippines does not cause human disease. Pigs have been known to carry the Reston Ebola virus as natural reservoirs, but have acquired Ebolavirus in experimental animals. Transmission from pigs to humans has not been described but it is possible. Inadequacies in health systems, eg paucity of personnel, equipment and protective equipment have largely fuelled the spread of the disease in epidemics. Because the causuative pathogen has an epizootic phase in its life cycle, the need for collaboration between animal and human health systems is important. Sometimes there is a disconnect between these two.

Persons at the highest risk11 of infection are health workers, family members and close contacts of Ebola patients; people who attend funerals of people who died of Ebola, and where especially touching and/or washing of bodies is done; hunters

8

and people who get in touch with animal blood or bush meat.

Surveillance The continuous collection, storage, analysis and dissemination of disease-related data for planning and intervention is very important. Through effective and efficient surveillance system, infectious diseases with potential to cause serious public health concern at international level should be detected early so that preventive interventions are put in place. WHO provides definitions of viral haemorrhagic fevers that may be used by both health care professionals and lay health workers like community health workers. Deaths and spread of haemmorrhagic fevers may occur in communities for long periods before the formal health systems get the reports. For that matter, it is important to strengthen the community aspect of surveillance so as to have a system that can detect occurrence of cases or deaths early enough for action.

9

Classification Standard Criteria (Definition) CHW Criteria (Definition) Alert Illness with onset of fever and no

response to treatment of usual causes of fever in the area, OR at least one of the following signs: bleeding, bloody diarrhoea, bleeding into urine OR any sudden death.

Index The first confirmed case of the disease in an outbreak Suspect (During epidemic)

Any person, alive or dead, who has (or had) sudden onset of high fever and had contact with a suspected, probable or confirmed Ebola case, or a dead or sick animal OR any person with sudden onset of high fever and at least three of the following symptoms: headache, vomiting, anorexia/ loss of appetite, diarrhoea, lethargy, stomach pain, aching muscles or joints, difficulty swallowing, breathing difficulties, or hiccup; or any person with unexplained bleeding OR any sudden, unexplained death.

Illness with onset of fever and no response to treatment for usual causes of fever in the area, and at least one of the following signs: bloody diarrhoea, bleeding from gums, bleeding into skin (purpura), bleeding into eyes and urine.

Probable (Clinic/Hospital during epidemic)

Any suspected case evaluated by a clinician OR any person who died from ‘suspected’ Ebola and had an epidemiological link to a confirmed case but was not tested and did not have laboratory confirmation of the disease. (Hospital Definition)

Confirmed A probable or suspected case is classified as confirmed when a sample from that person tests positive for Ebola virus in the laboratory.

Discussion and implications for East African Region This has been the largest EVD outbreak spreading majorly over four countries. There is no reason not to believe that another or the same outbreak may occur in the East African region. A simultaneous but smaller outbreak has occurred in the DRC, which borders EAC region. These are reasons for the EAC region to get prepared to respond in case EVD strikes. The preparations should pre-date the beginning of the outbreak. The WHO has

suggested a checklist15 of conditions that should be in place at all times, in order to stem the human loss, suffering and economic loss caused by EVD. These include:

Overall coordination: Countries should put in place national multi-sectoral coordination structure to ensure planned and well-managed preparedness and response activities.

Rapid Response Team (RRT): Countries should have a team of experts ready to

10

reach reported suspected EVD case within 24 hours anywhere in the country.

Public awareness and community engagement; Effective response requires a well-informed and mobilized community. Communication to provide the right messages on mode of EVD infection, transmission and care and support given in good time is essential. Communities need to be involved in surveillance as well.

Infection Prevention and Control: This is important to ensure safety of health workers and also prevent naslocomial transmission of EVD

Case management: Ebola Treatment Centre (ETC): Establish centers with staff dedicated to EVD care. These to be strategically placed in regions with the highest risk.

Safe Burials: to prevent transmission through funerals, dedicated burial teams should be trained and deployed during epidemics.

Epidemiological Surveillance: Surveillance to be strengthened and all sytems to be alert 24/7. Community aspects should be strengthened with training in IDSR and case detection and reporting.

Contact Tracing: a system to identify and locate contacts with any suspect or confirmed case should be in place. Ability to observe contacts starting within 72 hrs and continuing for 21 days (unless

symptoms/signs begin earlier) should be developed.

Laboratory: A system to correctly collect samples, transport them and have the right confirmatory tests done and results relayed back in the shortest possible time is needs.

Screening capacities at Points of Entry: EVD can cross boders very easily. Capacity should be developed at points of entry to be able to detect suspects, investigate them and appropriately refer to care centers.

The EAPHLNP is contributing to improved laboratory performance and accessibility, creating capacity at Points of Entry and improved epidemiological surveillance with special attention to cross-border areas. Given the high fatality among health workers, these should be trained to have a high suspicion index and to routinely practice rigorous infection prevention and control procedures at their places of work.

References

1. WHO. Ebola haemorhagic fever in Sudan, 1976. Bulletin of the World Health Organization. 1978;56(2):23.

2. WHO. Ebola haemorrhagic fever in Zaire, 1976. Bulletin of the World Health Organization 1978 1978;56(2):22.

3. Kuhn J.H. BS, Ebihara H., Geisbert T.W., Johnson K.M., Kawaoka Y., Lipkin W.I., Negredo A.I., Netesov S., Nichol S.T.,

11

Palacios G., Peters C.J. Proposal for a revised taxonomy of the family Filoviridae: classification, names of taxa and viruses, and virus abbreviations. Arch Virol. 2010;155(12):20.

4. WHO. Ebola and Marburg virus disease epidemics: preparedness, alert, control and evaluation. Interim version 1.2 Geneva, Switzerland2014.

5. Roddy P. HN, Van Kerkhove M., Lutwama J., Wamala J, Yoti Z., Colebunders R., Palma P., Sterk E., Jeffs B., Van Herp M., Borchert M. Clinical Manifestations and Case Management of Ebola Haemorrhagic Fever Caused by a Newly Identified Virus Strain, Bundibugyo, Uganda, 2007–2008. PLOS One. 2012;7(12).

6. Ministry of Health U. Clinical Management of Patients with Viral Haemorrhagic Fever in Uganda: A Pocket Guide for the Front-Line Health-Officer2013.

7. Clark D.V., Jahrling P.B., Lawler J.V. Clinical Management of Filovirus-Infected Patients. Viruses 2012. 2012;4:18.

8. What is contact tracing? . 2014. http://www.cdc.gov/vhf/ebola/pdf/contact-tracing.pdf. Accessed Oct 20 2014.

9. Organization CfDCaPaWH. Infection Control for Viral Haemorrhagic Fevers in the African Health Care Setting1998:1-198.

10. Roddy P. WD, Jeffs B., Zohra Abaakouk Z., Dorion C, Josefa Rodriguez-Martinez J., Pedro Pablo Palma P.P., De la Rosa O., Villa L., Grovas I., Borchert M. . The Me´decins Sans Frontie`res Intervention in the Marburg Hemorrhagic Fever Epidemic, Uige, Angola, 2005. II. Lessons Learned in the Community. The Journal of Infectious Diseases. 2007(196):S162-167.

11. Ebola Virus Disease. 2014. http://www.cdc.gov/vhf/ebola/exposure/index.html. Accessed Oct 22 2014.

12. WHO. WHO Response to the Ebola Virus Disease (EVD) Outbreak UPDATE BY THE WHO REGIONAL DIRECTOR FOR AFRICA As of 31 August 2014. WHO Afro Region: WHO;2014.

13. WHO. WHO: EBOLA RESPONSE ROADMAP UPDATE, 10 October 2014: WHO;2014.

http://www.who.int/csr/resources/publications/ebola/response-roadmap/en/

14. EBOLA RESPONSE ROADMAP SITUATION REPORT UPDATE 25 OCTOBER 2014. 2014. http://www.who.int/csr/resources/publications/ebola/en/.

15. WHO. Consolidated Ebola Virus Disease Preparedness Checklist. Geneva, Switzerland2014.

http://www.who.int/csr/disease/ebola/evd-preparedness-checklist-en.pdf

12

Ebola Virus Disease (EVD) Epidemics: 1976 to Date

(October 31st 2014)

West Africa EVD Outbreak 2014

Margaret Chan, the Director general of the World Health Organization described the current EVD outbreak in West Africa as “the largest, most complex and most severe we’ve ever seen”. This outbreak is the most geographically spread EVD outbreak in history. It has caused more deaths than all other EVD outbreaks combined. The outbreak was first reported in March 2014 in Guinea. But investigations revealed that it had been un-noticed for 3 months: it actually started in December 2013. Two-year old Emile Ouamouno of Meliendu village in Gueckedou Prefacture died in December 2013 of symptoms that were later known to be due to EVD. His family hunted and butchered fruit bats which were suspected to be the source of the infection. His sister, mother and grandmother got secondarily infected (and also died) and sparked of the epidemic. The epidemic then stread to Liberia and Sierra Leone.

A Liberian-American who was infected in Liberia flew to Lagos where he died soon after arrival on 25th July. By 20th September 2014, WHO declared that 20 persons had been subsequently infected in Nigeria, and 8 of them had died.

In Senegal, a Guinean national who had been under observation travelled by road to theat country where he developed symptoms. He was treated and improved. After recording no new cases over 21 days, WHO officially declared Senegal and Nigeria free of Ebola virus transmission on October 17 and 20, respectively.

In Mali, a two year old girl who had returned from the funerals of her parents in Guinea died on 23rd October. Raised

13

levels of surveillance and contact tracing have been put in place. No new cases have been identified to date.

Factors associated with the spread of Ebola virus in West Africa include: inadequate knowledge and poor mobilization of communities. In some situations communities falsely think that the virus is deliberately spread by health workers. Poor sanitation practices including inadequate supply of water and lack of soap for hand washing have provided potential for spread of the virus. Reliance on traditional medicine has also contributed. The outbreak in Sierra Leone was accelerated by a traditional healer, who misinformed her clients that Ebola was a fallacy. In addition cultural practices at funerals where close relatives touch and wash bodies has had a very big boost to the epidemic. Many people in this region, like the family of Emile, practice hunting as an important occupation. Contact with bush meat and animal bodily fluids is therefore common. Poor health systems with inadequate infection control syatems and staffing have had a negative effect. Poor infection control has been responsible for the high health worker toll

of about 10%. Because many health workers have shunned their jobs due to fear and panic, the people have lost faith in health services, health care has worsened in the affected countries. This in turn has resulted in many patients dying due to causes other than Ebola. Contact with bush meat in this region is very common practice..

Table 1: Progress of West African EVD Outbreak

Source: WHO Updates

This has been the most geographically widespread Ebola epidemic with the highest recorded case fatality.

14

DRC Outbreak 2014 The most recent EVD outbreak in the Democratic Republic of the Congo is the seventh since 1976 of such outbreaks. It is due to Ebolavirus, formally Ebola virus Zaire, like the species responsible for the West Arica epidemic, but genetically different. So the epidemics have been simultaneous but un-related. In August 2014, a woman in Ikanamongo village, Boende District in Equateur Region of DRC developed symptoms after butchering an animal her husband had killed. Relatives and neighbors who also got in contact with the animal and herself got infected and spread the virus. WHO declared an Ebola epidemic on 14th

August 2014 after notification by the mInistry of Health.

The epidemic in the Democratic Republic of Congo seems to have been contained. As at 28th October 2014 there had been reported 66 cases (38 confirmed, 28 probable, 1 suspected) of Ebola virus disease (EVD) in the DRC, including eight among health-care workers (HCWs). In total, 49 deaths (CFR 73%) have been reported, including eight among HCWs (CFR 100%). Contact tracing and follow-up of identified contacts was instituted. If after 42 days of follow-up of all contacts no new cases are reported, WHO will declare the outbreak over14.

15

Other Ebola Outbreaks 1976-2012 Table 2: Previous Ebola Outbreaks

Source: WHO

As seen above, EVD outbreaks are becoming more frequent in the EAC region (Uganda in particular). Since 2007 Uganda has reported four of them. With increased cross-border activities in the region with increasing efforts toward a political federation, joint regional effort in surveillance and emergency preparedness and response toward VHF and similar emergencies is required. EAC in collaboration with EACSA-HC through the EAPLN project have piloted a system

of community surveillance in Muyinga (Burundi), Zara (Tanzania) and Kirehi (Rwanda) through trained community health workers. The project has also established 8 cross-border surveillance committees to complement surveillance activities at borders. The Project has also conducted table-top simulation exercises for VHF as a means of providing skills and knowledge to a multi-sectoral regional team. These efforts should be strengthened and rolled out to more communiies in the region.

16

EAC and ECSA-HC Prepare the Region to Fight EVD

Outbreak

Summary of Cross-border meetings and table top simulation exercises for Ebola Virus Disease (EVD) Outbreak 29th September to 3rd October, 2014, Mbarara Uganda, Martin Matu

Background The East, Central and Southern Africa Health Community Secretariat (ECSA-HC) is collaborating with the East African Community, EAC Partner States, the World Health Organization (WHO), the US Centers for Disease Control and Prevention (US CDC) and other partners in the implementation of the World Bank supported “East Africa Public Health Laboratory Network Project (EAPHLNP)”. The project is also contributing to the strengthening of the “East African Integrated Disease Surveillance Network (EAIDSNet)”. This is a regional collaborative initiative of the EAC Partner States’ national ministries responsible for human and animal health, including wildlife as well as the national health research and academic institutions in both the public and private sector. Under article 118 of the Treaty on the Establishment of

the East African Community, the Partner States undertake to take joint action towards the prevention and control of communicable and non-communicable diseases that might endanger the health and welfare of the residents of the Partner States, and to cooperate in facilitating mass immunization and other public health community campaigns. In the support for the strengthening of disease surveillance and preparedness to disease outbreaks in the East African region and the neighboring countries, the project has been building capacities for the surveillance teams by (i) establishing joint collaborative framework for disease surveillance and joint response to outbreaks; (ii) establishing cross-border committees to collaborate in controlling the spread of outbreaks across the bordering countries; (conducting joint investigations in case of outbreaks; (iv) building capacities of the surveillance and other stakeholders in surveillance and outbreak management. It is in this regard that the ECSA-HC and EAC convened a cross-border meeting between bordering districts of the Republic of Rwanda and the Republic of Uganda and; the Republic of Uganda and United Republic of Uganda and a table top simulation training in order to prepare the respective border districts in the Republic of Rwanda, Republic of Uganda, Republic of Burundi, Republic of Kenya, the Democratic Republic of Congo (North and South Kivu) and the United Republic of Tanzania in handling Ebola Virus Disease Outbreak. The simulation

17

exercise was facilitated by experts from the Food and Agriculture Organization of the United Nations (UNFAO) and the University of Nairobi, Department of Veterinary Services. Objectives

The simulation exercise was conducted to assess the level of emergency preparedness and response capacity for Ebola/VHFs outbreak, in the EAC Partner States and North & South Kivu provinces of the Democratic Republic of Congo (DRC) and identify gaps so as to strengthen the surveillance and response system. The specific objectives of the table top simulation exercise were to; assess the level of preparedness and ability to detect VHF and contain a VHF outbreak at the cross-border areas; (ii) raise awareness of the roles, responsibilities and immediate emergency response actions of the participants in – Surveillance, laboratory testing and confirmation, risk communication; (iii) test application of Best Practices of One Health Approach; (iv) strengthen partnerships and the emergency response capacity of the participants; (v) test the efficacy of the preparedness tools- e.g WHO guidelines, selected SOPs, contingency plans of the participating organizations; (vi) test the coordination of emergency response at sub national, national and regional levels

Approach/Move

The table top simulation contained three scenarios with different level of complexities beginning with simple to more complex moves and table top demonstration of downing and doffing personal protective equipment (PPEs). Scenario 1 contained three moves (from simple regular clinical case to confirmation of initial cases of Ebola), scenario 2 contained two moves (increase in Ebola cases from contacts requiring improved clinical support and communications to the communities) and scenario 3 contained three moves (cases requiring establishment of burial teams to final control and outbreak control). The moves assessed the responses of various stakeholders involved in outbreak management including Disease Surveillance and Laboratory (diagnostics); Case Management (clinical staff); Risk Management; Coordination (policy makers and heads of programs) and Supportive Services (communication, immigration; security officials etc). The different stakeholders were expected to develop response actions appropriate for their functional areas and to coordinate, as would be necessary, with other groups. This methodology proved to be effective in identifying response actions and providing participants with an opportunity to develop command, control and coordination of their action plans necessary for a meaningful response to an Ebola outbreak. This also identified gaps in the

18

systems that would need to be addressed to improve an response system.

Recommendations

Following the discussions during the exercise recommendations were made to strengthen further the preparedness for EBV and communicable diseases of public health concerns. The following recommendations were based on the team’s observations during the exercise:-

i. Enhance sharing, publication and dissemination of surveillance information between neighbouring districts, regions and counties within countries and across the borders in the EAC region;

ii. Hold quarterly cross border meetings in the surveillance zones as indicated in the attached lists of current cross-border districts during inter- outbreak periods (peace-time) to build capacity and systems

iii. Establish communication inventory by exchanging personal and official contacts with each individual (mobile/email) to enhance free cross-border communication amongst participants and other officials on health matters;

iv. Exchange visits of country teams to learn from each other through the coordination of EAC, ECSA and other stakeholders;

v. Improve and harmonize country policies, strategies, laws, acts, rules, regulations, guidelines, Standard Operating Procedures (SOPs) or codes in order to facilitate smooth implementation

of both the International Health Regulations (IHR 2005) and also the National Public Health Laws and Regulations of each Country. This will empower the Rapid Response Teams (RRTs) to isolate and put other measures that may be provided under the relevant policies, laws and regulations to control Ebola Virus Disease (EVD) and other highly communicable diseases of International Public Health Concern (IPHC);

vi. Strengthen local community-based surveillance system to ensure early detection and rapid prevention, control and responses to communicable diseases in the region;

vii. Develop and/or finalize national and regional contingency emergency preparedness and response plans on Ebola Virus Disease (EVD) and other highly communicable diseases of International Public Health Concern (IPHC) and update them regularly through simulations and other experiences;

viii. Advocate for an in – country and regional emergency outbreak response fund that is readily/easily accessible (Ring fenced) during outbreaks of various highly communicable diseases of International Public Health Concern (IPHC);

ix. Plan and conduct regular Table Top, Drills and Field Simulation Exercises (semi-functional and fully functional) for Ebola Virus Disease (EVD) and other highly communicable diseases of International Public Health Concern (IPHC) at cross-border zones in order to improve the skills and confidence of the frontline health

19

workers and Rapid Response Teams (RRTs) within and between the respective districts and Countries. The District Medical Officers of Health/Directors of Health Services and the District Health Management Teams (DHMTs) should take this up and ensure it is implemented within their respective districts in each Country;

x. Strengthen capacity for Infection Prevention and Control (IPC) targeting health facilities, communities and other stakeholders in the region through implementation of Total Quality Management (TQM) systems and practices at all levels in each Country;

xi. Create an archive website portal for Ebola Virus Disease (EVD) and other highly communicable diseases of International Public Health Concern (IPHC) and populate with Standard Operating Procedures (SOPs) and various national and international guidelines;

xii. Establish isolation facilities at regional, national and sub-national levels in each Country for Ebola Virus Disease (EVD) and other highly communicable diseases of International Public Health Concern (IPHC);

xiii. The EAC Secretariat in coordination with the EAC Partner States and various stakeholders and international collaborating development partners will facilitate the establishment and operationalization of a mechanism for joint use of public health laboratories within EAC region for specialized testing of Ebola Virus Disease (EVD) and other highly communicable diseases of

International Public Health Concern (IPHC) by all the EAC Partner States and the neighboring countries such as the Democratic Republic of Congo, Ethiopia, Somalia and South Sudan in order to facilitate rapid confirmation and response to outbreaks.

xiv. The EAC partner states and the Democratic Republic of Congo should establish cross-border committees and make follow up cross-border meetings to address issues of common interest in disease surveillance and outbreaks management;

xv. Urge all Countries to implement the recommendation of the signed communiqué of the regional high level multisectoral Ministerial meeting on Ebola Virus Disease emergency preparedness and response that was held in Nairobi Kenya on 16th – 17th September, 2014. Conclusion

The exercise was considered as very successful by the participants, the evaluators and the observers. The Participant evaluation report was positive with respect to both process and outcome. The perceived success of the exercise was due in part to the participation of a wide variety of participants representing a spectrum of technical experts all of whom play a role in planning, prevention and response to Ebola Virus Disease outbreak in the region. The willing engagement of all participants and the application of their experience were critical to the success of this exercise and to the identification of

20

the plans, policies and procedures critical to guide local, national or regional response to diseases, conditions and events of international public health concern.

21

The Civil Aviation Industry Gets Involved in Emergency Preparedness and Response

for EVD

Meeting of the Civil Aviation Safety and Security Oversight Agency (CASSOA)

Entebbe, Uganda 21st August 2014 The current Ebola Virus Disease outbreak in the West African Region has become a global concern with serious consequences. Yje outbreak that was reported in March 2014, is thought to have actually started in December 2013. By August 31st a total of 3475 individuals had been recorded as infected 1849 (53%) of them had died of the disease. The outbreak continued to spead geaographically causing increasing deaths, human suffering and economic loss in the region. On 8th August 2014, the Director-General of the World Health Organization (WHO) declared the epidemic a “Public Health Emergency of International Concern” (PHEIC). The WHO further categorized the Republic of Kenya which is a member state of the East African Community as one of the high risk countries for the possible spread of the Ebola Virus Disease (EVD) from

West Africa to the East African Region. Another epidemic broke out in a counry that neighbours the East African Region, in the Democratic Republic of Congo.

Movement of infected persons by Air Transport (unknowingly or otherwise) is highly possible. People who were infected within the majorly affected countries of Guinea, Liberia and Serra Leone travelled with the pathogen to USA, Spain, UK, Saud Arabia, Turkey and France. Therefore appropriate measures to check the spread of the disease by air need to be put in place as a priority. East African Community (EAC) Partner States have individually introduced mechanisms to proactively address the matter in coordination with the Ministries responsible for Health, East African Community Secretariat and the World Health Organization (WHO).

The East African Community Civil Aviation Safety & Security Oversight Agency (EAC-CASSOA) strongly advocates for a regional approach to establishment of methods and strategies towards combating this scourge bearing in mind the fact that some operators based or transiting through the East African Community Partner States operate direct flights into the affected region. It was in this regard that CASSOA found it prudent to hold an emergency meeting of the EAC Partner States’ National Civil Aviation

22

Authorities and National Airport Authorities to discuss the issues related to preparedness and possible response to the scourge under the auspices of the Centre for Aviation Medicine. The emergency meeting, under the chairmanship of Mr. Harrison Machio, Safety Manager at the Kenya Airports Authority (KAA), was held on 21st August 2014 at the CASSOA Headquarters in Entebbe, Uganda. Participation included Mr. Barry Kashambo, Executive Director of EAC-CASSOA, Hon. Jesca Eriyo, Deputy Secretary General in charge of Productive and Social Sectors at the EAC Secretariat, Dr. Kirunda from the CASSOA Centre for Aviation Medicine who presented the Background Paper on the threat of Ebola Virus Disease in the Region; Dr Luswa Lukwago from Uganda Ministry of Health who presented the paper on the Uganda Experience on Ebola Virus Disease and Partner States representatives who gave presentations on the Status, Measures and Challenges in addressing the Threat of Ebola in the individual States. Organizations represented included: Kenya Airport Authority (KAA); Tanzania Civil Aviation Authority (TCAA); Tanzania Airport Authority (TAA); Burundi Civil Aviation Authority (BCAA); Rwanda Civil Aviation Authority (RCAA); Civil Aviation Authority Uganda (CAAU); Uganda Ministry of Health; Uganda Ministry of East African Community Affairs; Entebbe Airport Handling Services Limited; East African

Community Secretariat; and EAC Civil Aviation Safety & Security Oversight Agency. The short-t and long-term recommendations of the meeting were:

a) Conduct entry screening of all persons at international airports, seaports and major land crossings for suspected cases of Ebola Virus Disease especially those from the highest risk Countries of West Africa;

b) Provide medical advice about Ebola Virus Disease to all travellers to and from the high risk regions of the world;

c) Institute measures to detect, investigate and manage Ebola Virus Disease cases including access to qualified diagnostic laboratory, referral health services, isolation and evacuation;

d) Take measures to ensure the protection from Ebola infection of passengers, airline crew and staff including those working in affected regions of West Africa;

e) Take measures to restrict international travel of Ebola Virus Disease contacts or cases unless the travel is part of an appropriate supervised medical evacuation;

f) Mandate establishment and testing of National Aviation Public Health Emergency Preparedness and Response Plans;

23

g) Foster effective lines of communication between the Public Health Sector and the Civil Aviation Sector including airlines to mitigate and prevent the spread of Ebola Virus Disease and other communicable diseases into the East African Region;

h) Comply with Airport Preparedness Guidelines and strengthen infrastructure to prevent possible outbreaks of Ebola Virus Disease and other communicable diseases;

i) Develop and test contingency plans on business continuity management for airports, airlines and other related businesses at the airport;

j) Strengthen surveillance and management of on-board cases of suspected Ebola Virus Disease (EVD) and other communicable diseases through the provision of training and awareness campaigns for all airport stakeholders, including the provision of adequate sanitary facilities and First Aid kits;

k) Enforce the use of Public Health Passenger Locator Form (PLF) for contacts tracing of potentially exposed travelers;

l) Urge airlines to carry Surveillance Forms on-board to make it easier for all arriving passengers to fill-in;

m) Urge the EAC Secretariat and CASSOA to develop a Monitoring and Evaluation Tool to follow-up on the implementation of the above Recommendations and make a

detailed Report on the progress to the EAC Council of Ministers through the EAC Sectoral Council of Ministers of Health and Ministers Responsible for Transport before 30th November, 2014.

Conclusion The leadership of the civil aviation industry in EAC countries realized a serious threat to the populations they serve and work with. In a meeting they prudently held, they placed themselves in the center stage of preparing for the potential Ebola outbreak with short- and mid-term measures. The onus is on the EAC secretariat to ensure that these recommendations are followed through and implemented. Prevention and control of infectious diseases of international public health concern like Ebola is the responsibility of every individual and sector. The CASSOA initiative is the way to go.

24

High Level Regional Meeting on Ebola Emergency

Preparedness and Response

Successful public health programs must have the highest possible political commitment. Preparing to deal with a potential attack of a highly contagious and virulent pathogen like Ebola is no exception. Since December 2013, the largest ever reported Ebola outbreak has been raging in West Africa. The worst effects have been felt in Guinea, Liberia and Sierra Leone, but travelers and health workers involved in the fight against the outbreak have spread it to USA, Spain, UK, France, Norway, Saudi Arabia and Germany, Senegal and Nigeria. Another Ebola (different) outbreak has also started in the DRC. In all, xxx people are estimated to have been infected. Of these xxx have died of the infection. Among the dead, 8-10% are health workers. In West Africa, the outbreak has not only caused death, but the panic associated has reverberating effects. Health systems are collapsing as people are now shunning health facilities. Healh workers have been hit hard and are dying in big numbers. This therefore means death due to other conditions, and especially mortality, have increased. In addition, because people are not working due to fear, the

economies of the affected countries are almost collapsing. Given the foregoing, there is no reason for one to assume that the EAC region may not get the outbreak. The region borders DRC; movement of people and animals is unabated. Therefore, preparing all systems and mobilizing all stakeholders for a possible attack is the best way for the Eastern Africa region to avoid the morbidity, mortality, social upheavils and the negative effects to the economy that Ebola can precipitate to the region.

On 16th and 17th September 2014, the East African Community (EAC) Secretariat in collaboration with the Republic of Kenya, IGAD and WHO convened a two days High Level Multi-Sectoral Ministerial meeting on emergency preparedness and response to Ebola Virus Disease (EVD) outbreak. The meeting was attended by Regional Ministers Responsible for Health, Transport, EAC Affairs and Immigration from the Republic of Burundi, Democratic Republic of Congo, Federal Democratic Republic of Ethiopia, Republic of Kenya, Republic of Rwanda, Republic of South Sudan, United Republic of Tanzania, the Republic of Uganda, African Union Commission (AUC), World Health Organization, International Civil Aviation Organization(ICAO), EAC Civil Aviation

25

Safety and Security Oversight Agency (CASSOA), and the East African Community Secretariat. The meeting put forth recommendations for countries, the EAC Secretariat and related institutions and agencies and for Development Partners and the international community.

1.) Countries to:

a) Strengthen the Integrated Disease Surveillance and Response System at district, community and Points of Entry (PoE) for early detection and response to EVD outbreak;

b) Enhance preparedness for EVD and other public health events of international concern by updating and harmonizing national epidemic response plans, securing funds and conducting simulation exercises;

c) Countries should ensure their Ebola emergency and preparedness response plans meet the minimal WHO standards;

d) Enhance cross border collaboration and information sharing between countries;

e) Accelerate the implementation of IHR plan of action and attainment of IHR core capacities in accordance with the resolution AFR/RC62/R12;

f) Encourage research on Ebola and other Viral Haemorrhagic Fevers;

including research on medicines, serums and vaccines;

g) Provide technical and logistical support to affected countries;

h) Provide high level national leadership and commitment in the management of Ebola preparedness and response;

i) Strengthen existing Laboratory Capacities to facilitate early detection and diagnosis of Ebola and other Public Health Events of International Concern;

j) Expeditious release of laboratory test results and ensure the turnaround time is a short as possible;

k) Undertake resources mobilization to support preparedness and response plans to EVD;

l) Participate actively in the African Union Network of infectious diseases surveillance;

m) Participate actively in ICAO Collaborative Arrangement for the Prevention and Management of Public Health Events in Civil Aviation( CAPSCA);

n) Ensure compliance with the International Health Regulations- Emergency Committee (IHR –EC) recommendations and AU decisions on travel and trade restrictions;

o) Ensure the remittance of their financial contributions to the African Public Health Emergency Fund in

26

accordance with resolution AFR/RC61/R3 and decision AU Dec416-449(xix); and

p) Call upon the maritime organizations/authorities within countries and International Maritime Organization (IMO) to join in the management of the EVD outbreak.

2. EAC Secretariat and institutions/agencies to:

a) Coordinate the implementation of the Regional Plan of Action on EVD Emergency Preparedness and Response ;

b) Coordinate and facilitate the activities of the existing Standby Regional Rapid Response Teams for Ebola and other public health events of international concern;

c) Coordinate strengthening of animal health surveillance systems, to monitor animal movement and detection of Ebola Virus Disease;

d) Promote the implementation of the one-Health Concept;

e) Undertake resources mobilization to support preparedness and response plans to EVD;

f) Collaborate with other regional networks in the RECs through the AU Network on Infectious Disease Surveillance;

g) Encourage the Democratic Republic of Congo, the Federal Democratic Republic of Ethiopia and the Republic of South Sudan and Intergovernmental Authority on Development (IGAD) to join the East African Integrated Disease Surveillance Network (EAIDSNet);

h) Collaborate with the AUC in the implementation of the AU decision AU/Dec.499 (XXII) on the establishment of the an African Centre for Disease Control and Prevention;

i) Coordinate the monitoring and evaluation of the implementation of recommendations of the emergency meeting on Ebola convened by CASSOA; and

j) Coordinate, advice and support regional countries to participate in ICAO’s CAPSCA programme.

3. Development Partners and the international community to:

a) Provide technical and financial support for implementation of regional and country emergency Preparedness and Response Plans to Ebola Virus Disease Outbreak;

b) Ensure coordinated approach to resource mobilization.

c) Work with countries to progressively build capacities to

27

manage disease of public health importance

In conclusion the Ministers expressed their satisfaction in the way the meeting was organized and requested the Cabinet Secretary for Health, Hon. James W. Macharia, Republic of Kenya to thank His Excellency, Uhuru Kenyatta, the President of the Republic of Kenya for hosting the meeting. The meeting called upon President Uhuru Kenyatta, to champion the cause of the Emergency Preparedness and Response Plan to Ebola Virus Disease at the next Heads of State Regional Summits.

28

East African Community Legislative Assembly

Endorses Anti-Ebola Action

Determining of interventions of control and prevention of infectious diseases in the East African Community region starts at the level of the Technical Working Group (TWG) on Prevention and Control of Communicable and Non-Communicable Diseases. The TWG receives reports from Member States on major health issues in each country. The TWG evaluates the reports to determine what they consider to be priority for the region and forwards its recommendations to the Sectoral Committee on Health. The Sectoral Committee reviews the recommendations of the TWG and forwards its considered and favoured position to the East African Sectoral Council of Ministers of Health. The Council directs the EAC Secretariat to implement what it deems to be feasible (within available resources), and the priority for the region.

Meeting of the EAC Technical Working Group on Prevention and Control of Communicable and Non-Communicable Diseases Held on 8th-9th September 2014

The meeting reviewed Partner States reports on Ebola outbreak preparedness and response. According to the reports, the surveillance and response activities underway in the Partner States included:

• development and implementation of Ebola contingency plans,

• development of Standard Operating Procedures (SOPs),

• development guidelines on case management and infection prevention and control,

• improvement of screening measures at the ports of entry,

• establishment of isolation facilities, • public sensitization and awareness

creation, • capacity building and procurement

and provision of Personal Protective Equipment (PPEs) at selected sites.

The committee noted that the hindrance countries faced was inadequate and /or late release of funding (due to red tape). The TWG urged the upcoming 19th Ordinary Meeting of the EAC Sectoral Committee on Health to note the positive developments and assist the countries to do more. In particular, the TWG recommended that Sectoral Committee recommends to the Council of Ministers to:

• approve the allocation of supplementary budget of $750,000 to support the EAC regional

29

communicable diseases emergency preparedness and response activities and the EAC Regional Rapid Response Teams (RRTs) from the EAC General Reserve

• allocate annually the sum of $500,000 for the regional communicable diseases emergency preparedness and response activities and the EAC Regional Rapid Response Teams (RRTs);

• direct the EAC secretariat to collaborate with Partner States, Regional bodies (ECSA-HC, AU, SADC) and development partners in mobilizing resources for Ebola prevention and control including construction of isolation and quarantine facilities at National and Cross border areas.

• take note of the progress of the development of the “EAC Regional Contingency Plan for Epidemics due to Communicable Diseases, Conditions and other Events of Public Health Concern for the East African Community Region

19th Ordinary Meeting of the EAC Sectoral Committee on Health

The 19th Ordinary meeting of the EAC Sectoral Committee on Health meeting was held from 10th to 12 September 2014. The meeting considered resolutions of the

Technical Working Group on Prevention and Control of Communicable and Non-Communicable Diseases held on 8th and 9th of September 2014. The Committee reviewed the resolutions of the TWG and recommended that the Sectoral Council on Health adopt the resolutions; and urged EAC Secretariat to oversee the implementation of resolutions on regional emergency preparedness and response to Ebola and other public health events of public concern.

THE 10TH ORDINARY MEETING OF THE EAST AFRICAN COMMUNITY SECTORAL COUNCIL OF MINISTERS OF HEALTH

This The East African Community Sectoral Council of Ministers of Health, during their 10th Ordinary Meeting at the EAC headquarters in Arusha, from 13th to 16th October 2014 addressed various issues on regional cooperation on health. The meeting was follow-on to the Sectoral committee on health that was held at the same venue on 10th to 12th October. The Ministers were equally concerned about the threat of Ebola to the region and, among others, resolved to:

30

a) Approve the EAC Regional Ebola Emergency Preparedness and Response Plan of Action and directed the EAC Secretariat to mobilize USD 750,000 from the EAC reserve fund to support implementation

b) Approve the “East African Community Integrated Disease Surveillance Network (EAIDSNet)” as the regional Focal point (Hub) for the “African Union Network of Infectious Diseases (the AUNIDS)”.

c) Approve the establishment of an

EAC Regional Emergency Preparedness and Response Task Force on Ebola Virus Disease and other communicable diseases in the EAC

d) Directed the EAC Secretariat to

facilitate harmonization of the Standard Operating Procedures (SOPs) and Guidelines for screening passengers across the borders/international ports of entry in the EAC in line with IHR (2005)

e) Directed the EAC Secretariat to convene a regional meeting of experts within ten (10) days to provide technical guidance on models to address the existing logistical, human resource and infrastructural challeges of

implementing regional and National Level Epidemic Preparedness and Response Actions.

f) Urged Partner States and

directed the Secretariat to implement the recommendations of the meeting of the EAC Partner States National Civil Aviation Authorities (NCAAs) and National Airport Authorities (NAAs)held in Entebbe, Uganda on 21st August 2014.

g) Urged Partner States and

relevant Partner States’ Institutions to implement resolutions of the EAC Regional High Level Multi-Sectoral Ministerial meeting on emergency preparedness and response to Ebola Virus Disease (EVD) held in Nairobi, Kenya on 17thSeptember 2014.

h) Partner States committed to contribute a team of medical experts, health workers and funds to support the efforts aimed at containment of Ebola Virus Disease in West Africa.

This chronology of events shows a high level committed the leaders of the EAC region have placed on preparedness for Ebola outbreak and other infectious diseases. Their plans are in line with the checklist of requirements for preparedness and response that the

31

World Health Organization has suggested for countries (WHO, 17th Oct 2014). The Partner States need to act fast as WHO recommendations are time bound: interventions to be in place within 30-60 days from the publication date of the checklist. Ebola Virus Disease is a condition that is associated with high fatality and negative socio-economic effects. Given the example in West Africa, it does not respect borders and can spread very fast across international borders. Early warned is early armed. The East African region has no alternative but to prpare in advance before it strikes. The systems and structures that will be developed for Ebola may be used in the event of other haemorrhagic fevers and other diseases of public health concern. Therefore, resources to effect a good preparedness and response program against Ebola, would be leveraged to improve: surveillance, laboratory capacity, community awareness, health worker knowledge and skills, regional, national and sub-national coordination, and infection prevention and control measures in health facilities.